Stereotactic Pallidotomy in the Treatment of Parkinson Disease an Expert Opinion

NEUROLOGICAL REVIEW

SECTION EDITOR: DAVID E. PLEASURE, MD Stereotactic Pallidotomy in the Treatment of Parkinson Disease An Expert Opinion

Jeff M. Bronstein, MD, PhD; Antonio DeSalles, MD, PhD; Mahlon R. DeLong, MD; for the Workshop Participants

he objective of this workshop was to provide recommendations on several issues involving pallidotomy for patients with medically intractable Parkinson disease to physicians, patients, and other health care providers. An international consortium of ex- perts in neurology, neurosurgery, and neurophysiology who had extensive experience Twith pallidotomy were invited to the workshop. Participants were sent background materials from the scientific literature for review-based participant recommendations. A proposed agenda was circulated to all participants before the workshop, and the final agenda was based on their recommendations. Topics were introduced at the workshop by members of the organizing committee, followed by extensive group discussion. A draft of a consensus statement, based on the previous day’s discussion, was circulated and further modifications were made. The final statement was agreed on by all members.The conclusions of the participants were: (1) Pallidotomy should be performed only at centers that have a team of physicians with substantial expertise and experience in the field. (2) Patients with disabling idiopathic Parkinson disease, without dementia, and who have exhausted medical therapy should be considered for pallidotomy. (3) All patients should be examined by means of standardized rating scales both preoperatively and postoperatively to ensure quality of care at each center. (4) Symptoms that respond best to pallidotomy include medication- induced dyskinesias, rigidity, and tremor, while balance, gait disorders, and hypophonia are generally less responsive to surgery. Benefits of pallidotomy appear to be long lasting. (5) Each institution’s complication rate should be discussed before surgery. Arch Neurol. 1999;56:1064-1069

Surgical operations in the basal ganglia for geons moved to the thalamus because of un- idiopathic Parkinson disease (PD) were predictable outcomes with pallidotomy. described as early as 1940.1 Surgical Thalamotomy was found to result in long- approaches have concentrated on ablation lasting improvement in tremor and rigid- of small regions of the basal ganglia and ity but not bradykinesia.4 Surgical ap- thalamus, implantation of dopamine- proaches for the treatment of PD became less secreting cells, and deep-brain electrical frequent when levodopa therapy became stimulation. In early studies, stereotactic le- available in the late 1960s. Despite ad- sions in the globus pallidus appeared to im- vances in the medical management of PD, prove rigidity, but inconsistent results were however, patients often develop severe dis- reported for the relief of tremor and brady- abling medication-induced dyskinesias and kinesia.2,3 Even though Svennilson et al3 re- motor fluctuations. These persistent prob- ported consistent benefit for tremor, rigid- lems led to further investigations of a role ity, and bradykinesia with a more posterior, for stereotactic surgery in the treatment of ventral, and lateral target, many neurosur- PD and other movement disorders.5

