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breakfast and on an empty stomach. If you delay tak-
ing Sinemet and take it at breakfast, your morning
symptoms of PD will be worse. Taking levodopa with
food or milk can also reduce its effectiveness. Before
carbidopa was added to levodopa, many patients taking
levodopa alone experienced nausea so that it became a
common practice to advise them to take levodopa with
food. The addition of carbidopa eliminated the nausea
and made it possible to achieve better relief of symp-
toms from a smaller dose of levodopa. A lack of sleep
or depression can also aggravate the symptoms of PD.
If none of these are happening, then you should look
for an infection. Bladder infections or upper respira-
tory infections are the most likely culprits. It is likely
that any of these situations can cause a temporary
worsening of your symptoms without implying that
there has been progression of your PD. Sometimes,
changing the times when you take your drugs, clearing
up a bladder infection, or simply getting enough sleep
can relieve the problems.
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Progression
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PART SIX
Surgery
for PD
Is there surgery for PD?
What is a thalamotomy?
What is pallidotomy?
More . . .
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1 0 0 Q & A A B O U T P A R K I N S O N D I S E A S E
67. Is there surgery for PD?
Surgery for PD and other movement disorders was pio-
neered in the 1940s by Meyers (United States). Large
regions of the brain were exposed and using surface
landmarks (there were no CT scans or MRIs) the basal
ganglia a series of interconnected regions of the brain
including the striatum, globus pallidus, and thalamus
were located and ablated (destroyed). In 1947, Spiegel
and Wycis developed a crown-like stereotaxic frame
that held the head in place and allowed regions inside
the brain to be correlated with reference points on the
frame. In the 1950s Leksell (Sweden) pioneered palli-
dotomy for tremor. Later, in the late 1950s and 1960s
Cooper (United States) and Narabayashi ( Japan) pio-
neered thalamotomy for tremor. The introduction of
levodopa dramatically reduced the need for surgery.
Laitinen (Sweden) and De Long (United States) how-
ever, revived surgery by demonstrating the effectiveness
of pallidotomy for levodopa-induced dyskinesias.
Benebid (France) pioneered DBS of the STN. Lozano
(Canada), Lang (Canada),and Koller (United States)
refined DBS for PD and ET. All of these pioneers dra-
matically increased our understanding of the brain s
anatomy, circuitry, and its effects on movement. Cur-
Ablative rently three types of surgery are performed: (1) ablative
procedures
or destructive surgery; (2) stimulation surgery or deep
procedures that
brain stimulation (DBS); and (3) transplantation or
destroy damaged
restorative surgery.
tissues through
ablation, or
destruction using
Ablative or destructive surgery refers to locating, tar-
heat sources.
geting, then ablating or destroying a specific, clearly
defined brain area or region. The area chosen is usually
an area or region that s been altered or changed by PD,
or a region that generates or produces an aberrant or
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1 0 0 Q & A A B O U T P A R K I N S O N D I S E A S E
abnormal chemical or electrical discharge. An abnor-
mal discharge that in turn produces or generates an
abnormal signal or  static. The static, in turn, inter-
rupts the normal, harmonious operation of the brain.
Destruction of the abnormal discharging brain region
lessens or negates the static. This allows restoration of
more normal or closer to normal function. Destruction
of the abnormal discharging region rarely results in
restoration of completely normal function.
Why doesn t destruction of the abnormal discharging
region restore normal function? The brain is more than
a circuit board. There s more wrong in PD than one
abnormal discharging region. Only part of the abnor-
mal discharging region may have been destroyed and,
at a later date, the surgeon may have to operate again.
To understand why only part of the abnormal dis-
charging region may be destroyed requires understand-
ing of the surgical procedure.
To ablate or destroy the abnormal discharging region,
the surgeon heats the exploring probe or electrode
this coagulates, denatures, destroys the abnormal
region. As the patient s awake during surgery, the sur-
geon can monitor the extent of the ablation by observ-
ing the patient s response. As an example, a patient
with a left-hand tremor has the probe inserted into his
brain s right side. The brain s right side controls the
body s left side and vice-versa. The surgeon then heats,
coagulates, and destroys part of the patient s right-
thalamus, the abnormal discharging region. The [ Pobierz całość w formacie PDF ]