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==Overview==
==Overview==
[[Surgery]] is not the first option in treating any cause of tremor. It is applied once non-[[pharmacological]] and [[pharmacological]] [[therapy]] fails. [[Botulinum]] [[neurotoxin]] [[injections]], [[thalamotomy]], [[deep brain stimulation]], [[magnetic resonance]]-guided focused [[ultrasound]], and [[radio-surgical gamma knife]] [[thalamotomy]] are the most common interventional procedures to treat tremors.
==Surgery==
==Surgery==
Surgical intervention such as thalamotomy and deep brain stimulation may ease certain tremors. These surgeries are usually performed only when the tremor is severe and does not respond to drugs.
[[Thalamotomy]], involving the creation of lesions in the brain region called the thalamus, is quite effective in treating patients with essential, cerebellar, or parkinsonian tremor. This in-hospital procedure is performed under local anesthesia, with the patient awake.  After the patient’s head is secured in a metal frame, the surgeon maps the patient’s brain to locate the thalamus.  A small hole is drilled through the skull and a temperature-controlled electrode is inserted into the thalamus.  A low-frequency current is passed through the electrode to activate the tremor and to confirm proper placement.  Once the site has been confirmed, the electrode is heated to create a temporary lesion. Testing is done to examine speech, language, coordination, and tremor activation, if any.  If no problems occur, the probe is again heated to create a 3-mm permanent lesion. The probe, when cooled to body temperature, is withdrawn and the skull hole is covered.  The lesion causes the tremor to permanently disappear without disrupting sensory or motor control.


[[Deep brain stimulation]] (DBS) uses implantable electrodes to send high-frequency electrical signals to the thalamus. The electrodes are implanted as described above. The patient uses a hand-held magnet to turn on and turn off a pulse generator that is surgically implanted under the skin. The electrical stimulation temporarily disables the tremor and can be “reversed,” if necessary, by turning off the implanted electrode. Batteries in the generator last about 5 years and can be replaced surgically. DBS is currently used to treat parkinsonian tremor and essential tremor.
*[[Botulinum]] [[neurotoxin]] [[injections]]:
**It has shown improvement in [[patients]] with [[hand]] tremor, regardless of the [[etiology]]. <ref name="pmid30029483">{{cite journal| author=Niemann N, Jankovic J| title=Botulinum Toxin for the Treatment of Hand Tremor. | journal=Toxins (Basel) | year= 2018 | volume= 10 | issue= 7 | pages=  | pmid=30029483 | doi=10.3390/toxins10070299 | pmc=6070882 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30029483  }} </ref>
*[[Thalamotomy|Thalamotomy:]] <ref name="pmid23154796">{{cite journal| author=Bahgat D, Magill ST, Berk C, McCartney S, Burchiel KJ| title=Thalamotomy as a treatment option for tremor after ineffective deep brain stimulation. | journal=Stereotact Funct Neurosurg | year= 2013 | volume= 91 | issue= 1 | pages= 18-23 | pmid=23154796 | doi=10.1159/000342491 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23154796  }} </ref>
**Helpful in [[medication]]-[[resistant]] [[essential tremor]], [[cerebellar]] tremor, or [[Parkinson's disease]] related tremor.
**Tremor is permanently treated by creating [[lesions]] in the [[thalamus]] responsible for causing tremors.
**Most common [[side effect]]s are [[dysarthria]], [[cognitive]] impairment, and imbalance.
**It is an invasive [[procedure]].
*[[Deep brain stimulation|Deep brain stimulation:]] <ref name="pmid18394574">{{cite journal| author=Lyons KE, Pahwa R| title=Deep brain stimulation and tremor. | journal=Neurotherapeutics | year= 2008 | volume= 5 | issue= 2 | pages= 331-8 | pmid=18394574 | doi=10.1016/j.nurt.2008.01.004 | pmc=5084174 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18394574  }} </ref>
**[[Parkinson's disease]] and [[essential tremor]] may benefit from [[deep brain stimulation]].
**In this non-invasive procedure, [[electrodes]] are [[implanted]] to send high-[[frequency]] [[electrical]] signals to the [[thalamus]], [[substantia nigra]], or [[globus pallidus]]. The downside of [[deep brain stimulation]] is the expense, and long-term benefits are not established. It is reversible.
*[[Magnetic resonance]]-guided focused [[ultrasound]] (MRgFUS): <ref name="pmid28298022">{{cite journal| author=Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M, Schlesinger I| title=Magnetic resonance-guided focused ultrasound thalamotomy for tremor: a report of 30 Parkinson's disease and essential tremor cases. | journal=J Neurosurg | year= 2018 | volume= 128 | issue= 1 | pages= 202-210 | pmid=28298022 | doi=10.3171/2016.10.JNS16758 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28298022  }} </ref>
**[[Noninvasive]] [[thalamotomy]] procedure uses [[thermal]] [[ablation]].
**Used in severe [[medication]]-[[resistant]] [[essential tremor]] or [[Parkinsonian]] tremor.
**Most of the [[side effects]] reported did not last more than three months.
*[[Radio-surgical gamma knife]] [[thalamotomy|thalamotomy:]] <ref name="pmid25690750">{{cite journal| author=Campbell AM, Glover J, Chiang VL, Gerrard J, Yu JB| title=Gamma knife stereotactic radiosurgical thalamotomy for intractable tremor: a systematic review of the literature. | journal=Radiother Oncol | year= 2015 | volume= 114 | issue= 3 | pages= 296-301 | pmid=25690750 | doi=10.1016/j.radonc.2015.01.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25690750  }} </ref>
**It is found to be safe if done unilaterally.
**Optimum dose from 130 to 150Gy is well tolerated.
**Most common [[side effects]] are mild [[contralateral]] [[numbness]] and transient [[hemiparesis]].