From the Departments of Neurology (Dr Bronstein) and Neurosurgery (Dr DeSalles) and the Brain Research Institute (Drs Bronstein and DeSalles), University of This article is also available on our California, Los Angeles, School of Medicine; and Department of Neurology, Emory Web site: www.ama-assn.org/neuro. School of Medicine, Atlanta, Ga (Dr DeLong). A list of the workshop participants and institutions appears on page 1068.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Severalcentersaroundtheworldhaveappliedmagnetic Agenda resonance (MR) imaging, electrophysiological testing, and modern stereotactic neurosurgical techniques to improve We distributed a proposed agenda and several reprints the outcome of ablative therapy and reduce the rate of com- to all participants before the meeting. Participants were plications. The efficacy of stereotactic pallidotomy in treat- encouraged to suggest changes to the agenda and addi- ing patients with medically intractable PD is supported by tional articles. These additional materials were then dis- several recent reports (Table).6-21 None of these studies was tributed in a second mailing. double-blindedorplacebocontrolled,theyhadasmallpopu- lation size, and there were potential management biases; Meeting therefore, definitive conclusions regarding indications, ex- tent of improvement, and complications cannot be drawn. On arrival, all participants received a packet containing Recently, a preliminary report of a randomized study has the final agenda and names of all participants. Topics were been presented, and results from this study also support the introduced by one of us (J.M.B, A.D., or M.R.D.), and ex- efficacy of the procedure.18 The ethics and costs of sham sur- perts in that topic were asked to present their views. Dis- gery make blinded trials extremely difficult. Although more cussion was then opened to the floor, allowing all par- than390pallidotomiesarerepresentedintheliterature,many ticipants to contribute. Detailed notes of the discussions more operations have been performed but not formally re- were taken by 2 individuals, and the entire meeting was ported. Therefore, a workshop was conducted to bring to- tape recorded. Before the end of the meeting, a prelimi- gether many of the leading neurologists and neurosurgeons nary statement was prepared and distributed on the last in the field to address many issues involving the procedure day. Each issue was discussed again. The final state- that remain unresolved. A consensus was reached on rec- ment was prepared by us on the basis of this final dis- ommendations for patient selection, institutional require- cussion, and the manuscript was sent to all participants ments, preoperative and postoperative evaluation, lesion for their final comments and approval. targeting, and anticipated benefits of the procedure. Below are the recommendations agreed on at this workshop. RECOMMENDED INSTITUTIONAL REQUIREMENTS RATIONALE OF PALLIDOTOMY Stereotactic pallidotomy should be performed at centers Early surgical targets in treating patients with PD were dis- with a team of physicians and support staff. All patients covered serendipitously. The current model of basal gan- should be examined and medically treated by a neurolo- glia circuitry and dysfunction in disease at least partially gist with expertise in diagnosing and caring for patients predicts the therapeutic effects of pallidotomy.22,23 In gen- with PD. It is recommended that the neurosurgeon be eral, increased inhibitory output from the internal seg- trained in stereotactic and functional neurosurgery and ment of the globus pallidus (GPi) is associated with par- the institution be well equipped. Adequate facilities kinsonism, whereas decreased output is associated with should provide high-resolution MR imaging (with dyskinesias. Loss of striatal dopamine in the case of PD leads appropriate software) and full stereotactic capabilities. to overactivity of the indirect pathway (excitatory) and un- As with many surgical procedures, experience is impor- deractivity of the direct pathway (inhibitory) to the GPi. tant in obtaining optimal outcomes. It is therefore rec- This ultimately leads to excessive inhibition of the thala- ommended that a pallidotomy center perform at least 25 mus by the GPi. Lesions of the posteroventral aspects of procedures per year and have an established track the pallidum presumably interfere with the excessive pal- record. lidal inhibition of the thalamus and brainstem. This simple model does not predict, however, the dramatic effect pal- PATIENT SELECTION lidotomy has on drug-induced dyskinesias. This and other shortcomings of the current models have been discussed There was consensus in the panel that the following cri- in several recent reviews. teria be used to select patients for pallidotomy.

METHODS Inclusion Criteria

Panel Selection Patients with idiopathic PD who have exhausted medical therapy to control disabling symptoms should be consid- Participants of the panel were invited on the basis of their ered as possible candidates for pallidotomy. The criteria expertise in the area of pallidotomy and basal ganglia func- for the diagnosis of PD requires (1) the presence of at least tion. Ninety percent of those invited attended the work- 2 of the cardinal features of PD (rest tremor, rigidity, and shop or sent a representative from their institution. Their bradykinesia); (2) clear response to levodopa (patients expertise was based on having at least 1 peer-reviewed pub- should be examined in both the “on” and “off” states); lication in the field and/or practice at centers that per- (3) no evidence of other causes (encephalitis, exposure to form a high volume of procedures. Approximately an equal toxins, recent exposure to neuroleptics, head trauma, or number of neurologists and neurosurgeons were invited. relevant vascular disease); (4) lack of cerebellar ataxia, ver- All opinions in this statement represent those who tical gaze palsy, and pronounced autonomic features; and attended the workshop (13 neurologists, 12 neurosur- (5) MR images without lacunar infarcts that are thought geons, and 3 basic scientists). to be causative of the parkinsonism, normal-pressure

