Clinical Study
Stereotact Funct Neurosurg
DOI: 10.1159/000516237
A Scientometric Analysis of the 100 Most
Cited Articles on Pallidotomy
Mohit Agrawal a Kanwaljeet Garg b Raghu Samala b Roopa Rajan c
Manmohan Singh b  
aDepartment
of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India; bDepartment of Neurosurgery,
All India Institute of Medical Sciences, New Delhi, India; cDepartment of Neurology, All India Institute of Medical
Sciences, New Delhi, India
Keywords
Bibliometrics · Functional neurosurgery · Globus pallidum ·
Pallidotomy · Stereotactic ablation · Web of Science
Abstract
Background: Pallidotomy is the oldest stereotactically per-
formed neurosurgical procedure for movement disorders.
Consequently, there is a wealth of literature available on the
topic. Objectives: The aim of this analysis was to identify the
top-cited articles on pallidotomy in order to discern the ori-
gins, spread, the current trends, and the future directions of
this surgical procedure. Methods: We performed a search of
the Web of Science database on 19 October 2020 using the
keyword “pallidotomy.” The top-100 cited articles found
were arranged in descending order on the basis of citation
count (CC) and citation per year (CY). Relevant conclusions
were derived. Results: The 100 top-cited articles were pub-
lished between 1961 and 2017, in 24 journals. The average
CC and CY were 118.1 (range – 856–46) and 5.326 (range –
29.52–2.09), respectively. The 3 most prolific authors were
Lang AE (Neurologist – Toronto), Lozano AM (Neurosur-
geon – Toronto), and Vitek JL (Neurologist – Atlanta). The
Journal of Neurosurgery published the highest number of
top-cited articles [Neurology. 1960;10:61–9]. The maximum
karger@karger.com © 2021 S. Karger AG, Basel
www.karger.com/sfn
Received: February 19, 2021
Accepted: March 30, 2021
Published online: June 2, 2021
articles were from the USA. University of Toronto and Emory
University were the most productive institutions. Conclu-
sions: Pallidotomy has gone through several ebbs and flows.
Unilateral pallidotomy is currently recommended for the
treatment of motor symptoms of Parkinson’s disease and
dystonia. The need for further research and improved tech-
nology to make the technique safer and prove its efficacy is
highlighted, especially keeping in mind a large number of
populations to which the prohibitively expensive deep brain
stimulation is unavailable. © 2021 S. Karger AG, Basel
Introduction
Pallidotomy refers to the surgical procedure of lesion-
ing the internal segment of the globus pallidum, which is
an integral part of the cortico-basal ganglia-thalamic
loop, in order to relieve some of the abnormal motor
manifestations produced due to its malfunction. It is the
oldest stereotactically performed neurosurgical proce-
dure for movement disorders, and its acceptance and
adoption by the functional neurosurgery community has
seen several ebbs and flows through the decades [1–4].
Consequently, there have been several studies on the top-
129.215.16.30 - 8/12/2021 1:37:28 AM
Correspondence to:
Kanwaljeet Garg, kanwaljeet84 @ gmail.com
University of Edinburgh
Downloaded by:
ic which have helped to establish the role of the pallidot- Table 1. Main information about data
omy in the surgical treatment of movement disorders.
There has been an exponential increase in the number of Description Results
articles published concerning functional neurosurgery in Time span 1961–2017
general [5, 6], and specifically pallidotomy [7]. Even an Sources 24
expert peer reviewer cannot be expected to have a work- Documents 100
ing knowledge of all the landmark articles in a particular Average years from publication 21.2
Average citations per documents 118.1
field [8]. In this context, unbiased identification of the
Average CY per doc 5.326
most important research articles in any given field can be References 2,540
extremely difficult, especially for a new academician.
Document contents
Bibliometric analysis is a scientific analysis of any pub- Keywords plus 292
lished material [9]. Scientometrics is a subfield of biblio- Author’s keywords 127
metrics which analyses scientific publications. It provides
Authors
a measure of the impact that a given article has had on the Authors 382
field by computing the times the said article has been cit- Author appearances 583
ed by others. Further analysis and correlations provide us Authors of single-authored documents 4
the influence that a particular group of individuals, insti- Authors of multiauthored documents 378
tutes, countries, or journals have had on the specialty [6]. Author’s collaboration
This helps in providing a synopsis of the state of research Single-authored documents 5
in the area of interest. It also provides a ready reckoner Documents per author 0.262
Authors per document 3.82
pertaining to the experts in the field, to identify reviewers,
Co-authors per documents 5.83
and to help direct the limited research funding that might Collaboration index 3.98
be available for a particular field. Finally, it helps in iden-
tifying the research trends and pinpoint avenues to direct CY, citations per year.
future investigations. The aim of this study was to iden-
tify the 100 most cited articles on pallidotomy in order to
discern the important contributions to the development
of this surgical technique and to foretell future research Results
trends.
Our search retrieved a total of 1,759 articles on the top-
ic “pallidotomy.” Based on our inclusion criteria, the top
100 most cited articles were assorted and analyzed (Ta-
Material and Methods
bles 1, 2; see online suppl. material; for all online suppl.
Search Strategy material, see www.karger.com/doi/10.1159/000516237).
We performed a search of the Web of Science database on 19
October 2020 using the keyword “pallidotomy.” All the abstracts Year of Publication
were screened for suitable articles. The inclusion criteria were ar-
The top-cited 100 articles were published between
ticles relevant to pallidotomy. The 100 most cited articles were se-
lected and reviewed by the authors. 1961 and 2017. The maximum number (62) was pub-
lished in the last decade of the twentieth century (17 in
Data 1997). The reference publication year spectroscopy anal-
The articles were arranged in descending order according to ysis revealed a sharp fall in the top-100 cited publications
the number of citations. The parameters assessed were the title of
on the topic after 1999 (Fig. 1a). Two recent review arti-
the articles, authors, corresponding authors, country of origin,
journal of publication, year of publication, citation count, and the cles published in 2012 and 2017 were placed 11th and 6th,
citation per year (CY). respectively, according to the citations received per year
[11, 12].
Analysis
The statistical analysis was performed using R software (R
Foundation for Statistical Computing, Vienna, Austria) employ-
Most Relevant Sources
ing the “bibliometrix” package [10]. The VOSviewer software (Van The top-cited articles were published in 24 journals
Eck and Waltman, Leiden University, Leiden, The Netherlands) (Table 3). There were 64 case series, 20 review articles, 6
was also used to plot network and overlay plots [10]. case reports, 4 letters, 3 descriptions of technique, and 3
129.215.16.30 - 8/12/2021 1:37:28 AM

