Controversies in pallidal surgery

Posteroventral pallidotomy (PVP) has gained a worldwide acceptance after its reintroduction by Laitinen et al. in 1992 (56) and many studies have since been published. A review of the recent literature reveals that there is variation in the clinical indications for this procedure, the surgical technique used and the assessment of results. There is no uniform practice in the choice of the anatomical target point within the globus pallidus, the imaging of the target structure, the intraoperative assessment of the physiological target and the mode of evaluation of the surgical results. Although some neurosurgeons advocate that the lesion should be in the lateral pallidum, the majority insist it should be in the medial pallidum. It is shown here that, as long as the lesion is made at the posterior and ventral parts of the globus pallidus, it will necessarily include aspects of both medial and lateral posteroventral pallidum. There is a common agreement on the effectiveness of pallidal surgery on the L-dopa induced dyskinesias, but, its long-term effects on tremor, akinesia, freezing of the gait and other genuine parkinsonian symptoms need more extensive evaluation. The assessment of the outcome of pallidal surgery in terms of the patient's disability, quality of life and coping abilities following surgery seems to have been neglected.