Here is the text of the Houston Chronicle front page story reported by=20
Jerry Finch (taken from the Chronicle web site).
8:57 PM 1/21/1996
Related story: Experts look for treatment method [ see below ]
New procedure slows effects of Parkinson's
Surgery can restore balance to system
This is one in a series of stories on the state of the art and
controversies in the treatment of common health problems.
By RUTH SoRELLE
Copyright 1996 Houston Chronicle Medical Writer
The nerve cells in Gerald Furr's brain hyperfired with the sound of a swarm
of angry hornets.
But Dr. Robert Grossman and Dr. Joachim Krauss were not intimidated by the
noise as they attempted a surgical procedure designed to slow the crippling
effects of Parkinson's disease in the 62-year-old former coach from Baton
Rouge, La.
The procedure called a pallidotomy is neither new nor a panacea for what
ails Parkinson's patients. It is also not a cure.
But for patients who have had the movement disorder for a number of years
and for whom the strong medications now create crippling problems,
pallidotomy is a near-miracle.
Betty Matthews of Sugar Land had had Parkinson's for 25 years when she
underwent the procedure in November. She walked with a shuffle, and
sometimes she would freeze, as though her body had forgotten how to take
the next step. Once, she fell and broke her nose and chin. Her speech was
affected.
It was a difficult time for her.
The frustration of patients like Matthews and Furr led Grossman, the chief
of neurosurgery at Baylor College of Medicine, to attempt pallidotomy --
the destruction of a brain part called the globus pallidum. It was an
attempt to attack the basic problem in Parkinson's.
=B7 =B7 =B7 Parkinson's disease develops when the brain cells that make a
substance called dopamine begin to deteriorate. Dopamine is a chemical that
acts as a messenger that helps the brain control muscle activity. When the
neurons that make the chemical die, the body has less dopamine. With less
dopamine, patients begin to be plagued with the typical signs of
Parkinson's: stiffness, slowness of movement, difficulty in balancing and
walking.
While there is treatment for Parkinson's, there is no cure.
The introduction of L-dopa in the 1960s seemed a miracle because it was
metabolized into the brain's missing dopamine. But like many medical
miracles, it came with a price.
Patients became less sensitive to the drug. They had to take more of it
more frequently. But worse, it caused patients to develop disabling
movements called dyskinesias. They writhed and jerked.
"The price was overstimulation of the cells that respond to dopamine,"said
Grossman.
When neurosurgeons perform a pallidotomy, they destroy part of the globus
pallidum. The globus pallidum is a part of the basal ganglia, a portion of
the brain's gray matter that controls posture and coordination.
The globus pallidum contains the overstimulated cells that cause
involuntary movements when they hyperfire.
The difficulty lies in identifying the faulty cells. The inability to do so
has retarded the progress of pallidotomy development for nearly 50 years
years.
The first surgeries to address the problems of Parkinson's occurred in the
1930s, said Grossman. But they were not effective for a variety of reasons,
mainly because the tools did not exist for locating the cells that needed
destruction.
As refinements in locating areas of the brain were developed, doctors again
tried pallidotomy. Stereotactic surgery was a major step. Doctors developed
a frame that was fitted on the skull that allowed them to identify cells in
the brain with three-coordinates. It has become a standard in much of brain
surgery today. But it alone still was not sensitive enough to find the tiny
area of the brain that was causing the problem. CT scans and magnetic
resonance imaging honed the identification purposes even more, particularly
pairing the MRI with computers that can zero in to within two millimeters
of area that must be destroyed.
But monitoring the progress with probes that actually can reproduce and
amplify the sounds of brain cells firing makes that determination even more
precise.
When a surgeon destroys the overactive cells in the globus pallidum, he
restores balance to the system, said Grossman.
Patients no longer move with maddening slowness nor do they suddenly
freeze. But the results are variable, he said. And the operation is not
without risk -- the greatest being that the probe might stray into the
optic track that controls vision.
But there is also the possibility of a stroke. It is not a technique to be
undertaken lightly or by those lacking the full complement of tools needed.
In a study published in the April 1995 issue of the professional journal
Neurology, physicians at New York University School of Medicine and
Northshore University Hospital affiliated with Cornell Medical College
compared the effects of pallidotomy with the most aggressive medical
treatment in patients with advanced Parkinson's disease.
Overall, the patients who underwent the pallidotomy had fewer involuntary
movements than those who received medicine alone.
=B7 =B7 =B7 Gerald Furr underwent the procedure Nov. 11 with great hopes. I=
t was
a long day that started at 7:55 a.m., when doctors began to fit him with
the stereotactic frame.
Later in the operating room, he remained awake while a tiny hole was
drilled in his brain.
The high-pitched whine of the drill combined with the grinding sound of
bone was not pleasant, but Furr dosed through most of the procedure.