2 Stereotact Funct Neurosurg Agrawal/Garg/Samala/Rajan/Singh

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
Table 2. Top-10 cited articles on pallidotomy ranked according to CC [13, 19, 28–30, 36, 53, 68–70]

First author Country of Year Journal Article type Title Total Rank CY Rank
corresponding author CC (according (according
to CC) to CY)

Laitinen et Sophiahemmet 1992 Journal of Case series Leksell’s posteroventral 856 1 29.52 1
al. [13] Hospital, Stockholm, neurosurgery pallidotomy in the treatment of
Sweden PD
Lozano et al. Toronto Hospital, 1995 Lancet Case series Effect of GPi pallidotomy on 530 2 20.38 2
[28] Toronto, Canada motor function in PD
Baron et al. Emory University, 1996 Annals of Case series Treatment of advanced 474 3 18.96 3
[68] Atlanta, GA, USA neurology Parkinson’s disease by posterior
GPi pallidotomy: 1‐year results
of a pilot study
Lang et al. Toronto Hospital, 1997 New England Case series Posteroventral medial 372 4 15.50 4
[29] Toronto, Canada journal of pallidotomy in advanced PD
medicine
Dogali et al. Hospital for Joint 1995 Neurology Comparative Stereotactic ventral pallidotomy 368 5 14.15 5
[69] Diseases, New York, case series for PD
NY, USA
Lozano et al. Toronto Hospital, 1996 Journal of Description Methods for microelectrode- 304 6 12.16 7
[30] Toronto, Canada neurosurgery of technique guided posteroventral
pallidotomy
Iacono et al. Loma Linda 1995 Neurosurgery Case series The results, indications, and 243 7 9.35 10
[53] University School of physiology of posteroventral
Medicine, Loma pallidotomy for patients with
Linda, CA, USA PD
Vitek et al. Emory University, 1998 Journal of Description Microelectrode-guided 219 8 9.52 9
[70] Atlanta, GA, USA neurosurgery of technique pallidotomy: technical
approach and its application in
medically intractable PD
Lozano et al. Toronto Hospital, 1997 Movement Case report Globus pallidus internus 216 9 9.00 12
[36] Toronto, Canada disorders pallidotomy for generalized
dystonia
Laitinen et Sophiahemmet 1992 Stereotactic Case series Ventroposterolateral 182 10 6.28 25
al. [19] Hospital, Stockholm, and functional pallidotomy can abolish all
Sweden neurosurgery Parkinsonian symptoms

CC, citation count; CY, citations per year; PD, Parkinson disease.

randomized controlled trials. The journal with the great-
est number of top-cited studies was the Journal of Neu-
rosurgery with a total of 17 articles, followed by neurosur-
gery with 13, and movement disorders with 12.
Most Cited Documents
The article with the most number of total citations
(856) as well as the maximum CY (29.52) was authored
by Laitinen et al. [13] from the Sophiahemmet Hospital,
Stockholm, and University Hospital, Umea, Sweden
(published in the Journal of Neurosurgery, 1991) The av-
erage number of citations per document (citation count)
was 118.1 (range – 856–46) (Table 2, online suppl. mate-
rial). The average number of CY per document (CY) was
5.326 (range – 29.52–2.09).
Top Authors
The top-100 articles had a total of 382 authors. Five
were single-authored documents. Each article had an av-
erage of 3.82 authors per document. An analysis of the
article production frequency of the top authors with time
revealed that most of the top-cited articles were published
in the late nineties, with only a few articles published in
the last 2 decades, reflecting a waning interest in the top-
ic (Fig.  1b). The 3 most prolific authors were Lang AE
(Neurologist – Toronto), Lozano AM (Neurosurgeon –
129.215.16.30 - 8/12/2021 1:37:28 AM