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Age Source, y No. Range, y Design Mi Follow-up Results Complications Laitinen et al,6 38 30-80 Open No 2-71 mo 4-point scale, 81% good to 14% VFD, 1 of these also 1992 excellent with transient facial weakness Lozano et al,7 14 44-71 Open Yes 1 wk, 3 mo, CAPIT: 15%-33% 21% Transient facial 1995 and6mo improvement “off”; 92% weakness reduction in dyskinesia “on” Dogali et al,8 18/7† 42-79 Nonrandom No 3, 6, 9, and CAPIT: 38%-65% No complications 1995 controls 12 mo improvement “off”; significant “on” and dyskinesia Iacono et al,9 58/68‡ 31-80 Open Some 4.5 mo (mean) UPDRS, H&Y “on”: 2.4% Transient, 1.6% 1995 50%-70% improvement permanent hemiparesis; 1.6% permanent and Ͻ1% transient hemianopsia Sutton et al,10 5 64-75 Open No 2, 4, and 8 wk UPDRS, H&Y, S&E: 40% Transient facial 1995 improvement in weakness, 40% VFD, dyskinesia only 40% depression, 20% worsened speech and swallowing Baron et al,11 15 38-71 Open Yes 3, 6, and 12 mo CAPIT, S&E: 30% 7% Transient and permanent 1996 improvement, dramatic dysarthria, 7% VFD, reduction in dyskinesias, several transient confusion no neuropsychological and hemiparesis, deficits 13% asymptomatic hemorrhages Masterman 32 34-82 Open Some 3-6 mo UPDRS: 83% of patients 3% Transient facial et al,12 1998 improved 22%-61%; weakness, 13% transient H&Y and S&E: improved; confusion posturography: improved balance, no neuropsychological deficits Johansson 22 43-78 Open No 4 and 12 mo UPDRS: improved; timed 9% Transient confusion or et al,13 1997 motor: ND; movement dysarthria, 4.5% VFD analysis: ND Krauss et al,14 36 40-75 Open Yes 6 mo UPDRS motor: improved by 14% Transient effects, none 1997 43% when “off”; ADL: persistent improved by 42% when “off” Lang et al,15 40 44-72 Open Yes 6, 12, and some UPDRS: motor “off” 35% With Ն1 persistent 1997 at 24 mo improved 28%, adverse effect dyskinesia 82%; most contralateral improvements were long-lasting Uitti et al,16 20 49-78 Open Some 3 mo UPDRS: total improved 20% Transient confusion or 1997 22%, little change in incontinence, none neuropsychological persistent findings Samuel et al,17 26 40-72 Open Yes 3 and some UPDRS: motor “off” 2 Deaths (7.7%), 15% major 1998 at 12 mo improved 27%; and 39% minor dyskinesia improved 67% complications Vitec et al,18 27 NS Randomized Yes 6 mo Surgical treatment: UPDRS NS 1998 (surgical vs 33% improved, S&E “off” medical) improved 39%; medical treatment: UPDRS 5% worse Kishore et al,19 24 37-74 Open No 3-12 mo UPDRS: total “off” 4% Hemorrhage at 2 wk 1997 improved 38%, total “on” (died), 13% transient no change; dyskinesia hemiparesis, 13% improved 56% asymptomatic VFD, 4% persistent facial paresis

