Moment of Truth
Selman, of Birmingham, Ala., a divorced mother of two grown daughters, owes her renewed zest to a surgical technique that may give some Parkinson's patients new hope of relief from symptoms that include stiffness, tremors and immobility. Last May she underwent successful brain surgery at Emory University Hospital in Atlanta. The operation, known as a pallidotomy, stopped her tremors and allowed her to move more smoothly. The procedure, which has been in and out of medical favor for 50 years owing to mixed results and potentially dangerous side effects, is now being done at several hospitals around the country. The three-man team that performs it at Emory has refined it, they say, getting better results than ever before. So far, the numbers seem to bear them out. Of the 77 Parkinson's patients who have had pallidotomies at Emory in the past three years, 72 have seen their symptoms significantly abate and only three have had serious side effects such as partial paralysis or brain hemorrhage.
Selman, who survived lung cancer surgery in 1980 and has been cancer-free since then, was first diagnosed with Parkinson's in 1985, after she noticed that her hands were shaking and that she was having trouble walking. "I don't get colds and coughs and sore throats," she jokes. "I just get cancer and Parkinson's!" Like most Parkinson's patients, she was put on a drug—in her case Sinemet—meant to stimulate the brain's production of dopamine, a neurochemical that controls motor skills. She had four symptom-free years, but after that, she says, "it was downhill steadily." At first she became very rigid, sometimes freezing in place for several minutes after taking four or five steps. Then she began falling. She slurred or spoke in a staccato rhythm when under stress, but unlike some Parkinson's patients she had no memory problems. "My children thought I was pretty normal," laughs Selman, whose daughters Laurie Greenway, 29, and Kelly Green-way, 33—they are married to brothers—helped care for her as her condition deteriorated.
Parkinson's, a degenerative disease that afflicts as many as 1.5 million Americans, 80 percent of them over 60, interferes with the production of dopamine deep in the brain, causing certain motor-skill neurons in another area of the brain to fire erratically. It is not fatal but can cause potentially fatal complications such as falls or blood clots. In a pallidotomy, the malfunctioning neurons are, in effect, destroyed by a heated probe inserted through a hole drilled in the patient's skull.
First employed in the 1940s, pallidotomies soon fell into disuse because of mixed results and the later development of L-Dopa and other drugs. "Most people thought, 'We don't need surgery anymore. We've got a drug that will improve Parkinson's,' " says neurosurgeon Dr. Roy Bakay, who, with neurologists Dr. Jerrold Vitek and Dr. Mahlon De-Long, heads the pallidotomy team at Emory. "What they didn't know was what was going to happen five or seven years down the road." In time it became clear that the effectiveness of the drugs diminished after a few years' use and that their side effects—muscle spasms and abnormal motor movements, among others—were often as bad as the disease itself. At that point, in the 1980s, neurosurgeons began performing pallidotomies again.
The Emory group believes that because it uses a microelectrode rather than relying solely on MRIs or CAT scans, as most hospitals do, its technique is likely to yield better results than any that has been tried before. This enables the team to pinpoint the precise spot to make a lesion. "We now know, based on earlier work, that this procedure will work if the lesions are placed well," says Vitek. "The target area is close to the optic track and the cortical spinal track. If you're on the wrong target, you won't get any benefit. And, even worse, you can get partial visual loss or paralysis."
Though no surgery so far can cure Parkinson's, a pallidotomy offers hope that the most debilitating symptoms can be alleviated. It was that hope that brought Mary Selman, accompanied by her daughters, to Emory on a clear morning last spring.
Her first stop, at 6:30 a.m., was to the presurgery room, where she exchanged her white cotton-knit pantsuit for a blue hospital gown and prepared herself for surgery. "This is a very disgusting disease," said Selman. "It's a pain in the butt, if you want to know the truth—but it's not going to do me any good to feel self-pity."
When the hospital's Lutheran chaplain, James Korzun, dropped by, Laurie explained to him, "We did this five weeks ago today, but they had to stop. My mom's got a hole in her head with a plastic cap—like a Tupperware lid." Leaning forward in her wheelchair, Mary Selman laughed out loud.
Selman had first come for a pallidotomy five weeks earlier, but the procedure had to be aborted when Selman, conscious throughout the operation because the patient's cooperation is required, said she didn't feel well. Her blood pressure plunged, and she lost consciousness. Revived by the fast-working medical team, she was sent to intensive care to recuperate from an insufficient supply of blood to the brain that left her temporarily paralyzed.