Top-100 Cited Articles on Pallidotomy Stereotact Funct Neurosurg 3

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
Toronto), and Vitek JL (Neurologist – Atlanta) (Fig. 1c).
The collaboration index was 3.98.
Country of Origin of Articles
The maximum number of publications were from the
USA (45), followed by Canada (19), and the UK (7)
(Fig. 2a). The top 3 most productive universities were the
University of Toronto (16), Emory University (8), and
Baylor College of Medicine (5) (Fig. 2b).
Most Frequently Encountered Terms
The most common keywords clustering with pallidot-
omy have changed with time from “lesions,” “primate,”
“neurons,” and “monkeys” to “pallidal stimulation,”
“deep brain stimulation,” “motor function,” and “dysto-
nia” in more recent years (Fig. 3a). The co-citation analy-
sis revealed a shift from keywords such as “Parkinson,”
“bradykinesia,” and “dyskinesia” to “dystonia,” “review,”
and “deep brain stimulation” (Fig. 3b).
Discussion
Bibliometric analyses provide a synopsis of the re-
search done on a particular topic of interest. To the best
of our knowledge, this is the first study of its kind related
to pallidotomy. The initial years of functional neurosur-
gery were constrained by a limited understanding of the
basal ganglia networks. Pallidotomy was introduced in
the late 1940s by Spiegel and Wycis [1] for Huntington’s
chorea [2, 3]. The anterodorsal portion of the globus pal-
lidum was the initial intended target. Some of its most
vocal proponents were the Swiss group of Krayenbuhl
and Narabayashi in Japan [2, 3, 14–17]. Notably, the
Swedish group led by Leksell was lesioning the postero-
ventral part of the pallidum, which has since been proven
to be the most physiologically correct target. But their
technique did not gain much attention at the time [2, 3,
14–17]. Surgery was further limited by the inadequate lo-
calization of the intracranial target, inability to accurately
limit the lesion size, and no immediate objective method
other than clinical examination to ascertain the accuracy
of the lesion. Not surprising only inconsistent results
could be obtained with varying complication rates [2, 3].
Fig. 1. a RPYS analysis showing the maximum number of top-
cited articles published in the late nineties. b Bubble chart depict-
ing the most cited articles (more the citations and larger the bub-
ble) published by the top authors plotted against time. c Density
4 Stereotact Funct Neurosurg
DOI: 10.1159/000516237
Pallidotomy was soon abandoned due to the increasing
interest in thalamotomy for the treatment of tremor and
the discovery of levodopa as an effective medical therapy
for Parkinson’s disease (PD) [2, 3, 18]. Long-term follow-
up of medical therapy led to the reports of levodopa-in-
duced dyskinesia and treatment-resistant PD [2–4]. This
renewed interest in the surgical treatment of the condi-
tion. As depicted in the RPSY analysis of the most cited
articles, the last decade of the twentieth century can be
called the golden era of pallidotomy. Posteroventral palli-
dotomy was rediscovered by the Swedish group led by
Laitinen et al. [13, 19] at Umea. Their 1992 publication in
the Journal of Neurosurgery is the most cited article on
the subject to date. They reported results of pallidotomy
in 38 patients with PD (unilateral in 34 and bilateral in 4).
Beneficial effects on rigidity, hypokinesia, levodopa-in-
duced dyskinesia, and gait were seen in 92% of the pa-
tients. Further, an improvement was seen in 26 out of the
32 patients with preoperative tremors. The most com-
mon adverse effect was partial homonymous hemianopia
in 6 patients and motor weakness in 2 patients [13]. Along
with this pioneering case series, there was an increased
understanding of the function of the globus pallidum and
its effect on various movement disorders [20–23]. Animal
models provided further evidence of the abnormally in-
creased activation of the globus pallidum, thus providing
a rationale for its surgical lesioning for the treatment of
various movement disorders [22, 24]. Segregated senso-
rimotor pathways in distinct areas of the globus pallidum
were then discovered [20, 21]. More recently, the theory
that the basal ganglia are a part of a larger network involv-
ing the thalamus and the cortical structures has gained
traction [25–27]. Treatment, whether in the form of med-
ical therapy or surgery, is targeted to modify this network
to ameliorate the symptoms of a particular movement
disorder.
The majority of the recent research in the past 3 de-
cades has been conducted in North America. Sixty-seven
of the top-100 cited articles are from the USA or Canada.
The Toronto group led by neurosurgeon Lozano et al.
[28] and neurologist Lang et al. [29] has been the most
prolific, with 16 articles in the top 100. Articles in the top
10 included case series in high impact factor journals like
Lancet and New England Journal of Medicine. The article
map of author co-citation analysis in references on pallidotomy
(number of receiving citations increases from blue to yellow).
RPYS, reference publication year spectroscopy.
(For figure see next page.)
129.215.16.30 - 8/12/2021 1:37:28 AM
Agrawal/Garg/Samala/Rajan/Singh
University of Edinburgh
Downloaded by:
 Color version available online
Reference publication year spectroscopy

400

Cited references
200

–200
17
24
31
38
45
52
59
66
73
80
87
94
01
08
15
22
29
36
43
50
57
64
71
78
85
92
99
06
13
18
18
18
18
18
18
18
18
18
18
18
18
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
a Number of cited references (black line) - deviation from the 5-year median (red line)

Top-author’s production over the time

Lang Ae
Lozano Am
Vitek Jl
Delong Mr
Bakay Rae N.Articles
Hariz Mi 1
Obeso Ja 2
Beric A
Duff J 3
Grossman Rg 4
Author

Jankovic J
Dogali M TC per year
Dostrovsky Jo
Favre J 10
Fazzini E 20
Gross Re 30
Hutchison Wd
Krack P
Saint-cyr Ja
Sterio D

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
b Year

Krauss, jk

Fahn, s Fazzini, e
Lozano, a
Jankovic, j Johansson, f

Eidelberg, d Sutton, jp Dogali, m Iacono, rp

Lang, ae
Sterio, d
Hutchison, wd Uitti, rj
Baron, ms
Kishore, a
Goetz, cg
Langston, jw Lozano, am Samuel, m
Filion, m
Lenz, fa
Schaltenbrand, g Merello, m
Scott, r
Kelly, pj

Kumar, r
Marsden, cd Obeso, ja
Vitak, ji
Laitinen, lv
Delong, mr
Svennilson, e De bie, rma
Alexander, ge Guridi, j Pahwa, r
Hariz, mi Gross, re

Bergman, h Limousin, p
Hassler, r
Tasker, rr

Ghika, j Krack, p
Meyers, r Guiot, g
Bakay, rae
Cooper, is Siegfried, j
Benabid, al
Narabayashi, h
Spiegel, ea

VOSwiewer
c

1
129.215.16.30 - 8/12/2021 1:37:28 AM

Top-100 Cited Articles on Pallidotomy Stereotact Funct Neurosurg 5

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
 Table 3. List of journals ranked according to the number of top-cited articles published.