The most common side effects of tremor surgery include [[dysarthria]] (problems with motor control of speech), temporary or permanent cognitive impairment (including visual and learning difficulties), and problems with balance.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 19:59, 25 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Surgery is not the first option in treating any cause of tremor. It is applied once non-pharmacological and pharmacological therapy fails. Botulinum neurotoxin injections, thalamotomy, deep brain stimulation, magnetic resonance-guided focused ultrasound, and radio-surgical gamma knife thalamotomy are the most common interventional procedures to treat tremors.

Surgery

References

  1. ↑ Niemann N, Jankovic J (2018). "Botulinum Toxin for the Treatment of Hand Tremor". Toxins (Basel). 10 (7). doi:10.3390/toxins10070299. PMC 6070882. PMID 30029483.
  2. ↑ Bahgat D, Magill ST, Berk C, McCartney S, Burchiel KJ (2013). "Thalamotomy as a treatment option for tremor after ineffective deep brain stimulation". Stereotact Funct Neurosurg. 91 (1): 18–23. doi:10.1159/000342491. PMID 23154796.
  3. ↑ Lyons KE, Pahwa R (2008). "Deep brain stimulation and tremor". Neurotherapeutics. 5 (2): 331–8. doi:10.1016/j.nurt.2008.01.004. PMC 5084174. PMID 18394574.
  4. ↑ Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M, Schlesinger I (2018). "Magnetic resonance-guided focused ultrasound thalamotomy for tremor: a report of 30 Parkinson's disease and essential tremor cases". J Neurosurg. 128 (1): 202–210. doi:10.3171/2016.10.JNS16758. PMID 28298022.
  5. ↑ Campbell AM, Glover J, Chiang VL, Gerrard J, Yu JB (2015). "Gamma knife stereotactic radiosurgical thalamotomy for intractable tremor: a systematic review of the literature". Radiother Oncol. 114 (3): 296–301. doi:10.1016/j.radonc.2015.01.013. PMID 25690750.
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