UF movement team battles Parkinson’s symptoms

Neurosurgeon Kelly Foote, M.D., asked his patient if she needed anything.

Betty Johns, a 42-year-old Palm Bay, Fla., woman with early onset Parkinson’s disease, was still. Her head was secured to a metal frame bolted to a table in Operating Room 9 at Shands at UF. Her limbs were in an uncomfortable posture, the muscles within them working against each other because of dystonia, a movement problem associated with Parkinson’s disease.

Johns and her doctors agreed that a deep-brain stimulation procedure was her best chance to regain some normal movement.

She spoke softly. Foote listened nodded and called out, “Pepsi and Fritos. Did anyone bring the Pepsi and Fritos?”

Johns smiled. It was not yet 9 a.m. Earlier, a CT scan was taken of her brain and sent to a targeting computer, where it was fused with a magnetic-resonance imaging scan — a stereotactic surgery technique pioneered at UF — to create a guide for the surgery.

Soon Foote and neurologist Michael Okun, M.D., co-directors of the Movement Disorders Center at UF’s McKnight Brain Institute and Shands at UF, would make a small hole in her skull and insert a probe tipped with an electrode as thin as a hair. They would listen to the static-like sounds that would be auditory signposts on their way to the subthalamic nucleus.

Once there, they would implant an electrode and bury the lead just under her scalp. Eventually, with additional operations, two leads will connect her brain to a small battery-powered device similar to a pacemaker in her chest. The electrical stimulation combats Parkinson’s symptoms by altering brain activity, without destroying brain tissue.

The challenge is to place the electrodes in the correct spots.

“The probe enables us to get right up next to single cells and listen to their activity,” Okun said. “We combine the imaging technology with the microelectrode recordings in the operating room to perform a procedure that allows us to map within half-millimeter steps structures that can be smaller than a pea. Our goal is to find the exact right spot in the structures that will relieve symptoms and not cause patients to have side effects.”

Foote carefully washed and sterilized his patient’s hair, so that there was no need to cut it prior to surgery.

“I went to school for a lot of years to learn how to do this,” Foote said, massaging betadine soap into her scalp.

Johns’ smile reappeared.

Actually, both Foote and Okun put in additional years beyond what’s required in order to learn specialized surgery and brain-mapping techniques, according to William Friedman, M.D., chairman of UF’s neurosurgery department.

Foote completed a one-year fellowship in stereotactic neurosurgery and radiosurgery under Friedman and trained at the Université de Grenoble in Grenoble, France, as well as at Emory University — two of the pioneering institutions for movement-disorders surgery. Okun completed two fellowships at Emory University, one in movement disorders and a second in microelectrode recording and surgical treatments of movement disorders.

During the procedure, Okun slowly advanced the electrode, listening and calling out coordinates, reminiscent of the way mariners threw weighted ropes overboard and called out soundings but profoundly more refined. Okun’s “rope” was measured not in inches but microns, and the coordinates were not in fathoms but in fractions of millimeters.

“What’s outside static to most people is a ‘window’ into being able to listen to how the brain is functioning,” Okun said. “We use a microelectrode the size of a hair. When you put something that small into the brain and you move it with a hydraulic wheel, you’re able to slide up next to these nerve cells. They give you a signal you can see on an oscilloscope, and they also hum and make different sounds. Oftentimes you pick up more than one cell, so you have to be able to differentiate the sounds in a difficult, static-filled background. What you end up doing is constructing a very elegant map.”

Johns was awake throughout the procedure. She received only local anesthetic, just before doctors made an incision in her scalp. Near the end, Okun said, “It was a very nice pass. Your brain has a lot to say. The part that’s chattering so much, causing you problems, we’re going to ask it to be quiet.”

Johns went home a few days later, in preparation for two additional surgeries to come. Foote said there were signs that her symptoms were relieved even without the stimulator being connected, something he called the “impact effect.”

Johns hopes the procedure will enable her to move and function normally. When she was 36, she began to carry her right arm as if it were in a sling. Then she began to drag her leg, but she kept working, cleaning houses for a living, and caring for her family. She thought she had a pinched nerve. Then, her local neurologist diagnosed her with Parkinson’s disease. Her symptoms worsened to the point where the medications that allowed her to move caused dyskinesia — too much involuntary movement. She moved so forcefully, she broke her neck, an occurrence that led her to UF’s Movement Disorders Center for treatment.

“By luck, Dr. Foote saw her and said, ‘I think we know a little something about Parkinson’s disease,’ That’s how it innocently started; she was lucky to bump into him,” Okun said.

Foote and Okun stress that deep-brain stimulation is not suitable for all Parkinson’s patients. But there are other methods to improve their lives.

“It’s gratifying to be able to see patients in clinic, offer alternatives in everyday care, change their medications, treat their depression or their sexual dysfunction, improve their ability to interact in society and to look at each one and say, ‘What can this patient teach us about this disease?’ Then we go back to our laboratory and try to develop better therapies, medicines and surgeries,” Okun said. “We have people here at UF vested in stem cell, viral-vector and gene therapy research for Parkinson’s, and many other specialists for treatment in areas such as speech, language and thinking. The idea that an interdisciplinary team can work together and try to solve the problems is terrific. No single person working alone can cure Parkinson’s.”