Rank Journal name Articles, n Impact factor

(2018)

1 Journal of neurosurgery 17 4.130

2 Neurosurgery 13 4.605
3 Movement disorders 12 8.222
4 Annals of neurology 9 9.496
5 Brain 9 11.814
6 Neurology 9 8.689
7 Stereotactic and functional neurosurgery 5 1.905
8 JAMA neurology 4 12.321
9 Lancet 3 59.102
10 Brain and cognition 2 2.619
11 Journal of neurology 2 4.204
12 Journal of neurology, neurosurgery, and psychiatry 2 8.327
13 New England journal of medicine 2 70.670
14 Arquivos de Neuro-Psiquiatria 1 1.048
15 Bailliere’s clinical neurology 1 NA
16 Clinical neurology and neurosurgery 1 1.672
17 European journal of neurology 1 4.387
18 Experimental brain research 1 1.878
19 Journal of geriatric, psychiatry, and neurology 1 2.747
20 Journal of pediatrics and child health 1 1.688

The journal impact factor was based on Thomson Reuters web of knowledge journal citation reports ranking
(2018).

in New England Journal of Medicine described the results
of pallidotomy in 40 patients with PD. At 6 months, an
improvement of 28% in overall motor function (more in
the contralateral limbs), 82% improvement in contralat-
eral dyskinesias, 44% for ipsilateral dyskinesias, and 29%
improvement in activities of daily living were reported.
Eleven patients were followed up to 2 years, and improve-
ment in contralateral limbs was maintained, while the im-
provements in ipsilateral limbs were lost. No reduction in
medications could be achieved [29]. An eloquent descrip-
tion of the surgical technique, published in 1996 further
popularized the role of pallidotomy in the surgical arma-
mentarium of PD [30]. Microelectrode recordings uti-
lized in these cases also led to another landmark discovery
of neurons causing rest tremor associated with PD and
the reason behind the relief of tremor after pallidotomy
[31]. Sustained long-term improvements in contralateral
dyskinesia have been reported even up to 10 years after
surgery [32, 33]. The neuropsychological outcomes fol-
lowing pallidotomy were also elucidated [34, 35].
In 1997, Lozano et al. [36] published a landmark case
report describing pallidotomy for the treatment of gener-
alized dystonia. This, along with other reports of its ben-
eficial effect led to the addition of another important in-
dication for pallidotomy, which has since supplanted PD
as the most common indication [4, 37–39]. Improved re-
sponsiveness of primary as compared to secondary dys-
tonia was also demonstrated in a comparative case series
published in 2004 [40]. Several centers in the USA simul-
taneously adopted this technique, published several land-
mark articles, and cemented the status of pallidotomy as
an efficacious technique for PD. Newer indications were
found for the technique. It was found to be efficacious in
status dystonicus, severe cervical dystonia, hemiballis-
mus, and even in selected cases of secondary dystonia
[41–46]. Overall, this represents a significant contribu-
tion to the clinical advancements as well to the patho-
physiological understanding of the impact of pallidotomy
on movement disorders.
Our results reveal that there is a paucity of randomized
controlled trials on pallidotomy. This is because double
blinding cannot be ethically achieved in surgical proce-
dures involving lesioning, unlike deep brain stimulation,
where the electrical signal can be turned off to create a
control group. The first clinical trial was reported from
The Netherlands in 1999, which clearly showed the ben-
efit of unilateral pallidotomy over medical therapy [47].
Another trial from Emory University, USA showed simi-
129.215.16.30 - 8/12/2021 1:37:28 AM

6 Stereotact Funct Neurosurg Agrawal/Garg/Samala/Rajan/Singh

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
 Color version available online
Corresponding author’s country

Usa

Canada

United Kingdom

Spain

Sweden
Countries

Netherlands

Argentina

Germany

Switzerland

Australia
Collaboration ■ SCP ■ MCP
Brazil

0 10 20 30
Documents, n

a SCP: single country publications, MCP: multiple country publications

Most relevant affiliations

Univ Toronto
Emory Univ
Baylor Coll Med
Toronto Hosp
Univ Amsterdam
Sch Med
Raul Carrea Inst Neurol Res
Univ Calif Los Angeles
Univ So Calif
Affiliations

Univ Texas
Toronto Western Hosp
Brown Univ
Inst Neurol
Umea Univ Hosp
Ctr Int Restaurac Neurol
Ctr Neurol
Movement Disorders Ctr
Sophiahemmet Hosp
Univ Hosp No Sweden
Univ Kansas

0 10 20 30
b Documents, n

Fig. 2. Bar chart depicting the corresponding author’s country (MCP SCP) (a), and the most relevant universi-
ties/hospitals (b). MCP, multiple country publication; SCP, single country publication.

lar results, with a sustained benefit at 2 years [48]. This
absence of high-quality Class I evidence could explain the
high number of review articles (20) which have made it to
the list of top-100 cited articles. This also highlights the
importance of well-performed case series and the humble
case reports in driving advancements and the establish-
ment of surgical techniques.
The arrival of DBS in the late nineties resulted in an-
other plunge in popularity of pallidotomy. Analysis of co-
occurrence of keywords depicts this shift in focus by the
129.215.16.30 - 8/12/2021 1:37:28 AM