*Mi indicates microelectrode recordings; open, open enrollment; VFD, visual field defects; CAPIT, Core Assessment Program for Intracerebral Transplantation; UPDRS, United Parkinson’s Disease Rating Scale; H&Y, Hoehn and Yahr Staging Scale; S&E, Schwab and England Scale; ND, not done; ADL, activities of daily living; and NS, not stated. †Pallidotomy/control. ‡Unilateral/bilateral.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 hydrocephalus, and marked cerebellar and/or brain- no major preexisting cognitive deficits,11,12,16,30 although stem atrophy. this is not firmly established. Since patients with demen- An appropriate surgical candidate should have per- tia may worsen after pallidotomy, the panel believed that sistent disability despite optimal medical management. it is imperative to perform an adequate preoperative cog- The degree of disability depends on the individual and nitive evaluation on all patients. In general, patients who the nature of the disability. It was the general opinion at fulfill criteria of the Diagnostic and Statistical Manual of the workshop that no maximum or minimum age or stage Mental Disorders, Fourth Edition,31 for dementia or have of the disease should preclude consideration for pal- a substantial isolated amnestic syndrome should be ex- lidotomy. This opinion was based on the fact that effec- cluded. Formal neuropsychological testing may not be tive pallidotomies have been safely performed on pa- necessary for all patients. Masterman et al12,30 found a tients from 30 to 82 years of age, although some 4-part cognitive battery adequate as a first screening tool participants suggested that younger patients obtain bet- to identify those who should undergo more formalized ter results from pallidotomy than older patients. Be- testing. This battery includes a Mini-Mental State Ex- cause several disorders can easily be mistaken for PD and amination,32 memory problem checklist, Superspan the management of advanced PD can be difficult, the panel Memory Test,33 and a behavioral assessment (ie, Neuro- believed that patient evaluations and treatment should psychiatric Inventory,34 Beck Depression Inventory,35 or be performed by a neurologist with expertise in move- Hamilton Depression Scale36). Verification of this or other ment disorders. preoperative cognitive evaluation is required before any one evaluation could be endorsed by the panel. Exclusion Criteria PREOPERATIVE COUNSELING Patients with Parkinson-plus syndromes (multiple- system atrophy, progressive supranuclear palsy, vascu- Several issues should be discussed with all patients be- lar parkinsonism, etc) should not be considered for pal- fore surgery. It should be made clear that pallidotomy lidotomy, since it has been found to be ineffective in these treats some symptoms better than others and that pa- disorders. Patients with dementia should not be consid- tients should have realistic expectations. In general, le- ered for pallidotomy because the cognitive status of the vodopa-induced dyskinesias and dystonias (especially “on- patient may worsen as a result of the procedure (see “Cog- time” painful dystonias) and motor fluctuations are highly nitive Screening” section, below). Patients with medical responsive to pallidotomy in the majority of patients. Ri- conditions that add unacceptable surgical risk or have gidity, bradykinesia or akinesia, tremor, and facial mask- MR imaging evidence of other intracranial disease are poor ing are also clearly responsive to surgery. Less and more candidates for this procedure. Substantial psychiatric dis- variably responsive symptoms include gait disorders (fes- orders, including severe depression and psychosis, should tinating gait, turning, and step size), posture, balance, exclude patients from pallidotomy, although patients hypophonia, micrographia, and “off-time” freezing. Non- with depression can be treated and then considered for responsive symptoms include autonomic dysfunction, surgery. sphincteric signs (ie, incontinence), drooling and swallowing difficulties, and cognitive impairment. On- PREOPERATIVE AND POSTOPERATIVE period disability that is unrelated to dyskinesias rarely EVALUATIONS improves in response to pallidotomy. Benefits from surgery appear to be long lasting,15 with 1 report demon- Standardized outcome analysis is extremely important in strating improvements up to 4 years.37 Detailed studies ensuring quality of care at each center, especially as they on larger series are necessary to fully define long-term are becoming established. The participants believed that results of pallidotomy. all patients should be examined in the on and off states In general, surgical complications from pal- both preoperatively and postoperatively by means of the lidotomy are infrequent, but substantial morbidity and United Parkinson’s Disease Rating Scale,24 the Hoehn and mortality have been reported (Table). In the published Yahr Staging Scale,25 and the Schwab and England ac- literature, 3.6% (15/416) of all patients sustained a per- tivities of daily living scale.26 It is also recommended that manent visual field defect, 1.4% (6/416) sustained a a measure of quality of life be used, although no one scale permanent hemiparesis, and several patients had tran- has yet been universally accepted.27,28 The Parkinson’s Dis- sient symptoms.38 In 1 report, 3 delayed internal cap- ease Study Group is developing a quality-of-life rating sule infarcts occurred 13 to 117 days after pallidotomy, system for patients with PD (the PDQUALW), and the all in patients with known vascular risks.39 Three deaths panel believed that it should also be considered when have been reported in the modern literature,17,19 2 of them available. Positron emission tomography may have some occurring in their early cases. In fact, most centers re- usefulness in predicting outcomes in some patients,29 but ported that the majority of their complications occurred the participants thought that further investigation is nec- early in their series, and the rate fell with experience. For essary before its use can be endorsed. this reason, the panel recommends that centers have a con- siderable amount of experience in performing pallidoto- COGNITIVE SCREENING mies (see recommended institutional requirements) and that patients discuss with their physician the complica- The cognitive status of patients with PD does not ap- tion rate for each center. Potential surgical patients should pear to change markedly after pallidotomy if there are also understand that they may be excluded from future

