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But this is only a prelude. What struck me
through the Conference was the - way medicine moves forward. The major
thrust of stereotaxics surgery is of course the advances in the
treatment of Parkinson's and we will use this disease to speak about how
medicine moved forward in the last half century.
-
First there is the luck factor - It
started in the 50s. Dr.Cooper, a surgeon, was operating on a
Parkinson's patient with an aneurysm. The aneurysm ruptured and he
was forced to clip the vessel blind and clipped the anterior
choroidal artery. Suprise surprises ! when the patient was awake the
SAH was treated and the Parkinsonian tremor had disappeared. Lady
luck had stepped in
-
Then the introspection - As is has been
said before, many people stumble on the truth, but most just grumble
a bit at the fool who left the stone in the way, and go on their
way. Cooper paused to think over the chance finding why this luck
had occurred. He wondered why that should be, and not getting a good
explanation he decided to try his luck and see what happens in other
patients of Parkinsonism if he did the same - and he was reasonable
successful. The surgical treatments of Parkinson's had begun.
-
The third is technology - Neurology and
innovation entered. Why not make the same lesion produced by
occlusion of the anterior choroidal in a different non invasive way?
This gave birth to Stereotaxy. The formation of the Leskell frame
the wedding of technology and a dedicated medical man so that using
3 planes, sagittal, coronal and axial and a rotating arm, we could
introduce a probe through the skull to hit a predetermined area
round 3 mm's cube in the depth of the brain without incision of
injuring superficial areas. As far as I know, it was the first such
procedure in any discipline in medicine.
-
Then we advanced by accumulating
experience - Stereotaxic ablation of the ventral intermediate
nucleus of the thalamus became one of the treatments of Parkinson's
in the 50s. Many surgeons all over the world started using the
technique. The biggest centre in India was undoubtedly Ramamurthy's
Dept. in Madras, and before that the surgical unit in Vellore.
Mumbai started a little later and by the time I had passed, things
had crystallized. Stereotaxy was good for tremor predominant
Parkinson's. You required a relatively young patients whose main
problem was tremor and who had predominantly unilateral disease. If
that were so, he was markedly improved by the stereotactily placed
lesion in the thalamus. But bilateral surgery was not desirable and
if the problem was bilateral, Stereotaxic surgery was dangerous, it
often worsened the patients and caused dysphonia and aphasia.
-
The 4" step. Medicine make surgery
redundant. Remember surgery for peptic ulcer, the commonest major
surgery as I became a resident and junior consultant. So also
stereotaxy. Two ideas now surfaced. First was the recognition that
the nigrostriatal pathway was important for Parkinson's disease and
that dopamine was the neurotransmitter of this pathway. The second
was cotzias method of getting dopamine into the brain by use of
L.dopa rather than published "Reversal of the pathophysiology
of Parkinson's disease" and Stereotaxic frames were
mostly dumped. There was no need for stereotaxy, or if no need at
all, certainly the need decreased for the rare case, so, as
Dr.Bhagwati told me he was doing one case in 3-4 months and no other
neurosurgeons were interested in learning the methodology.
-
Then advance occurred with the wheel
turning full circle. We realized that after 5-10 years of treatment
with L.dopa, lots of problems arose and we could hardly help the
resistant cases anymore. With that came additional knowledge. We
realized that palidotomy of Globus Pallidus Interna (GPi) not only
helped a tremor but in fact helped bradykinesia, and hypertonia and
freezing too and surgery returned first in Europe and US and now in
the last few years in India. We saw, how, as soon as the electrode
enters the GPi of thalamus, tremor disappears. Dr.Ho showed us a
video of a case he had done and the dramatic change in the tremor
and the hand was most impressive. But I was sitting near Dr.
Ramamurthy and Dr.Bhagwati and they looked at one another and
smiled. Reminds us of 35 years ago they felt. We had seen this and
been impressed with the self same finding 30-40 years ago when we
were young like the dozens watching today.
-
But technology marches on. Medicine
does not move in a circle. It's more like a spiral so through we are
coming backwards to what our forefathers were doing or thinking, we
are doing it better. The lesion is more exact, the Pallidotomy
replaces the thalamic lesion. We can bilateral cases putting the
lesion on the more affected side.
-
Then a new idea surfaces - Deep brain
stimulation. A needle is put in the pallidum GPi and it is attached
to a stimulator. We can stimulate the area at high speed stimulus
and thereby cause a loss of function. What is the advantage of deep
brain stimulation?
Progress in Medicine - The Last Half Century
-
We can increase or decrease the current
so if the effect reduces, we can adjust the stimulating parametres
to get effects again.
-
The affect is not permanent. The needle
can be removed, put in another area by the side to give us
flexibility.
-
We can keep the stimulus off when the
effect is not required (sleep) and on when required.
-
While pallidotomy is still a little
troublesome if done bilaterally, one can do pallidotomy on one side
and deep brain stimulus on the other or deep brain stimulation on
both sides. And then a new idea. One can put the deep brain
stimulation in the substantia nigra and get results even better than
GPi lesions. During the conference, Dr.Ho put electrodes for deep
brain stimulation in bilateral substantia nigra in a patient at RHC
with excellence results. For non- neurologists - which cases of
Parkinson's are suitable for stereotaxy today?
-
The patient must have previously
responded to L dopa well and there should be no dispute about the
diagnosis. Parkinson's plus syndromes which have Parkinson and some
other atypical features are not desirable. Nor added dementia etc.
-
The patient must have had a proper drug
trial and having initially responded now the effects are not
satisfactory and various methods of trying to improve medicals
results have failed.
-
If one of the major problems is drug (L
dopa) induced dyskinesia and that is causing it difficult to trat,
that is an ideal candidate because undoubtedly one advantage of
surgery is that drug induced chorea / dystonia disappears and thus
we can use more L dopa for further control.
-
The patient must realize that drug
treatment will have to continue but control will be smoother.
Subsequent failure of surgical affects is also likely.
-
The patient must not be too old or too
infirm to benefit long term.
-
The last stimulus to advance in
medicine is of course competition. The best centre in the world is
believed to be in France where patients come from all over the world
for surgery and doctors to learn the technique. The placement of the
lesion is done by Robots. From France we have surgeons who have
worked there and come to India and are doing stereotaxy for
Parkinson's in Trivandrum and Mumbai etc. In Pune, the first surgery
was done at PIN, but now there are fledging units at JNH, RHC and
soon in Poona Hospital. My experience in case is not too
impressive. One done in the US failed and has a hemiplegia. Another
done in the US is not too happy, though surgeons say the result is
satisfactory. Two went earlier to Mumbai and Trivandrum and were
turned down. But one last week, I hadn't sent for surgery, came back
after his operation was done! He learned of the surgery, and has
taken the chance himself and relations seem happy (I haven't seen
him yet). Patients of Parkinson's are now regularly asking is not
there something else when medicine is no longer useful? And in truth
there is. This then is the way medicines advanced in the last half
century. An idea (Brain's) a little luck (chance), Experience (i.e
hard work carefully documented) more ideas, Technology, more
Technology and Competition (ego, money!) and that is the way
medicine goes round and round and spirals forward. -
What of the future of Parkinson's
disease? Long ago I had read that there are stages in the advances
in medicals treatment. The halfway stage is one which is difficult
to do, very costly, requires expertise and is not available to all.
The final stage is one which is simple, cheap and available to all
and causes the disease to decline and go. The iron lung for Polio
and the distribution of ventilators in all hospitals was the halfway
stage for Polio. Now with the Polio vaccine we are at the end goal
and target year 200 for eradication is near. Looked at this way CABG,
dialysis, transplant, stereotaxy, deep brain stimulation is halfway
stage. The end goal appears far away but will come with a medical
therapy the nature I do not know. A neuromodulation? a
neurotransmitter? a free radial scavenger? a preventive strategy?
Once again the wheel of medicine will turn full circle and the
museum. And then - then who knows. For was not Chloromycetin the end
stages of enteric fever and DDT the end stage for malaria? And small
pox vaccine the end stage of small pox.
Patients Statistics for the pe1riod JUNE
'99 to AUGUST'99
|
|
June'99
|
July'99
|
August'99
|
Total
|
|
Total No.of OPD Patients
|
7278
|
7677
|
7601
|
22556
|
|
Total No. of Indoor Patients
Admitted
|
1564
|
1594
|
1583
|
4741
|
|
Total No. of Free and Concessional
cases in OPD (All Dept)
|
948
|
1217
|
1108
|
3273
|
|
Free cases treated (General Ward
Patients Only) Indoor
|
19
|
28
|
37
|
84
|
|
Concessional cases treated (General
Ward Patients Only) Indoor
|
31
|
71
|
41
|
143
|
Dr R.S.Wadia (M.D)
Consultant Neurologist. |
