SECTION TWO
Current Treatments
TOPICS ON THIS PAGE:Medications
Surgery
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| LINKS TO: Section One: Parkinson's Disease | Section Three: Starting Treatment | Section Four: Glossary |
| Current Treatments: The Therapeutic Choices Available | |
Medications
|
Surgery
|
There are many options available now as regards medications, with four or five arriving on the
scene in the last few years. Options include:
History
Before any surgery for PD had been done, James Parkinson, after whom PD has been named, noticed that
a stroke patient had tremor relieved on the side opposite to a stroke. In 1939, a Dr. Russell
Meyers in New York, performed open brain surgery for PD (not the current stereotactic surgery), with benefit in about 6% of patients, but there was a high rate of mortality,
in the region of 10% to 15%.
We are not yet doing these operations in Ireland. The equipment has arrived, except for
one machine, a microelectrode recording system, which is still being held up in Europe, and without
which the stereotactic system cannot be fully used. Mr. Pidgeon and I have a Movement Disorder
Clinic in Beaumont, and we now have a list of patients whom we have assessed as being suitable
for surgery.
Before going any further,
I should mention that, if anyone comes to see me about having surgery
for PD, I usually throw barriers in their way. I have to be certain that
they have fully explored all the medical aspects. It's not something to be rushed at
recklessly.
There have been quite a lot of holes put in brains over the years to try and get the tremor
under control. At the turn of the century, they tried operating right at the top of the
motor cortex and doing incisions up there to see if it would help. Some patients reported
benefit, but many patients had a stroke.
Clumps of nuclei deep in the
brain are responsible for controlling automatic movement. There is a very complicated system
in the brain, of different pathways, of communications back and forth, that control movement. It
is known that, in Parkinson's Disease, the Pallidum gets overactive, and it is thought that
knocking out that system might restore a balance. This is a very simplified explanation as the
whole system is quite complicated.
1. Pallidotomy
In this operation, a hole (or lesion) is burned in the Globus Pallidus, and seems to work.
The Globus Pallidus gets overactive in PD, but it is not known why exactly the
operation works.
For a Pallidotomy:
A pallidotomy:
It is interesting to do a neuropsychological
analysis before and after one of these operations, as there are changes. It
has been noted that some people develop emotional debility and decision-making
problems. The other thing to emphasize is that you should not operate if people
have cognitive problems such as forgetfulness, because by operating you can make a
slight problem worse. People with cognitive problems have been operated on, and
have taken weeks to return to their normal cognitive state. There are exceptions to that, of course. Medications can cause
forgetfulness and confusion, so you have to determine if the confusion is medication-based.
This is a similar operation, but with the lesion placed instead in the Thalamus. This
operation is good for controlling tremor, with an 80% to 90% improvement in the tremor of
PD, or in Benign Essential Tremor. The same risks of complications exist, as with the
other operations, in 1 to 2% of people. Among them are:
We should be doing some of these this year, providing the remaining equipment arrives.
3. Deep Brain Stimulation of the Sub-Thalamic Nucleus
Rather than burning a lesion, in this operation, a stimulator is inserted which is then
connected to a pacemaker. There have been dramatic videos made of the results of this operation.
When you switch the pacemaker on, the tremor and stiffness go away - it does work.
It is a nice procedure, but the risks are the same as in the other operations, and the Sub-Thalamic Nucleus is a tricky
area to get into. So you don't operate on someone with cognitive deficits or on someone who has more
complicated syndromes than Parkinson's Disease.
This operation is more expensive, about £10,000. The Health Board will pay for these
operations in another EU country, upon referral by a neurologist. The battery needs to be replaced every three to five years.
On the positive side, there is no permanent damage to the brain.
I haven't yet sent anyone away for a stimulator. The group that I think are the best at it today
are the surgical group led by Professor Benabid in Grenoble. It's a long procedure. You are sitting on
the table for about twelve hours, which is a long time to wait, and you can feel quite
uncomfortable. Also, the neurologist can spend up to sixty hours trying to ensure that
the stimulator goes in the right place.
That's a real problem for us neurologists in Ireland - there are only eleven of us. As you
all know, it can be a problem getting to see a neurologist here, as there are too few of us.
Ireland actually has the lowest numbers of neurologists per head of the population in the
whole of Europe! We have written to the Department of Health to advise that there should be at least
forty neurologists in the country within the next few years.
So this procedure, from the biological point of view, is a nice one because you are not doing
any damage.
The Sub-Thalamic Stimulation,
while only about a year old,
gives impressive results. Stimulation can also be done in the Globus Pallidus, but
it is not clear whether it will be quite as good.
The following are some other procedures that may come on board in the future:
4. Gamma Knife Surgery
A cobalt radioactive probe is used to burn a hole, with no surgery. Some improvement has
been reported using this technique, but it is not as accurate as in the more established operations.
So, while there is no risk of stroke with Gamma Knife Surgery, your results may not be as good.
5. Other Surgical Techniques
In
one trial done, with a group of forty patients, half had foetal cells implanted, and half had
sham operations. After a year, those patients who had had sham operations were offered the real
thing. The problem of course is the ethics of performing sham operations.
The latter (GDNF) hasn't worked in trials on motor neurone patients, so I am somewhat
skeptical about their potential for PD patients.
Alternative Therapies
This is a more
humane way of providing treatment. We don't have one in Ireland yet, but are hoping to get
one in the Mater. Rather than using electrical shocks, you can use magnetism to stimulate parts of
the brain. In some studies on PD, it has been shown to help some of the stiffness and soreness
in the short term.
Medications
There are more
drugs coming on board, and we would expect another five or six in the next few years. The choice for
patients is increasing, so if one drug doesn't work or doesn't suit, another one may.
Surgery - An Overview
In the 1950s, Dr. Leskell in Sweden, performed Postero-Ventral Pallidotomies, and reported quite good benefit in about 80%
of patients. With the
arrival of Sinemet in the 1960s, surgery was in general stopped, although Dr. Leskell
continued with the operations. By the late 1970s, it had become apparent that, while Sinemet worked well,
its eventual side-effects were hard to control. Dr. Leskell's student, Dr. Laitenen continued with
operations starting in the mid-eighties. There was
a growing realisation that these operations worked, particularly for dyskinesias, and by the
1990s, pallidotomies were performed worldwide.
2. Thalamotomy
Follow-ups have only been done
now for about five years. Will the patient need a top-up in about ten years?
Section One: Parkinson's Disease |
Section Three: Starting Treatment |
Section Four: Glossary
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