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Participants in the Workshop continued for at least 2 weeks. The blood pressure should be well controlled preoperatively, postoperatively, and in- traoperatively to avoid intracerebral hemorrhage. Anti- New York University School of Medicine, New York, NY:Ron parkinson medications should be limited the day of sur- Alterman, MD; Aleksandar Beric, MD. Barrow Neurologi- gery to achieve a modest off state but avoid dangerous and cal Institute, Phoenix, Ariz: Konstantin Baev, MD, PhD; Abraham Lieberman, MD, Andrew Shetter, MD. Univer- uncomfortable severe rigidity, akinesia, and off dystonia. site´ Joseph Fourier de Grenoble, Grenoble, France: Alim Benabid, MD, PhD. University of California, Los Angeles, TARGET SELECTION School of Medicine, Los Angeles: Jeff Bronstein, MD, PhD; Marie-Franc¸oise Chesselet, MD, PhD; Jeffery Cummings, There is some variation between centers as to where le- MD; Antonio DeSalles, MD, PhD; Robert Frysinger, PhD; sions are targeted. Benefits from surgery have been shown Donna Masterman, MD; Alan Tobin, PhD. Massachusetts to result in both patients and animal models from le- General Hospital, Boston: G. Rees Cosgrove, MD, FRCS. sions confined to the caudal (sensorimotor) portion of Emory University School of Medicine, Atlanta, Ga: Mahlon the globus pallidus pars interna (GPi). Lesions directed DeLong, MD; Jerrold Vitek, MD, PhD. University of South- to the posteroventral pallidum that include both GPi and ern California School of Medicine, Los Angeles: Michael external segment of the globus pallidus (GPe) have been Dogali, MD; Cheryl Waters, MD. Conemaugh Memorial 6,13 Medical Center, Johnstown, Pa: Karl Green, MD. Univer- reported to be effective in patients. Further studies are sity Hospital, Umea, Sweden: Marwan Hariz. Good Samari- necessary to better define ideal lesion placement. tan Hospital, Los Angeles: Dean B. Jacques, MD; Oleg The techniques used to determine the target coor- Kopyov, MD, PhD. Sophiahemmet Hospital, Stockholm, dinates varied at different centers, but most used MR im- Sweden: Lauri V. Laitinen, MD, PhD. Toronto Western aging–guided stereotaxis. Computed tomography– Hospital, Toronto, Ontario: Anthony Lang, MD; Andre guided targeting has also been reported to be relatively Lozano, MD, PhD. University of Kansas Medical Center, safe and effective.19 Since both MR imaging– and com- Kansas City: Edison Miyawaki, MD. University of London puted tomography–determined targets can be inaccu- Queen Square, London, England: Niall Quinn, MD. Mayo rate and since the target cannot be adequately deter- Clinic Jacksonville, Jacksonville, Fla: Ryan J. Uitti, MD; Robert E. Wharen, Jr, MD. mined on anatomical grounds alone, there is general agreement on the need for electrophysiological guid- ance (stimulation) and intraoperative examination. For this reason, it is strongly recommended that radiosur- medical and surgical trials and that pallidotomy may alter gery (eg, gamma knife) not be used to perform pal- the effectiveness of future therapies. lidotomy. Consensus regarding the added value of microelectrode mapping was not reached because of a lack BILATERAL PALLIDOTOMY of data. Safe and effective pallidotomies have been performed both with and without microelectrode record- There are much fewer data available evaluating the ben- ings (Table). The panel believed that there is no evi- efits and complications of bilateral pallidotomy.9,40,41 There dence that microelectrode mapping is associated with have been a few reports of speech and swallowing diffi- additional surgical complications (eg, hemorrhage, in- culties after bilateral pallidotomy, but there is little evi- fection). Microelectrode mapping requires both special dence that bilateral surgery poses additional cognitive risks equipment and experienced personnel and should be per- after well-placed lesions are administered. Many of the formed only at centers with expertise in this technique. participants at the workshop have successfully per- Many centers perform postoperative MR imaging or formed staged bilateral pallidotomies with good results, computed tomography to determine if a hemorrhage has although some complications have occurred. It is un- occurred. It was generally agreed that these images offer clear whether these complications reflect poorly placed little in determining lesion placement at conventional reso- lesions or the risk of adverse events is inherently greater lution. when a second procedure is performed (ie, more than twice the risk of unilateral pallidotomy). Since unilat- CONCLUSIONS eral pallidotomy often has bilateral benefits and bilateral surgery may pose additional risks, the panel be- In our deliberations, we reached consensus on several is- lieved that bilateral pallidotomy should be considered only sues involving pallidotomy. It is recommended that pal- as a staged procedure with at least a 6-month interval be- lidotomy be performed at centers that have a team of ex- tween surgeries. Indications for a second pallidotomy in- perts to ensure that patients are adequately examined and clude severe drug-induced symptoms on the side not op- medically treated before surgery is considered. Neuro- erated on and a good response to the previous surgery. surgeons should be trained in stereotactic and func- Patients with speech or swallowing difficulties (by his- tional surgery, be well equipped, and have an estab- tory and examination) or cognitive decline after the first lished track record. Only patients with idiopathic PD and procedure should be excluded from a second operation. persistent disability who have exhausted medical therapy should be considered for pallidotomy. Good candidates SURGICAL CONSIDERATIONS should not have dementia or other medical conditions that would add substantial surgical risk. Standardized rat- Before surgery, all antiplatelet agents (aspirin, noncorti- ing scales are recommended to ensure quality of care at costeroidal anti-inflammatory agents, etc) should be dis- each center. Several issues should be discussed with all

