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Subject: Peer comments on iacono pallidotomy study The June 1995 edition of Neurosurgery, contained a study by Robert P. Iacono,M.D. et al. The Results, Indications, and Physiology of Posteroventral Pallidotomy for Patients with Parkinson's Disease. The study was done on 126 Parkinson's patients who underwent posteroventral pallidotomy. The text is available in your nearest medical library. Peer review comments were provided by Patrick J. Kelly,M.D. who said, "Today in contrast to the pre-levodopa era, we are presented with a different type of Parkinson patient: the "levodopa failure." Because levodopa/carbidopa is usually so effective in palliating the symptoms in these patients, they now come in for surgical therapy much later in their deteriorating clinical course than they did in the time before levodopa was available. These patients, who have severe on-off phenomena, bradykinesia, gait disorder, reduced voice volume, and occasional dementia, are not usually good candidates for thalamotomy. However, the risk for worsened gait and speech problems after thalamotomy is unacceptable in this group of severely dibilitated patients. Pallidotomy, in contrast, carries much less risk and appears to have measurable benefit not only in the elimination of dyskinesia, the reduction in the off periods, but also (as this article reports) an astounding improvement in akinesia. This last finding bears further investigation...by committed neurologists who are not in association with the group performing the surgical procedures. As we have learned, surgery in Parkinson's disease patients has a marked placebo value for both patients and surgeons." Roy AE Bakay,M.D. of Atlanta, GA commented, "The efficacy and safety of the posterior ventral pallidotomy remains to be proven. As a referral center, Dr. Iacono and colleagues have undoubtedly overestimated their surgical success and underestimated their surgical complication rate. This is further compounded by the lack of any independent neurological evaluation by a movement disorder specialist and the absence of sufficient long-term follow-up(mean, only 4.5 mo). The tragic story of Dr. I.S. Cooper was not in his work but in his inability to objectively evaluate and present his work....In summary, this study has too many flaws to answer the questions of the safety and efficacy of posterior ventral pallidotomy but does suggest the potential for the procedure."