Hi All,
Following the program on Pallidotomy on BBC1 (in the UK), here are two
items provided by the Parkinson's Disease Society of the UK. Copies of
these were sent to local branches and press contacts last week. These were
provided by Simon Hope, their PR person (thanks for the disk, Simon!).
- Pallidotomy for Parkinson's Disease - an update
- Pallidotomy - a need for more research
As well as being of direct relevance to those of us in the UK, I thought
the rest of you might be interested in how pallidotomy is viewed on this
side of the Atlantic. I certainly find your perspective very interesting.
You can contact the PDS in the UK at:
The Parkinson's Disease Society
22 Upper Woburn Place
London
WC1H 0RA
UK
The two articles follow.
Simon
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PALLIDOTOMY FOR PARKINSON'S DISEASE
AN UPDATE
There are three main symptoms of Parkinson's Disease (PD), tremor, muscle
rigidity, and slowness of movement (akinesia). In the 1960s a new drug
therapy, levodopa, was introduced, which helped to alleviate all three of
the main symptoms of PD. Prior to the introduction of levodopa surgical
operations, including pallidotomy, had been performed. These operations
were abandoned as it was thought that drug treatment with levodopa would be
more effective.
However, it soon became evident that levodopa, though a dramatically
effective treatment, was not a perfect one. After several years of
treatment many people with PD develop hour-to-hour, and sometimes
minute-to-minute, fluctuations in their physical state. This ranges
between on the one hand a return to the symptoms of Parkinson's and on the
other sudden, involuntary movements of the body and limbs (dyskinesia).
In an attempt to combat this a Swedish surgeon, Lauri Laitinen, has revived
an operation pioneered in Sweden in the 1950s. This operation,
pallidotomy, involves making small discrete lesions in the area of the
brain concerned with movement, destroying a part of the brain structure
called the globus pallidus (pallidum, for short).
If the lesion was placed in the appropriate part of the pallidum (internal
pallidum) it was found that pallidotomy could not only relieve the three
main symptoms of Parkinson's, but it could also reduce the sudden,
involuntary movements that result from drug therapy.
Over the last couple of years a number of other centres, particularly in
North America, have also been doing pallidotomy operations, and reporting
favourable results at scientific meetings. A number of centres in the UK
have also been preparing to carefully study the effects of pallidotomy in
the context of a clinical trial.
During the course of 1994 a dozen carefully selected people with PD went
through complex pre-operative assessments at the National Hospital for
Neurology and Neurosurgery in London. So far, nine of them have had a
pallidotomy. Although immediate benefits have been seen in most people, it
is important to assess whether improvement is maintained in the long term.
Initial results of these studies will not emerge until early 1996, and
follow-up data will continue to be gathered for several years. Other UK
centres known to be doing, or planning, pallidotomy operations are Bristol,
Liverpool, Oxford, West Midlands, and the Maudesley/King's College Hospital
in London.
If the results of these experimental surgical programmes are good the
procedure can then be offered more widely as a treatment for people with
PD. Potential subjects are currently being seen to assess their
suitability for surgery in 1996. At present, the operation is only being
offered to people with Parkinson's who are severely disabled, have
uncontrollable, involuntary movements, and if they can no longer be managed
on conventional drug treatment.
Details of the operation
------------------------
The operation is performed under local anaesthetic, in the 'off' state,
after overnight withdrawal of medication. The 'off' state is part of the
on/off phenomenon, which affects people who have had Parkinson's for a long
time. It causes them to change from being 'on', where they are able to
move, to being 'off', where they can hardly move, within a very short
period of time.
A stereotactic frame is fixed to the head in the operating theatre. The
person with PD then has a brain scan. Once back in theatre, a small hole
is made in the skull. Electrode wires are then inserted and electrical
recordings made to identify the appropriate target site. This electrode is
then removed, and a second, lesioning electrode is inserted with its tip at
the optimum point indicated by the recordings. A small, destructive lesion
is then made by passing a higher electric current through the tip of this
second electrode. The whole procedure can take up to eight hours, during
part of which sedation with a short-acting anaesthetic drug may be
necessary.
Risks
-----
There are some risks involved with a pallidotomy operation. These include:
- the risk of a short anaesthetic;
- a low (about 2-3%) risk of the needles or electrodes accidentally causing
unwanted damage or bleeding, which could result in a stroke;
- as the area to be lesioned is next to part of the visual pathway, there is
an estimated 5-10% risk of causing an additional 'blind spot' in a small
part of the visual field on the side opposite the lesion;
- a low (2-5%) risk of developing fits (which can only be controlled by
medication);
- a 10% risk of confusion of sleepiness for several days after the operation;
- a 15% risk of an increase in speech or swallowing abnormality.
The Parkinson's Disease Society welcomes any developments which improve the
quality of life of people with PD, and looks forward to the publication of
clinical data on pallidotomy and its possible role in the future treatment
of Parkinson's Disease.
Parkinson's Disease Society
August 1995
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PRESS STATEMENT
PALLIDOTOMY - A NEED FOR MORE RESEARCH
The Parkinson's Disease Society (PDS) welcomes the broadcasting of last
night's QED programme 'A Hole in Fred's Head' (BBC1 10.00pm), on
pallidotomy, an experimental operation that can ease the symptoms of
Parkinson's disease (PD) and some of the side effects of administered drug
therapy. The symptoms of PD, a progressive, degenerative, neurological
condition, include stiffness, slowness, and tremor. Side effects of drug
therapy include sudden, involuntary movements. The pallidotomy operation
involves making small, discrete lesions in the area of the brain concerned
with movement.
The PDS welcomes any developments in treatment that can improve the quality
of life of people with PD, including the benefits of pallidotomy, but
stresses that more research is needed into its immediate and long term
effects and any disadvantages associated with the treatment. There is a
lack of published clinical data on the results of the operation, and the
Society looks forward to the findings of clinical trials currently taking
place. Once these trials have been completed a judgement can then be made
on the suitability of this operation as a treatment for some people with
PD.
Pallidotomy is not a widely available form of treatment. Of the few centres
who are carrying out the operation, most are doing so in the form of an
experimental project. At present, owing to its experimental nature people
with Parkinson's are only considered for this treatment if they are
severely disabled, have uncontrollable, involuntary movements, and if they
can no longer be managed on conventional drug treatment.
It is vital that research into the treatments for Parkinson's continues.
There are 120,000 people in the UK who live with this currently incurable
condition, and more than 10,000 people are diagnosed each year. The PDS
helps to fund research, and provide support for people with Parkinson's and
their carers, but much more work is needed.
Parkinson's Disease Society
22 August 1995
-ends-
For further information contact
Simon Hope
PDS Press Office
Tel: 0171-383 3513
Fax: 0171-383 5754
Simon J. Coles | "Far better it is to dare mighty things,
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