Top-100 Cited Articles on Pallidotomy Stereotact Funct Neurosurg 7

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
increase in research on DBS in the last 2 decades (Fig. 3).
The irreversible nature of the lesion produced by palli-
dotomy also resulted in permanent adverse effects when
the target was misplaced [3, 4, 49]. Aggressive marketing
by the newly emerging DBS industry, the reversibility of
the stimulation, and the ability to perform simultaneous
bilateral procedures drew attention away from lesioning.
A randomized trial comparing unilateral pallidotomy
and bilateral DBS showed better outcomes with DBS [50,
51]. No comparative trial has been conducted comparing
bilateral pallidotomy with bilateral DBS, probably due to
the perceived high complication rate with the former
[52]. This claim has been disputed by some authors who
have demonstrated bilateral procedures with minimal
complications [33, 53–55]. Even after all these years and
criticisms, unilateral pallidotomy continues to endure as
one of the recommended procedures of choice by the In-
ternational Movement Disorders Society for the surgical
treatment of motor symptoms of PD [56]. It is still the
procedure of choice in patients who are unable to afford
the high cost of DBS, who are unable to travel for long
distances for DBS programming, those who are medical-
ly unfit to undergo a long procedure and to endure gen-
eral anesthesia, or those who are unwilling to get hard-
ware implanted in their bodies, and in selected patients
with generalized dystonia in whom there are concerns
over lead breakage and rapid drainage of battery [3, 4].
This forms a sizable portion of the world population, with
more than two-thirds residing in low- to middle-income
countries, with an increasing focus on reducing health-
care-related costs even in high-income countries. Public
health systems of most counties demand financial ac-
countability from health care providers. A review article
from Brazil highlighted the cost-effectiveness of pallidot-
omy as compared to DBS, especially in patients of low
socioeconomic status with no insurance and those with
comorbidities [57]. The low- and middle-income coun-
tries are leading the resurgence of this technique. Thus, it
is crucial to continue to train the newer generation of
neurosurgeons in the operative technique of pallidotomy
as a lack of training in pallidotomy may itself contribute
to a decrease in the popularity of the procedure [58]. The
recent introduction of diffusion tensor imaging to clearly
identify the relevant tracts in the critical neighborhood to
avoid complications has the potential to improve out-
Fig. 3. a Network visualization map of trends in research based on
keyword analysis (blue denotes older, and yellow denotes recent
trends). b Network visualization map of co-citation analysis of
8 Stereotact Funct Neurosurg
DOI: 10.1159/000516237
comes and reduce complications [11, 59–61]. Further
technological advances have seen the development of
noninvasive techniques for pallidotomy like gamma knife
and MR-guided focused ultrasound [11]. The efficacy of
such procedures is slowly being proven by Class I evi-
dence. In a short span of time, there have been numerous
studies on these topics in order to work out the nuances
of providing the best results with minimum patient dis-
comfort [62, 63].
Limitations of this study include some of the inherent
drawbacks of bibliometric analysis. The reasons why an
article is cited multiple times may be diverse and may not
accurately reflect the influence of the study in question
[64]. Sole reliance on these indicators can lead to missing
some of the articles reporting important results as con-
firmed by expert’s review [65]. Similarly, recent publica-
tions on the topic as well as young researchers might not
have accrued enough citations to make it to the list of top
100 articles [66]. The ranking according to CY is an at-
tempt to correct this deficiency. The top 100 articles have
been published in the English language. There could be
possible bias against articles published in other languages
[67]. The search was conducted on Web of Science, which
is the most common database used for bibliometric anal-
yses, but still, fallacious exclusions of some articles could
have happened due to the keyword-specific results ob-
tained. Nevertheless, the importance of this method of
analysis lies in its transparent and objective nature. It pro-
vides a broad overview of the direction, in which the field
is headed, and complements the expert peer-review pro-
cess [6].
Conclusions
The scientific process is becoming more and more
complex. Therefore, it is important to identify the most
important topics and contributors to the field so that a
notion of the priorities and trends in research can be at-
tained, as well as to identify lacunae to direct future re-
search. Our analysis provides a unique evidence-based
comparative visualization of the research output and its
impact pertaining to the field of pallidotomy. In the last 2
decades, DBS has supplanted pallidotomy as the proce-
dure of choice. This has led to a gradual reduction in the
keywords (blue denotes older and yellow denotes recent). PD, Par-
kinson disease.
(For figure see next page.)
129.215.16.30 - 8/12/2021 1:37:28 AM
Agrawal/Garg/Samala/Rajan/Singh
University of Edinburgh
Downloaded by:
 Color version available online
Parkinsons-disease

Generalized dystonia

Dystonia Functional neurosurgery

Stereotactic surgery

Ventroposterolateral pallidoto

Advanced parkinsons-disease
Monkeys

Movement-disorders Dyskinesia
Thalamic-stimulation
Posteroventral pallidotomy
Pallidal stimulation

Surgery Tremor Movement

Pallidotomy
Unilateral pallidotomy Thalamotomy

Neurons
Motor function

gpi pallidotomy
Parkinsons-disease
Subthalamic nucleus stimulation
Thalamus Symptoms
Deep brain stimulation
Deep brain-stimulation Globus-pallidus

Lesions

Stereotaxic pallidotomy Basal ganglia

Globus pallidus
Deep-brain-stimulation Stereotaxy

Follow-up

Medial pallidotomy Primate

Posterior gpi pallidotomy
Subthalamic nucleus

Stereotaxic surgery
Unilateral posteroventral pall

Core assessment program

Motor

VOSviewer
a 1996 1998 2000 2002 2004

b 1998 1999 2000 2001 2002 2003

3
129.215.16.30 - 8/12/2021 1:37:28 AM

Top-100 Cited Articles on Pallidotomy Stereotact Funct Neurosurg 9

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
number of pallidotomies performed all over the world.
An unexpected consequence of this might be the loss of
training opportunities for the newer generation of neuro-
surgeons to successfully and safely perform this proce-
dure. We must safeguard against the eventual loss of the
skill set, which may occur if this continues. Newer ad-
vances in technology like focused ultrasound and im-
proved targeting techniques have the potential to renew
interest in pallidotomy and lead to a fresh wave of publi-
cations in the coming years.
Statement of Ethics
This article does not contain any studies involving human par-
ticipants or animals performed by any of the authors.
Funding Sources
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Author Contributions
Mohit Agrawal: writing – original draft; writing – review and
editing; investigation; methodology; and visualization. Kanwaljeet
Garg: conceptualization; data curation; formal analysis; investiga-
tion; methodology; project administration; resources; software;
supervision; validation; visualization; writing – original draft; and
writing – review and editing. Raghu Samala: writing – review and
editing; investigation; and methodology. Roopa Rajan: investiga-
tion; methodology; and writing – review and editing. Manmohan
Singh: project administration and supervision.
Data Availability Statement

Conflict of Interest Statement All data generated or analyzed during this study are included
in this article [and/or] its supplementary material files. Further
The authors have no conflicts of interest to declare. enquiries can be directed to the corresponding author.

