Correspondence

Living with Parkinson's Disease

N Engl J Med 1996; 335:130-131July 11, 1996

Article

To the Editor:

Dr. Salzman gives a moving account (Jan. 11 issue)1 of his 20 years as a patient with progressive Parkinson's disease. His description of the various phases of the illness and his struggle to stay in control present a fine model for other patients to discover ways to accommodate themselves to the disease without surrendering their dignity.

We are concerned that his overly generous praise of pallidotomy may mislead readers who uncritically accept his statement that pallidotomy “relieves most of the manifestations of the disease in most patients.” Pallidotomy effectively reduces levodopa-related dyskinesias and limb rigidity on the side contralateral to the lesion, and to a lesser extent it can lessen tremor and improve walking. Unfortunately, many of the medically intractable symptoms, such as postural instability, falling, muffled speech, dysphagia, and cognitive decline, do not improve. Even when the benefit of surgery is dramatic, the duration of the response is still unknown.

It is gratifying that pallidotomy has become a serious treatment option for well-selected patients with Parkinson's disease. However, it is a mistake to make unqualified generalizations about all patients when the evidence at this time permits only cautious optimism for some.

Howard I. Hurtig, M.D.
Matthew Stern, M.D.
Amy Colcher, M.D.
Graduate Hospital, Philadelphia, PA 19146

1 References

1
Salzman EW. Living with Parkinson's disease. N Engl J Med 1996;334:114-116
Full Text | Web of Science | Medline

To the Editor:

Our medical students and young physicians spend more and more time learning how to diagnose and treat disease, often at the expense of learning how to take care of the patient. Salzman's essay reminds us and our students that behind every disease is a patient whose feelings and struggles it is our responsibility, and indeed our privilege, to explore.

Steven R. Simon, M.D.
University of Hawaii, Honolulu, HI 96813-2427

To the Editor:

Ed Salzman's account of his intense personal experience was very valuable for anyone, but especially for those of us who see patients with Parkinson's disease on a daily basis and still often fail to appreciate the impact that the disease has on even the most minuscule activities of living. I have circulated the article to our residents. Thanks for a very nice contribution.

J. Richard Baringer, M.D.
University of Utah, Salt Lake City, UT 84132

To the Editor:

We welcome Salzman's insightful comments on his experience after pallidotomy, but in ending his editorial with the words “Independent at last! A personal victory,” he may be offering false hope to patients with degrees of Parkinson's disease different from his before surgery.

Pallidotomy has become a very controversial treatment for Parkinson's disease.1,2 Some physicians have grown skeptical of the results because of sensationalized coverage by the media and the recurrence of symptoms in a few patients weeks after surgery. The reason for the transient benefits is not clear, but it is probably at least one of the following: the lesion was in the wrong place; the lesion was not large enough; or the patient did not have idiopathic Parkinson's disease.

We recently studied the time course of radiofrequency lesions in the brain with serial magnetic resonance imaging immediately after surgery.3 The edema related to these lesions appeared within 20 minutes of the placement of the electrode.4 Therefore, patients could experience the benefits of the decreased ventroposterior pallidal activity due to the formation of edema, although the lesion was not quite in the desired site. Moreover, long-term follow-up with magnetic resonance imaging shows that in some patients the lesion is completely healed and almost imperceptible (Hariz M: personal communication). We also evaluated a number of patients with poor outcomes who underwent pallidotomy at other centers. The majority of these patients did not have idiopathic Parkinson's disease but had progressive supranuclear palsy, multiple-system atrophy, or vascular parkinsonism. These disorders do not generally respond favorably to stereotactic pallidotomy.

To avoid this pitfall, we adopted a plan involving several steps. First, each patient is evaluated by a neurosurgeon and a neurologist specializing in movement disorders. Second, the patient is monitored closely by a neurologist during the procedure. Third, 2-Hz stimulation is used to detect the internal capsula or optic tract. Stimulation with 50 Hz can increase outflow from the globus pallidus internum to the thalamus, and therefore an increase in tone suggests proper placement of the electrode. A gradual increase in the stimulation current provides a physiologic measure of the distance of the probe from structures to be avoided. Fourth, the lesions are created in two steps. The temperature is first increased to 45°C during the time needed for a complete neurologic examination. Then, if a positive response is observed and no undesirable effects are detected, the temperature is increased to 80°C and held constant for one minute.5 The importance of electrophysiologic studies and neurologic examination during surgery cannot be overemphasized. This serves to advise patients to avoid radiosurgical (“gamma knife”) pallidotomy, because electrophysiologic and neurologic monitoring are impossible with this technique.

Antonio A.F. De Salles, M.D., Ph.D.
Jeff Bronstein, M.D.
Donna Masterman, M.D.
University of California, Los Angeles, Los Angeles, CA 90024-6975

5 References

1
Iacono RP, Shima F, Lonser RR, Kuniyoshi S, Maeda G, Yamada S. The results, indications, and physiology of posteroventral pallidotomy for patients with Parkinson's disease. Neurosurgery 1995;36:1118-1125
CrossRef | Web of Science | Medline

2
Sutton JP, Couldwell W, Lew MF, et al. Ventroposterior medial pallidotomy in patients with advanced Parkinson's disease. Neurosurgery 1995;36:1112-1117
CrossRef | Web of Science | Medline

3
De Salles AA, Brekhus SD, De Souza EC, et al. Early postoperative appearance of radiofrequency lesions on magnetic resonance imaging. Neurosurgery 1995;36:932-937
CrossRef | Web of Science | Medline

4
Anzai Y, Lufkin R, De Salles A, Hamilton DR, Farahani K, Black KL. Preliminary experience with MR-guided ablation of brain tumors. AJNR Am J Neuroradiol 1995;16:39-48
Web of Science | Medline

5
Laitinen LV. Pallidotomy for Parkinson's disease. Neurosurg Clin N Am 1995;6:105-112
Web of Science | Medline

To the Editor:

Better tell Oliver Sacks there's a new kid on the block. I think Ed Salzman's article about living with Parkinson's disease was the best description I have ever read of this problem. I plan to show it to a few of my patients.

Not only the writing, but also the courage and grace under stress, show through very clearly.

David L. Sagman, M.D.
Columbia University, New York, NY 10034-1159

To the Editor:

I very much enjoyed Ed Salzman's editorial. I was particularly delighted with the last paragraph, his report of a successful pallidotomy. What a story! The only question I have for him is this: “Did you catch any fish?”

Harold F. Dvorak, M.D.
Harvard Medical School, Boston, MA 02215

Author/Editor Response

Dr. Salzman replies:

To the Editor: I welcome the advice of Hurtig et al. and De Salles et al. that caution should be used in deciding to perform a pallidotomy. Clearly, this is not an operation suited to every patient. The need for accurate diagnosis is well recognized; as the writers warn, a patient who does not have Parkinson's disease does not appear to be a good candidate. Their statement that pallidotomy is primarily effective in treating dyskinesia and rigidity is misleading, however, since considerable evidence, both old and new, indicates that pallidotomy can substantially reduce tremor and bradykinesia and improve gait and balance as well as posture. It is now well known that much of the morbidity associated with the disease results from its treatment. Pallidotomy relieves these symptoms.

My report was not, of course, an analysis of pallidotomy, but rather a description of the effect of a chronic, debilitating disease on the life of a physician.

I am grateful to Drs. Simon, Baringer, Sagman, and Dvorak for their kind remarks, and especially to Dr. Dvorak for his fish question. Unfortunately, I did not catch any fish. After all, no medicine is perfect.

Edwin W. Salzman, M.D.
Beth Israel Hospital, Boston, MA 02215

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