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 patients before surgery so they will have realistic expec- 13. Johansson F, Malm J, Nordh E, Hariz M. Usefulness of pallidotomy in advanced Parkinson’s disease. J Neurol Neurosurg Psychiatry. 1997;62:125-132. tations of potential benefits and surgical risks. It was gen- 14. Krauss JK, Desaloms JM, Lai EC, King DE, Jankovic J, Grossman RG. Micro- erally agreed that contralateral medication-induced dys- electrode-guided posteroventral pallidotomy for treatment of Parkinson’s dis- kinesias, rigidity, and tremor are the most responsive ease: postoperative magnetic resonance imaging analysis. J Neurosurg. 1997; 87:358-367. symptoms, while gait disorders, hypophonia, balance, and 15. Lang AE, Lozano AM, Montgomery E, Duff J, Tasker R, Hutchinson W. Postero- freezing are less or more variably responsive symptoms. ventral medial pallidotomy in advanced Parkinson’s disease. N Engl J Med. 1997; Nonresponsive symptoms include autonomic dysfunc- 337:1036-1042. 16. Uitti RJ, Wharen RE, Turk MF, et al. Unilateral pallidotomy for Parkinson’s dis- tion, incontinence, drooling and swallowing difficul- ease: comparison of outcome in younger versus elderly patients. Neurology. 1997; ties, and cognitive impairment. Surgical complications 49:1072-1077. 17. Samuel M, Caputo E, Brooks DJ, et al. A study of medial pallidotomy for Parkin- are generally few, but the complication rate at each cen- son’s disease: clinical outcome, MRI location and complications. Brain. 1998; ter should be discussed. There was less agreement on bi- 121:59-75. lateral pallidotomy, since much less information is avail- 18. Vitec JL, Bakay RAE, Freeman A, et al. Randomized trial of pallidotomy for Par- kinson’s disease [abstract]. Neurology. 1998;50(suppl 4):A80. Abstract S10.006. able, but it may pose an increased risk of speech and 19. Kishore A, Turnbull IM, Snow BJ, et al. Efficacy, stability and predictors of out- swallowing difficulties. It was agreed that if bilateral pro- come of pallidotomy for Parkinson’s disease: six-month follow-up with addi- cedures were to be performed, they should be staged. Con- tional 1-year observations. Brain. 1997;120:729-737. 20. Alterman RL, Kelly PJ. Pallidotomy technique and results: the New York Univer- sensus was reached on the general region where the le- sity experience. Neurosurg Clin N Am. 1998;9:337-343. sion should be placed (posteroventral pallidum including 21. Shannon KM, Penn RD, Kroin JS, et al. Stereotactic pallidotomy for the treat- the GPi), but the panel believed that insufficient data were ment of Parkinson’s disease: efficacy and adverse effects at 6 months in 26 patients. Neurology. 1998;50:434-438. available to make more specific recommendations. 22. Albin RL, Young AB, Penney JB. The functional anatomy of basal ganglia disorders [see comments]. Trends Neurosci. 1989;12:366-375. 23. 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Correction Correction

Error in Text. In the Neurological Review by Bronstein et al titled “Stereotac- tic Pallidotomy in the Treatment of Parkinson Disease: An Expert Opinion,” published in the September issue of the ARCHIVES (1999;56:1064-1069), an error occurred in the boxed listing of “Participants in the Workshop” on page 1068. In that boxed copy, the full listing for Marwan Hariz should have appeared as follows: “University Hospital, Umea, Sweden: Marwan Hariz, MD, PhD.” The journal regrets the error.

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