References
  1 Wycis HT, Spiegel EA. The effect of thalamot-
omy and pallidotomy upon involuntary
movements in chorea and athetosis. Surg Fo-
rum. 1950;329–32.
  2 Guridi J, Lozano AM. A brief history of palli-
dotomy. Neurosurgery. 1997;41(5):1169–3.
  3 Gross RE. What happened to posteroventral
pallidotomy for Parkinson’s disease and dys-
tonia? Neurotherapeutics. 2008;5(2):281–93.
  4 Cif L, Hariz M. Seventy years with the globus
pallidus: pallidal surgery for movement disor-
ders between 1947 and 2017. Mov Disord.
2017;32(7):972–82.
  5 Cole S, Meyer GS. Little science, big science re-
visited. Scientometrics. 1985;7(3–6):443–58.
  6 Belter CW. Bibliometric indicators: opportu-
nities and limits. J Med Libr Assoc. 2015;
103(4):219–21.
  7 Hariz MI. From functional neurosurgery to
“interventional” neurology: survey of publi-
cations on thalamotomy, pallidotomy, and
deep brain stimulation for Parkinson’s dis-
ease from 1966 to 2001. Mov Disord. 2003;18:
845–53.
  8 Cabezas-Clavijo A, Robinson-García N, Esca-
bias M, Jiménez-Contreras E. Reviewers' rat-
ings and bibliometric indicators: hand in
hand when assessing over research proposals?
PLoS One. 2013 Jun 28;8(6):e68258.
  9 Mingers J, Leydesdorff L. A review of theory
and practice in scientometrics. arXiv. 2015.
10 Synnestvedt MB, Chen C, Holmes JH.
CiteSpaceII: visualization and knowledge dis-
covery inbibliographic databases. AMIA
Annu Symp Proc. 2005;2005:724–8.
11 Krack P, Martinez-Fernandez R, Del Alamo
M, Obeso JA. Current applications and limi-
tations of surgical treatments for movement
disorders. Mov Disord. 2017;32(1):36–52.
12 Rodriguez-Oroz MC, Moro E, Krack P. Long-
term outcomes of surgical therapies for par-
kinson’s disease. Mov Disord. 2012; 27(14):
1718–28.
13 Laitinen LV, Bergenheim AT, Hariz MI. Lek-
sell’s posteroventral pallidotomy in the treat-
ment of Parkinson’s disease. J Neurosurg.
1992;76:53–61.
14 Svennilson E, Torvik A, Lowe R, Leksell L.
Treatment of parkinsonism by stereotactic
thermolesions in the pallidal region: a clinical
evaluation of 81 cases. Acta Psychiatr Scand.
1960;35:358–77.
15 Krayenbuhl H, Wyss OA, Yasargil MG. Bilat-
eral thalamotomy and pallidotomy as treat-
ment for bilateral Parkinsonism. J Neurosurg.
1961;18:429–44.
16 Narabayashi H, Okuma T. Procaine oil block-
ing of the globus pallidus for the treatment of
rigidity and tremor of parkinsonism. Psychi-
atr Neurol Jpn. 1953;56:471–95.
17 Narabayashi H, Shimazu H, Fujita Y, Shikiba
S, Nagao T, Nagahata M. Procaine-oil-wax
pallidotomy for double athetosis and spastic
states in infantile cerebral palsy: report of 80
cases. Neurology. 1960;10:61–9.
18 Hassler R, Riechert T, Mundinger F, Umbach
W, Ganglberger JA. Physiological observa-
tions in stereotaxic operations in extrapyra-
midal motor disturbances. Brain. 1960; 83:
337–50.
19 Laitinen LV, Bergenheim AT, Hariz MI. Ven-
troposterolateral pallidotomy can abolish all
parkinsonian symptoms. Stereotact Funct
Neurosurg. 1992;58:14–21.
20 Alexander GE, DeLong MR, Strick PL. Paral-
lel organization of functionally segregated cir-
cuits linking basal ganglia and cortex. Annu
Rev Neurosci. 1986;9:357–81.
21 Draganski B, Kherif F, Klöppel S, PA, DC,
GJM, et al. Evidence for segregated and inte-
grative connectivity patterns in the human
basal ganglia. J Neurosci. 2008; 28(28): 7143–
52.
22 DeLong MR. Primate models of movement
disorders of basal ganglia origin. Trends Neu-
rosci. 1990;13(7):281–5.
23 DeLong MR, Wichmann T. Circuits and cir-
cuit disorders of the basal ganglia. Arch Neu-
rol. 2007;64(1):20–4.
24 Obeso JA, Rodriguez-Oroz MC, Rodriguez
M, Arbizu J, Gimenez-Amaya JM. The basal
ganglia and disorders of movement: patho-
physiological mechanisms. News Physiol Sci.
2002;17:51–5.
25 Pujol S, Cabeen R, Sébille SB, Yelnik J, Fran-
çois C, Fernandez Vidal S, et al. In vivo explo-
ration of the connectivity between the subtha-
lamic nucleus and the globus pallidus in the
human brain using multi-fiber tractography.
Front Neuroanat. 2016;10:119.
26 Hahn PJ, McIntyre CC. Modeling shifts in the
rate and pattern of subthalamopallidal net-
work activity during deep brain stimulation. J
Comput Neurosci. 2010;28(3):425–41.
129.215.16.30 - 8/12/2021 1:37:28 AM

