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February 25, 1995 TO: Kuo-Yung Chyan <[log in to unmask]> RE: Pallidotomy Barbara Patterson of the Parkinson's disease List has forwarded your message concerning pallidotomy along to me. I have been one of the "caution-sayers" as regards this operation, especially as related to the glowing reports which some have made concerning the procedure, especially as related to the work going on at Loma Linda University of Southern California. I was also quoted (very briefly) in the Wall Street Journal article of February 22. Below, I am "pasting" the text of the e-mail that I had sent to David Stipp, the author of the WSJ article, and this, I think, provides an overview of my opinions regarding Parkinson surgery these days: ------------------------------------------------------------------------ --------- TO: David Stipp <[log in to unmask]> RE: Pallidotomy Dear David: I am a neurosurgeon who has been active on the Parkinson's Disease List, and I have become involved in the ongoing debate on pallidotomy. I did pallidotomies back in the sixties while I was a resident at the University of Chicago, this during the era when this kind of surgery (including thalamotomy, which was done more specifically for tremor) was quite popular. In the late sixties, two things happened which markedly decreased the usage of this type of surgery; one was the failure, after much hoopla, of Margaret Bourke-White's operation; and later, the discovery of L-DOPA by Cotzias, which revolutionized the treatment of Parkinson's at that time. Bourke-White, a LIFE magazine photographer (and Pulitzer winner, I think), had a dramatic result for her tremor when operated by Irving Cooper in New York; but several years later, the disease advanced, and she died after becoming an invalid. The problems with the Parkinson's surgery back in the sixties were that those earlier operations seemed to reduce, sometimes dramatically, the tremor, but had less effect on the rigidity that is associated with PD, and almost no effect on the "slowness" that is characteristic of the disease in the later stages. The beneficial effects of the surgery, also diminished with time. By the mid-seventies, almost nobody was doing PD surgery anymore. A few years ago, a Swedish surgeon (Lauri Laitinen, M. D.) resurrected the operation (as done by a now-deceased Swedish colleague, Lars Leksell, M. D.), and added some newer technology to same. Laitinen has published a few articles reporting some improvement in the rigidity and slowness problems (he went back to the globus pallidus as the site for the lesion), and a number of other neurosurgeons, some in the USA, have started to do the operation again (I, personally do not). The results of this new work, as published in the scientific literature (and I have searched such), are still somewhat equivocal, especially as to the *length of time* that the beneficial effects last; and, in my opinion, it is too soon to call the present-day work with pallidotomy more than "experimental". For certain patients, there may be a role for this approach, especially since the drug therapy of PD also seems to lose its beneficial effects with time. The way that I got involved with this debate was when, on the Parkinson List, a man named Don Berns, from Southern California, began making posts there extolling the pallidotomy operation (he has had one). His posts were almost "testimonial" and full of what was almost "religious zeal", this as it pertained to a program going on at Loma Linda University in Southern California, this program being directed by Robert Iacono, M. D., a neurosurgeon there. I did not object to the program in any way; but I was highly disturbed at Mr. Berns' posts (because of their, IMHO, unrealistic optimism) to a group made up of people with a chronic and disabling disease; and this debate, including some personal and direct correspondence between myself and Mr. Berns, has become somewhat heated. I have written directly to Dr. Iacono (as a colleague) to ask whether he is aware of the "testimonializing" of one of his patients, and I have not yet received a response. There are exchanges going on in the Parkinson's List from as far away as Israel (from family members of severely disabled people with PD), and it almost sounds like "snake oil", especially in view of what I think is a premature endorsement based on what actually does appear in the medical literature. Recently, I have taken up this problem with several other neurosurgical colleagues, many of whom share my views (that the research being done by Dr. Iacono at Loma Linda and elsewhere is worthwhile but not "proven" yet); and I refer you to Patrick J. Kelly, M. D., Professor of Neurological Surgery and Chairman of the Department at NYU Medical School in New York City. Dr. Kelly does pallidotomies and believes that the surgery may be useful in selected cases, but he shares my skepticism and concern over the "testimonializing" that has recently been going on. I would suggest that you may wish to contact Dr. Kelly and discuss the situation with him, this to get a reasoned approach to a complex problem. Dr. Kelly's e-mail address is: <[log in to unmask]>, and you can use my name when you write to him. If you wish, you can feel free to correspond further with me (see my "sig" at the end of this message); but I think that you will get more information about the current "state of the art" in Parkinson's surgery from Dr. Kelly. I would very much appreciate receiving a copy of your article when it is completed. Thank you for your interest. Best wishes, Robert A. Fink, M. D. ------------------------------------------------------------------------ ------------- In essence, I think that the "first line" of treatment in PD is medication. L-DOPA (usually Sinemet), along with Selegiline (Eldepryl) appears to be quite effective in PD, and, in the beginning, is often dramatic in its restoration of good function in patients. This occurred with my father-in-law, a retired physician, who was in his eighties when he was found to suffer from PD. As you probably know, however, the effects of the medication "wear off" in time, and the side-effects of increased dosage can be difficult. The "new pallidotomy" as done by Laitinen in Stockholm *may* offer some relief in patients who no longer obtain good relief with medications, and it appears that this new operation (a variant of a very old procedure) *may* help such things as rigidity and "slowness", these symptoms that were not helped much by the older procedures (the surgery used in the sixties seemed to mainly help tremor); but I do not think that *anyone* (except perhaps some of Dr. Iacono's patients) feel that surgery is a "cure", since what the surgery appears to do is to restore a balance between the inhibitory and excitatory pathways which have been "imbalanced" by the disease. Furthermore, patients who have had a pallidotomy *may* be excluded from trials using some newer (and still unproven) techniques using, for example, implantation of fetal cells. From what I have read in the literature, it would seem that candidates for pallidotomy would include elderly patients who have totally "escaped" the beneficial effects of the medication (despite good medical management), very young patients with the same problem; and (perhaps), patients with severe rigidity and/or bradykinesia (slowness) who have not responded to medication in a satisfactory way. Dr. Laitinen can probably be reached at the Karolinska Institute in Stockholm (the main neurological hospital there is the Serafimer Lazarettet); but there is an institution here in Northern California (since you are at UC Davis, we are "neighbors") where some work is being done with Parkinson surgery. Contact Dr. Nicholas Barbaro, neurosurgeon at UC San Francisco, as I think that Dr. Barbaro is doing pallidotomies. I would also strongly recommend consultation with Dr. Patrick Kelly, Professor of Neurosurgery at NYU in New York City; who has, I believe, done more of such surgery than has Dr. Barbaro. Dr. Kelly's address is: Patrick Kelly, M. D. Department of Neurosurgery, New York University Phone: 212-263-8002 E-Mail: <[log in to unmask]> I wish you good luck in your quest for information. Please keep in touch. Best wishes, Bob -- ******************************************************** Robert A. Fink, M. D., F.A.C.S. Phone: 510-849-2555 Neurological Surgery FAX: 510-849-2557 2500 Milvia Street Suite 222 Berkeley, California 94704-2636 USA E-Mail: [log in to unmask] CompuServe: 72303,3442 America Online: BobFink "Ex Tristitia Virtus" ********************************************************