Now she was back to try again. The worst part of the surgery would come at the beginning, when she was fitted with a steel head frame that was literally screwed into her skull in four places. Designed to hold a patient's head steady during surgery, the halo also has metal bars that provide reference points for the surgeon. First, Dr. Alan Waitze, a neurosurgery resident, injected Selman with lidocaine, numbing the four points—one on either side of the forehead and two on the back of the head above the neck—where the frame was attached. "This is the worst part, because I know so much now," said Selman, remembering how it had hurt the last time. She grimaced and whispered, "Oh, mercy," as Waitze attached the frame. After five minutes, though, with the frame in place, she was able to say, "That wasn't bad."
Next came a CAT scan that would give Dr. Bakay an image of Selman's brain in relation to the bars on the head frame. At 9:30 a.m. the patient was wheeled into the pre-op area and transferred to a bed. "I'm scared to death," Selman told a nurse. At 10 a.m., the anesthesiologist began inserting an arterial line in her left arm so the doctors could monitor Selman's blood pressure without using a cuff. After 20 minutes and three tries, he was successful.
A little before 11, Selman was finally ready for OR No. 15. Lying on a special operating table to which her head frame was attached, she appeared relaxed despite the crowd of medical personnel around her. The anesthesiologist taped her arterial line and IV to her arm, and a nurse slid a grounding pad underneath her. The pad, the nurse explained, must be used because the electrode poses a danger of electric shock. "I'd be fried without it," laughed Selman. "It's a good thing you still have a sense of humor," said the nurse. "Well I don't have anything else right now," Selman replied. "I'm stripped of my dignity, my hair and my makeup."
At 11:35, Dr. Bakay made an incision in Selman's scalp, peeled the skin back, then used a drill to penetrate the plastic cap, which was one inch in diameter, in her skull. As he prepared to insert the electrode into her brain, Selman said, "I don't remember any of this last time." Dr. Vitek smiled. "That's because we didn't get this far," he said.
At noon, the electrode was lowered into Selman's brain, the lights in the OR were dimmed so they would not interfere with the light-sensitive electrode, and the speakers next to a six-foot cart filled with recording devices came alive with a noise resembling radio static. It was the sound of Mary Selman's brain going about its business of firing neurons—and the guide her doctors would use to determine where to make the lesions. As Dr. Vitek drove the electrode deeper by turning the handle on what looked like an old-fashioned crank, the sounds from the speakers changed. Finally, Dr. Vitek heard the fast, continuous popping that told him that the electrode has reached its destination—the globus pallidus area of the brain. Turning to Selman, he asked her to move her arms and legs to help pinpoint the spot for the lesions. After four long hours of probing, sounding and minute calculations based on the static from Mary Selman's brain, the medical team was ready to make four lesions in a 6-millimeter area. Through it all, there was one consolation: because there are no pain receptors in the brain, Selman felt nothing.
Dr. Bakay began turning a dial that uses radio frequency to heat the tip of the probe and began to destroy the target tissue. "This," he told Selman, "is like having a microwave inside your brain." Each time he made a lesion, the neurologists, to observe the effect of the lesions and make sure there was no bleeding in the brain—which could cause slurred speech—asked Selman to recite the days of the week and to move various limbs.
As the lesions were made, Selman's movements began to appear more fluid. She became more animated, more talkative, even crossing her right leg over her left. "Pallidotomy patients start doing things like that—crossing their legs, gesturing when they talk—after the procedure," said Vitek. "They say they have to think about moving because of the disease, but after the pallidotomy they start making these natural moves."
The last lesion was placed at 5:17 p.m., six hours after the start of surgery, and as the OR staff began clearing out equipment, Dr. Bakay's assistant plugged the hole in Selman's skull with plastic. "Honey, it was worth every minute of it," said Selman, close to tears. "If this is as successful as I think it's been, I'm amazed. Break out the martinis."
For the first time all day, the anesthesiologist gave Selman enough sedation to put her to sleep. Her head frame was removed, and her head was wrapped in a bandage. Then she was wheeled into the recovery room. At 6:30 she was removed to the intensive care unit to spend the night. The next morning she was placed in an ordinary room and a day later released from the hospital—the $40,000 procedure paid for by a second mortgage on her home. Her daughters drove her home to Birmingham, where Selman lives alone.
Less than a week later, on May 9, as Laurie was about to leave for her home in Atlanta, she found her mother leaning against the kitchen counter looking pensive. "Would you rather have stayed the way you were?" she asked. "No. I'm just scared," said Selman. "Everyone had become accustomed to the way I was. My friends were used to waiting for me—to go out the back door, to get in the car, to eat my lunch. They accepted me the way I was. Now I'm so much better. It's almost too good to be true."
Selman, who continues to take Sinemet, but in much smaller and less frequent doses than previously, still freezes up, especially if she's in a hurry or excited. But, says Laurie, "it's like the disease has regressed. They've taken her back to where she was five years ago."
That, for Mary Selman, is a place she is delighted to be. "I'll settle for anything I can get," she says, "because in five years they might find a cure for this damn thing."
MEG GRANT in Atlanta