10 Stereotact Funct Neurosurg Agrawal/Garg/Samala/Rajan/Singh

DOI: 10.1159/000516237
University of Edinburgh
Downloaded by:
27 McIntyre CC, Hahn PJ. Network perspectives
on the mechanisms of deep brain stimulation.
Neurobiol Dis. 2010;38(3):329–37.
28 Lozano AM, Lang AE, Galvez-Jimenez N, Mi-
yasaki J, Duff J, Hutchinson WD, et al. Effect of
GPi pallidotomy on motor function in Parkin-
son’s disease. Lancet. 1995;346(8987):1383–7.
29 Lang AE, Lozano AM, Montgomery E, Duff J,
Tasker R, Hutchinson W. Posteroventral me-
dial pallidotomy in advanced Parkinson’s dis-
ease. N Engl J Med. 1997;337(15):1036–42.
30 Lozano A, Hutchison W, Kiss Z, Tasker R,
Davis K, Dostrovsky J. Methods for micro-
electrode-guided posteroventral pallidotomy.
J Neurosurg. 1996;84(2):194–202.
31 Hutchison WD, Lozano AM, Tasker RR, Lang
AE, Dostrovsky JO. Identification and char-
acterization of neurons with tremor-frequen-
cy activity in human globus pallidus. Exp
Brain Res. 1997;113(3):557–63.
32 Fine J, Duff J, Chen R, Chir B, Hutchison W,
Lozano AM, et al. Long-term follow-up of
unilateral pallidotomy in advanced Parkin-
son’s disease. N Engl J Med. 2000; 342(23):
1708–14.
33 Hariz MI, Bergenheim AT. A 10-year follow-
up review of patients who underwent Leksell’s
posteroventral pallidotomy for Parkinson
disease. J Neurosurg. 2001;94:552–8.
34 Trépanier LL, Saint-Cyr JA, Lozano AM,
Lang AE. Neuropsychological consequences
of posteroventral pallidotomy for the treat-
ment of Parkinson’s disease. Neurology. 1998;
51(1):207–15.
35 Trépanier LL, Kumar R, Lozano AM, Lang
AE, Saint-Cyr JA. Neuropsychological out-
come of GPi pallidotomy and GPi or STN
deep brain stimulation in Parkinson’s disease.
Brain Cogn. 2000;42(3):324–47.
36 Lozano AM, Kumar R, Gross RE, Giladi N,
Hutchison WD, Dostrovsky JO, et al. Globus
pallidus internus pallidotomy for generalized
dystonia. Mov Disord. 1997;12(6):865–70.
37 Iacono RP, Kuniyoshi SM, Lonser RR, Maeda
G, Inae AM, Ashwal S. Simultaneous bilateral
pallidoansotomy for idiopathic dystonia
musculorum deformans. Pediatr Neurol.
1996;14(2):145–8.
38 Ondo WG, Desaloms JM, Jankovic J, Gross-
man RG. Pallidotomy for generalized dysto-
nia. Mov Disord. 1998;13(4):693–8.
39 Cersosimo MG, Raina GB, Piedimonte F, An-
tico J, Graff P, Micheli FE. Pallidal surgery for
the treatment of primary generalized dysto-
nia: long-term follow-up. Clin Neurol Neuro-
surg. 2008;110(2):145–50.
40 Eltahawy HA, Saint-Cyr J, Giladi N, Lang AE,
Lozano AM. Primary dystonia is more re-
sponsive than secondary dystonia to pallidal
interventions: outcome after pallidotomy or
pallidal deep brain stimulation. Neurosur-
gery. 2004;54(3):613–21.
41 Suarez JI, Metman LV, Reich SG, Dougherty
PM, Hallett M, Lenz FA. Pallidotomy for
hemiballismus: efficacy and characteristics of
neuronal activity. Ann Neurol. 1997; 42(5):
807–11.
Top-100 Cited Articles on Pallidotomy
42 Kyriagis M, Grattan-Smith P, Scheinberg A,
Teo C, Nakaji N, Waugh M. Status dystonicus
and Hallervorden-Spatz disease: treatment with
intrathecal baclofen and pallidotomy. J Paediatr
Child Health. 2004 May–Jun;40(5–6):322–5.
43 Teive HA, Munhoz RP, Souza MM, Antoniuk
SA, Santos MLSF, Teixeira MJ, et al. Status
dystonicus: study of five cases. Arq Neurop-
siquiatr. 2005;63(1):26–9.
44 Işlekel S, Zileli M, Zileli B. Unilateral pallidal
stimulation in cervical dystonia. Stereotact
Funct Neurosurg. 1999;72(2–4):248–52.
45 Singh M, Garg K. Musician’s dystonia: what a
neurosurgeon can offer! Neurol India. 2020
Jan–Feb;68(1):152–3.
46 Justesen CR, Penn RD, Kroin JS, Egel RT. Ste-
reotactic pallidotomy in a child with Haller-
vorden-Spatz disease. Case report. J Neuro-
surg. 1999;90(3):551–4.
47 de Bie RM, de Haan RJ, Nijssen PC, Rutgers
AW, Beute GN, Bosch DA, et al. Unilateral
pallidotomy in Parkinson’s disease: a ran-
domised, single-blind, multicentre trial. Lan-
cet. 1999;354(9191):1665–9.
48 Vitek JL, Bakay RA, Freeman A, Evatt M,
Green J, McDonald W, et al. Randomized tri-
al of pallidotomy versus medical therapy for
Parkinson’s disease. Ann Neurol. 2003;53(5):
558–69.
49 Gross RE, Lombardi WJ, Lang AE, Duff J,
Hutchison WD, Saint-Cyr JA, et al. Relationship
of lesion location to clinical outcome following