First, a tiny sleeve was inserted into the hole and then into the brain. A
probe was slipped inside the sleeve known as a cannula.
The soft whir of white noise issued from a receiver and speakers near the
operating table. It was the sound of Furr's brain. As the probe gets
closers to the problem area, the sound increased.
Grossman and his colleagues listened closely. This is the art of medicine.
They need to hear sharp, intense bursts of sound that indicate they are
nearing the problem cells.
Grossman moved to Furr's side and began pumping his arm up and down, trying
to force the nerve cells into firing. "Squeeze my hand," he said to Furr.
"Relax. Close your eyes. Can you see spots of light?"
When Furr said he could not, Grossman relaxed. The probe had not invaded
the optical area.
Finally, they hit the right spot, and the sound of angry hornets filled the
operating room. They were nearing the right spot, and Furr's hand began to
tremble.
Slowly, Grossman signaled for the firing of the probe. He warned Furr that
it would be scary. Slowly, the tremor in Furr's hand stopped.
"OK, my friend," said Grossman. "We're all finished. You were great. You're
a hero."
It would take time for the effect of the surgery to become apparent.
=B7 =B7 =B7 Two months later, Furr is happy he had the procedure. He suffer=
ed a
little stroke after his surgery, and he has been a while recovering. But he
has resumed golfing. While he did not achieve all the improvement he had
hoped, he is pleased.
"It's working great on my right side, but the left is not so good. I'm glad
I did it," Furr said.
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4:42 PM 1/21/1996
Treatment only temporary for debilitating disease
Experts look for ways to deal with symptoms
By RUTH SoRELLE
Copyright 1996 Houston Chronicle Medical Writer
Even Dr. Joseph Jankovic, the Baylor College of Medicine expert on
Parkinson's disease, was shocked when a recent study showed roughly one in
three people over the age of 65 have some symptoms of the disease.
"What it means is that if you live long enough, you will develop
Parkinson's," Jankovic said.
Many famous Americans have continued their careers for years after being
diagnosed with the disease. But it is chronic, meaning it does not go away,
and its course is invariably debilitating.
U.S. Attorney General Janet Reno is the most recent public figure to
announce she suffers from the disease. Her doctors have told her she should
be able to continue her activities and continue to serve in her post.
Harris County Attorney Mike Driscoll continued to serve at least six years
after his diagnosis with Parkinson's disease and only recently announced
that he will not seek re-election when his term ends in 1997. The Rev.
Billy Graham carried on his ministry, even though he was in the early
stages of Parkinson's. Former heavyweight champion Muhammad Ali also has
Parkinson's disease.
Parkinson's disease is caused when the substantia nigra, the part of the
brain that controls the motor functions, loses the cells that make
dopamine, a chemical critical to the direction of muscle activity. The
disease was first described by a British physician, Dr. James Parkinson, in
1817, but he had no clue to its cause.
The disease is characterized by tremor, rigidity or stiffness, slow
movement, and impaired balance and coordination.
Early in the disease, the symptoms are often minor and can be overlooked or
explained in other ways. However, as the disease becomes more obvious,
patients have trouble completing daily tasks.
It is a particularly cruel condition, said Dr. Mick Perez-Cruet. A
perfectly good mind is trapped in a deteriorating body.
It affects more than one-half million Americans at any one time. It strikes
men and women in equal numbers, and it does not vary with social or
economic status.
Jankovic said it can be confused with other conditions. The confusion can
be cleared up after an autopsy is performed.
Doctors find then that no more than three-quarters of people who were
thought to have had Parkinson's actually had the disease. The others have
one of several conditions that can mimic the symptoms. But all the patients
are considered to have Parkinsonism because they have symptoms.
"The first question I ask is does the patient have Parkinson's disease or
one of the other conditions?"Jankovic said.
There are clues that something else may be at fault, he said. Patients with
Parkinson's rarely lack tremors and they rarely suffer from dementia, he
said.
If the patient does not have a tremor or has serious dementia, more
intensive tests, such as a magnetic resonance image or blood tests, are
required.
If the patient has Parkinson's disease, treatment requires serious
consideration, Jankovic said. He saves the most serious drugs for last.
"I ask if the patient is functionally disabled," he said. A patient may
suffer from tremor, but that is not disabling.
He then considers treating the patient with a drug called deprenyl, which
seems to delay the need for L-Dopa, the most potent anti-Parkinson's drug
in use.
"Deprenyl seems to slow the progression of the disease, but it does not
really improve symptoms," he said.
A recent study in Britain seemed to indicate that patients who took
deprenyl died at a higher rate than those who did not use the drug.
But Jankovic wants to see a new study done with lower drug doses to
determine if the results can be repeated.
