Targeting Tremors
For patients who struggle with movement disorders, a nonsurgical treatment can help.
INTERVIEW WITH
Robert Gross, MD, PhD
Sipping a hot cup of coffee or tea might sound like a great way to start your morning, but for many people, it's not so easy. Those affected by essential tremor (ET) struggle to manage their steadiness, making everyday tasks, such as eating, drinking and buttoning clothing, a challenge—or sometimes even an impossibility.
"It can greatly affect quality of life," says Robert Gross, MD, PhD, joint chair of Neurosurgery at Rutgers Robert Wood Johnson Medical School and Rutgers New Jersey Medical School, senior vice president for Neurosurgical Services at RWJBarnabas Health, and a member of RWJBarnabas Health Medical Group.
An expert in functional and stereotactic neurosurgery, Dr. Gross addresses common movement disorders, including essential tremor and Parkinson's disease, as well as rarer forms, such as dystonia, Tourette syndrome and Huntington's disease.
Fortunately, when medication doesn't provide enough symptom relief, other treatment options can help.
The Evolution of Care
Since the 1950s, ET has been treated with radiofrequency (RF) thalamotomy, a procedure that requires inserting a probe through a small hole in the skull. The probe channels heat generated by radio waves to create a small lesion in the thalamus (a structure in the brain that controls movements). This lesion disrupts the abnormal circuits that are causing tremors.
What Is Essential Tremor?
Essential tremor (ET) is characterized by involuntary shaking, commonly in the hands and arms, face, voice, jaw, tongue and voice box; it rarely affects the lower half of the body. ET is diagnosed based on self-reported symptoms and a neurological examination. The condition is most common in adults over age 40, but people with a family history (50% of patients) may experience symptoms earlier. While tremor might increase over time, it does not shorten life expectancy. Treatment for ET can include:
Medication
Botulinum toxin, or Botox
Focused ultrasound
Deep brain stimulation
Occupational therapy
Lifestyle changes
If you're experiencing shaking in your upper body that interferes with your daily activities, such as eating, drinking, writing or working, consult a healthcare provider.
In the 1990s, deep brain stimulation became the preferred approach. "That's been a great treatment for essential tremor, Parkinson's disease and other disorders, but it does require implantation of hardware and the adjustments and maintenance that go along with that," Dr. Gross says.
Now, focused ultrasound (FUS) can be used to perform thalamotomies. This technique employs high-intensity sound waves to create the necessary lesion and, unlike RF thalamotomy, does not require an incision. "FUS procedures can be done in just a couple of hours without ever cutting skin," says Dr. Gross, who leads the FUS program at Robert Wood Johnson University Hospital Somerset. "It has been revolutionary."
How FUS Works
FUS relies on acoustic energy. "There are approximately 1,000 small probes that focus their energy at one spot, such that the rest of the brain only experiences a very trivial amount of heating," Dr. Gross says. "Where they come together, we can heat to temperatures that allow us to burn a hole, much like taking a lens and focusing the sun's energy on a leaf to burn it."
The procedure is performed inside an MRI scanner, where the patient is positioned in a frame that attaches to the head. Imaging is used to focus the sound waves on the target area. "We do that over a series of three or four steps while we're testing tremor and possible side effects in our patient," Dr. Gross says. "We monitor how we're doing, and when there's a noticeable improvement in the tremor, we know we're done."
Many patients can go home the day of the procedure. If tremor is present in both hands, patients must wait nine months between FUS treatments.
Who Can Benefit
If you have essential tremor, have failed a trial of beta blockers and Mysoline, and are healthy enough to undergo a procedure, then you could be a candidate for FUS, Dr. Gross says. It's a popular choice for patients who prefer to avoid a surgical procedure that requires anesthesia, or don't want a permanently implanted device.
"But FUS is not right for everyone," he says. "For example, the skulls of some people don't let enough of the sound waves through to complete the procedure. For those patients and for those wanting to have simultaneous surgery on both sides, we have other options, such as deep brain stimulation."
Some patients with tremor caused by Parkinson's disease also can be treated with FUS.
"For some of the more challenging conditions, we aim to offer our patients anything that's available anywhere across the country," Dr. Gross says. "We're making great progress with that. We're up to date and helping to advance the latest research into these conditions."
Learn More
To learn more about neurosurgery at RWJBarnabas Health, visit www.rwjbh.org/neuro.