microelectrode-guided pallidotomy for Parkin-
son’s disease. Brain. 1999;122(Pt 3):405–16.
50 Esselink RA, de Bie RM, de Haan RJ, Lenders
MWPM, Nijssen PCG, Staal MJ, et al. Unilat-
eral pallidotomy versus bilateral subthalamic
nucleus stimulation in PD: a randomized tri-
al. Neurology. 2004;62(2):201–7.
51 Esselink RA, de Bie RM, de Haan RJ, Steur
ENHJ, Beute GN, Portman AT, et al. Unilat-
eral pallidotomy versus bilateral subthalamic
nucleus stimulation in Parkinson’s disease:
one year follow-up of a randomised observer-
blind multi centre trial. Acta Neurochir. 2006;
148(12):1247–55.
52 Merello M, Starkstein S, Nouzeilles MI, Kuzis
G, Leiguarda R. Bilateral pallidotomy for
treatment of Parkinson’s disease induced cor-
ticobulbar syndrome and psychic akinesia
avoidable by globus pallidus lesion combined
with contralateral stimulation. J Neurol Neu-
rosurg Psychiatry. 2001;71:611–4.
53 Iacono RP, Lonser RR, Kuniyoshi S. Unilat-
eral versus bilateral simultaneous posteroven-
tral pallidotomy in subgroups of patients with
Parkinson’s disease. Stereotact Funct Neuro-
surg. 1995;65(1–4):6–9.
54 Iacono RP, Carlson JD, Kuniyoshi S, Mo-
hamed A, Meltzer C, Yamada S. Contempo-
raneous bilateral pallidotomy. Neurosurg Fo-
cus. 1997;2(3):e5.
55 Blomstedt P, Hariz MI. Are complications
less common in deep brain stimulation than
in ablative procedures for movement disor-
ders? Stereotact Funct Neurosurg. 2006;84(2–
3):72–81.
Stereotact Funct Neurosurg
DOI: 10.1159/000516237
56 Fox SH, Katzenschlager R, Lim SY, Barton B,
de Bie RMA, Seppi K, et al. International Par-
kinson and movement disorder society evi-
dence-based medicine review: Update on
treatments for the motor symptoms of Par-
kinson’s disease. Mov Disord. 2018; 33(8):
1248–66.
57 Spindola B, Leite MA, Orsini M, Fonoff E,
Landeiro JA, Pessoa BL. Ablative surgery for
Parkinson’s disease: Is there still a role for
pallidotomy in the deep brain stimulation
era? Clin Neurol Neurosurg. 2017;158:33–9.
58 Garg K, Samala R, Agrawal M, Rajan R, Singh
M. Letter to the editor. The role of unilateral
pallidotomy in cervical dystonia. J Neurosurg
Spine. 2020;68:1–2.
59 Na YC, Chang WS, Jung HH, Kweon EJ,
Chang JW. Unilateral magnetic resonance-
guided focused ultrasound pallidotomy for
Parkinson disease. Neurology. 2015; 85(6):
549–51.
60 Moosa S, Martínez-Fernández R, Elias WJ,
Del Alamo M, Eisenberg HM, Fishman PS.
The role of high-intensity focused ultrasound
as a symptomatic treatment for Parkinson’s
disease. Mov Disord. 2019;34(9):1243–51.
61 Sammartino F, Hodaie M. Diffusion tensor
imaging of the basal ganglia for functional
neurosurgery applications. Prog Neurol Surg.
2018;33:62–79.
62 Krishna V, Sammartino F, Rezai A. A review
of the current therapies, challenges, and fu-
ture directions of transcranial focused ultra-
sound technology: advances in diagnosis and
treatment. JAMA Neurol. 2018;75(2):246–54.
63 Lozano CS, Tam J, Lozano AM. The changing
landscape of surgery for Parkinson’s disease.
Mov Disord. 2018;33(1):36–47.
64 Garfield E. Is citation analysis a legitimate
evaluation tool? Scientometrics. 1979; 1(4):
359–75.
65 Allen L, Jones C, Dolby K, Lynn D, Walport
M. Looking for landmarks: the role of expert
review and bibliometric analysis in evaluating
scientific publication outputs. PLoS One.
2009 Jun 18;4(6):e5910.
66 Wang J. Citation time window choice for re-
search impact evaluation. Scientometrics.
2013;94(3):851–72.
67 Ren S, Zu G, Wang HF. Statistics hide impact
of non-English journals. Nature. 2002; 415:
732.
68 Baron MS, Vitek JL, Bakay RA, Green J,
Kaneoke Y, Hashimoto T, et al. Treatment of
advanced Parkinson’s disease by posterior
GPi pallidotomy: 1-year results of a pilot
study. Ann Neurol. 1996;40(3):355–66.
69 Dogali M, Fazzini E, Kolodny E, Eidelberg D,
Sterio D, Devinsky O, et al. Stereotactic ven-
tral pallidotomy for Parkinson’s disease. Neu-
rology. 1995;45(4):753–61.
70 Vitek JL, Bakay RA, Hashimoto T, Kaneoke Y,
Mewes K, Zhang JY, et al. Microelectrode-
guided pallidotomy: technical approach and
its application in medically intractable Par-
kinson’s disease. J Neurosurg. 1998; 88(6):
1027–43.
129.215.16.30 - 8/12/2021 1:37:28 AM
11
University of Edinburgh
Downloaded by: