New Treatments for Movement Disorders. Part 4

Now the first point to make, the pallidal surgeries, as I said before – what’s old is new. This pallidotomy stuff was way back when, in 1952. Early. Irving Cooper. You know the story. You know the whole story about this? I’ve got to tell the story. So Cooper has got this guy with an anterior choroidal aneurysm and he is going to go in and do an aneurysm clip. And he’s Irving Cooper, he’s a neurosurgeon. So he goes in there and the patient is parkinsonian. It’s a left anterior choroidal artery aneurysm. So he goes in there with his clip. He clips the aneurysm and the artery. So he says, “Oh, my. Oh darn. This is going to be a rather large subcortical basal ganglionic infarction because I have just clipped off the anterior choroidal artery. Oh, cest la vie” and closes him up. The next morning he goes into the patient’s room and the patient says, “Dr. Cooper. It’s amazing. You are absolutely amazing.” And Cooper, standing at the bedside, says “Thank you very much. We try our best.” And walks out of the room. True story. He leaves the room and he spends the next 25 years trying to figure out what he did. Honest to God, that’s a true story. A completely serendipitous observation that lesions in the pallidum can be associated with improvement in parkinsonism in the contralateral side. Absolutely serendipitous. So what is old is new.

The over-activity of certain subcortical structures, specifically subthalamic nucleus and globus pallidus pars intern, key to the understanding of how these surgeries might work. The primary indication for pallidotomy and pallidal stem, levodopa-induced dyskinesia. There is no controversy about it. People say, “Oh, it clearly improves the major cardinal features of the disease. It clearly treats rigidity, it clearly treats bradykinesia, it clearly treats this and that..” the major thing that we see in study after study after study, consensus conference after consensus conference, for pallidotomy; it works for levodopa-induced dyskinesia. Now Anthony Lang and his group in Toronto have also made the observation that if you are asking the question, who is best for this surgery, ask the question, who is responding to levodopa. Because they think that the people who respond best to pallidotomy are the people who respond to levodopa still. Long term efficacy is still debated. Now Laury Lightman from Sweden, now in someplace else – in semi-retirement – had a huge experience. He gets up, Laury Lightman – a very nice man – he gets up publicly and describes his experience based on his work and the work of his mentors before him. He’s got hundreds of patients and he is absolutely crucified because he does not have long term follow-up in a systematic way. Laury Lightman, incredibly thick skinned, lets it wash off his back. He doesn’t even worry, but the Americans and the Canadians are all over him for lack of follow-up. The reason why Lang’s paper was published just two years ago, because it is systematic follow-up for two years and that’s the longest study we’ve got, interestingly enough. After some 50 years of experience with pallidotomies. Systematic follow-up, two years is the longest study. It’s longer now if you read the abstracts. But the upshot seems to be that the long term efficacy of pallidotomy is still debated but it seems to be effective for at least two years, based on the literature that we have. Levodopa is still required after surgery. There may be an allowance for some decrease in dose initially, and then because there is less likelihood of levodopa-induced dyskinesia in the appropriate contralateral hemibody, yeah, you can probably increase levodopa dosage over time. But they still need some levodopa. It ain’t no cure. The difference though is the subthalamic nucleus, the lesions of subthalamic nucleus with the stimulation of subthalamic nucleus, seems to be associated with a virtual lack of need for levodopa in the post-operative course, and that’s pretty striking.

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