Parkinson's patients discover new hope

Parkinson's patients  discover new hope

Phil Lammers is sitting in his kitchen with an array of prescription bottles spread out in front of him.

He puts six pills in his mouth and, with a shaky hand, brings a glass of water to his lips. Six down and 19 to go.

Lammers takes 25 pills a day to control his worsening Parkinson's disease. He has to use a partially filled glass of water, just like everything else he drinks, because his tremors cause spills.

Since he was diagnosed with the disease 22 years ago, his life has been a glass half empty.

When doctors told him he would have to add more medication to his daily regimen, he had had enough.

"That's when I looked into this procedure," he said.

Lammers decided to join a growing number of people with advancing Parkinson's who have put their fate in the hands of neurosurgeons and an operation known as deep brain stimulation. For Lammers, who celebrated his 65th birthday Christmas Eve, the result has been a remarkable gift.

The surgery involves drilling two nickel-size holes in the top of the head, pushing a thin, metal guide tube deep into the brain and implanting long electrodes no thicker than angel hair pasta. The electrodes are attached to a pacemaker device implanted under the collarbone so that a steady stream of low-voltage shocks can be delivered to a specific spot in the brain.

Doctors don't know exactly how the therapy works, although it is believed to disrupt electrical impulses in the brain that cause movement disorders such as the tremors and rigidity that are hallmarks of Parkinson's.

First approved for Parkinson's in 2002, deep brain stimulation and other neuromodulation procedures are being studied more and more as potential treatments for a variety of neurological and psychiatric disorders, including epilepsy, obsessive compulsive disorder, pain, addiction and depression.

A total of 18 ongoing clinical trials involve deep brain stimulation, according to the National Institutes of Health.

The versatile therapy actually allows doctors to change the way different brain regions talk to each other, said Michael Okun, an assistant professor of neurology and neurosurgery at the University of Florida.

"There is a small revolution going," said Okun, who also is co-director of the university's movement disorders center. "The boundaries are endless."

However, although deep brain stimulation is a "wonderful treatment" in properly selected patients, "it's not a cure," he said.

At 7:08 a.m. on December 5, Lammers was put in a wheelchair and brought into the pre-operation area of Milwaukee's Froedtert Memorial Lutheran Hospital for a quick, painless and low-tech first procedure in a day that he hoped would change his life.

He got his head shaved.

The buzz cut provided a bit of light diversion, but the mood got serious when neurosurgeon Brian Kopell assembled a metal frame that soon would be screwed into Lammers' skull. The stereotactic frame would be a crucial component to the surgery, allowing doctors to precisely place the electrodes in a deep region of the brain known as the subthalamic nucleus.

If the frame moves even the smallest bit during the surgery, "you're done," Kopell said. "It's like being in the middle of the ocean and losing your compass and sextant."

With a large syringe filled with a local anesthetic, Kopell injected four spots on Lammers' head, two in the forehead and two in the back of the head. Using a screwdriver and an Allen wrench, Kopell turned the screws deeper, firmly affixing the frame to Lammers' cranium. When Lammers is in stressful situations, his tremors often get worse. His right hand and arm shook vigorously as the frame was attached.

"This is where it gets tight," Kopell said, making one last turn. "All right, you're headed off to a CAT scan. I'll see you in the operating room."

The metal box now spread across his eyes, nose and ears evoked an image of Frankenstein's monster meets Hannibal Lecter.

With his right hand shaking, Lammers was placed on the movable table of a CT scanner and rolled inside a large ring for one more picture of his brain, this time with the metal frame around his head.

The frame, as well as a guide device and other attachments that get bolted to it, allows doctors to precisely insert the metal probe that will be driven down into the brain.

The positioning is done by merging a magnetic resonance imaging picture of Lammers' brain that was taken a week earlier with the CT scan of his brain and the head frame taken the morning of the surgery.

Ultimately, doctors need to place the tip of the electrode at an exact spot about five inches beneath the top of the skull.

And then they need to do it a second time for the corresponding spot on the other side of the brain.

The target brain region for both electrodes - the subthalamic nucleus - is an oblong mass of cells about the size of a small black olive that sits near the bottom of the brain. It is involved in regulating movement.

Exacting science

"Hitting the right part of the subthalamic nucleus is like being in Earth's orbit and trying to hit home plate at Yankee Stadium with a baseball," said Kopell, "If you put it in the wrong area, you're going to get more side effects or you're not going to get the (beneficial) effects you are looking for."

Although Lammers has had Parkinson's for more than two decades, much of his decline has taken place over the last five years, including worsening tremors, rigidity, slowness of movement and dyskinesia, a type of involuntary movement such as jerking or twisting caused by levodopa, the main drug used to treat Parkinson's.

He had to retire from his job as a precision woodworker in 1999 because his work pace had slowed so much. When he walks, at times, it looks as if he is marching in place.

"It's especially bad in crowds," said his wife, Joan. "He can't walk without me pulling him."

She said they try to do things during his "good" hours of the day, usually in the later morning and early afternoon.

"Nights are almost always a no-no," she said. "When he gets tired, he's had it. He just can't function."

In the right patients, deep brain stimulation can reduce symptoms by about 50 percent as well as allow them to significantly reduce their medications.

Two years ago, researchers writing in the New England Journal of Medicine found that many of the benefits of deep brain stimulation persisted for at least five years. The researchers concluded that the therapy works best for relatively young patients who can carry out the activities of daily living independently and who have motor complications caused by their levodopa treatment.

Three of the patients died after their surgeries, including one who suffered a brain hemorrhage during the surgery and was bedridden for three years and another who was severely depressed and committed suicide six months after the surgery.

An editorial that accompanied the study called the treatment a major advance in the treatment of Parkinson's.

But nearly everyone who undergoes the treatment gets some improvement, said Bradley Hiner, one of Lammers' doctors and an assistant professor of neurology at the Medical College of Wisconsin.

"This is not a cure for the disease," Hiner said. "If Parkinson's is a long, downhill slide, we're pushing you back up the ramp five or 10 years." But those years could be especially important because they may keep patients functional until new breakthroughs such as stem cell transplants or gene therapy are developed, he said.

Updated : 2021-04-17 11:34 GMT+08:00