If symptoms are disabling, he opts for stronger drugs that stimulate the
receptors, areas on cells that take in the dopamine.
The two, either pergolide or bromocriptine, can control the disease for a
time. But eventually, patients need L-Dopa (also called levodopa), Jankovic
said.
"They usually sustain a vast improvement," he said.
It would make sense to give the patient straight dopamine, but the chemical
does not cross from the patient's blood into the brain. That defense called
the blood-brain barrier is a frequent problem when developing treatments
for diseases that affect the central nervous system.
However, L-Dopa does cross the barrier and is converted into dopamine in
the brain.
But the clocks starts ticking once a patient is given L-Dopa, said
Jankovic.
The first four to five years are fine, but then the patient begins to
develop dyskinesias -- the involuntary movements that plague them.
"The duration of benefit decreases, and there is a shorter time between
doses," he said.
Soon patients find their symptoms returning less than an hour before their
previous L-Dopa dose.
"These patients are good candidates for a pallidotomy," said Jankovic.
Pallidotomy is a procedure that eliminates the side effects of Parkinson's
drugs. Nationwide, hundreds of patients are undergoing the procedure in a
variety of settings.
Some patients are also good candidates for another procedure called
thalamotomy, which can control tremors. The procedure involves killing
cells in the area of the brain called the thalamus.
Development of precise methods of locating the cells to be killed was
important in this procedure as it has been in pallidotomy.
Another procedure, called deep brain stimulation, is effective in treating
patients with wide-ranging tremors. An electrode is permanently implanted
in the thalamus, said Jankovic. The patient controls the electrode's action
with a small magnet implanted under the skin.
The electrode effectively stops the tremor, Jankovic said. The patient can
activate the electrode with the magnet, he said.
In the future, there may be more permanent methods of dealing with
Parkinson's, Jankovic said.
Fetal tissue transplants, which received a lot of attention several years
ago, have not proven as effective as researchers hoped, he said. "They are
still very experimental."
But research is ongoing in developing tissue banks to grow the material
needed to implant into brains and new ways to implant the material, he
said.
Other researchers are looking at ways to implant cells from animal brains,
such as those of pigs.
The brain is immunologically inert, said Jankovic. That means it will not
reject foreign tissue. However, he said, there are concerns that such
tissue could contain unknown organisms, such as viruses, that will cause
serious, unsuspected diseases.
Those problems will have to be resolved before animal grafts can be used in
people, Jankovic said.
U.S. Attorney General Janet Renois the most recent public figure to
announce she suffers from Parkinson's disease.The disease is characterized
by tremor, rigidity or stiffness, slow movement, and impaired balance and
coordination. Early in the disease, the symptoms are often minor and can be
overlooked or explained in other ways.""
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Parkinson's Glossary
* Basal ganglia: Large nerve cell clusters deep in the brain that are
important in translating the commands to muscles.
* Blood-brain barrier: The protective membrane separating circulating
blood from the brain.
* Bradykinesia: Slow movement.
* Bromocriptine: An anti-Parkinson drug.
* Deep Brain Stimulation: The permanent implantation of an electrode
deep in the thalamus to alleviate strong tremors.
* Deprenyl: An anti-Parkinson drug.
* Dopamine: A chemical substance in the brain called a neurotransmitter.
It regulates movement and balance. Parkinson's occurs when the brain
loses the cells that make this chemical.
* Dyskinesia: Involuntary movements typical of patients with Parkinson's
who have been on powerful drugs for a long time.
* Ganglion: A cluster of nerve cells.
* Levodopa or L-Dopa: The single most effective anti-Parkinson's drug.
It changes into dopamine when it crosses the blood-brain barrier.
* Neuron: Cells that conduct and generate electrical impulses to carry
information from one part of the brain to another.
* Neurotransmitter: Chemical substances that carry impulses from one
nerve cell to another. Dopamine is a neurotransmitter.
* Pallidus globus: The area of the brain where cells become
overstimulated after long-term L-Dopa treatment. Some of these cells
are destroyed during a treatment called pallidotomy.
* Pallidotomy: A surgical treatment for Parkinson's that uses electric
probes to destroy cells in an area of the brain that has become
overstimulated by long-term treatment with L-Dopa.
* Parkinson's disease: A disease in which brain cells that make a
chemical critical to controlling the body's movement die. Gradually,
people with the disease develop tremors, rigidity and slowness of
movement. There is treatment but no cure. It is a long-term, chronic
ailment that becomes progressively worse.
* Pergolide: An anti-Parkinson drug.
* Thalamotomy: A surgical treatment for Parkinson's that destroys cells
in the thalamus in an effort to alleviate severe tremors.
* Rigidity: Increased resistance to the passive movement of a limb.
* Tremor: Rhythmic shaking of a limb or other part of the body.
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