Lesioning Surgery for Tremor and Dystonia

Abstract

  Surgical treatment, including deep brain stimulation (DBS) and ablative surgery targeting the basal ganglia-thalamo-cortical circuit, can provide substantial improvement even in refractory conditions. Ablative procedures include radiofrequency, gamma knife, and focused ultrasound. In particular, focused ultrasound ablation has attracted the most attention, allowing intracranial focal lesioning without incision.

  Tremor is the first common movement disorder, which is the best candidate for DBS or ablative surgery of the thalamic nucleus (ventral intermediate nucleus : Vim). Bilateral thalamotomy was abandoned because of severe complications, such as dysarthria, dysphonia, and dysphagia, and in those who require bilateral intervention, DBS plays a significant role. However, recent studies have emphasized the safety and efficacy of bilateral Vim thalamotomy. Tremor is the most well-investigated minimally invasive procedure, such as gamma knife and focused ultrasound ablation.

  Dystonia can develop from focal to generalized, and the available treatment targets differ according to their distribution. The globus pallidus internus (GPi) is the current mainstay target for cervical, segmental, or generalized dystonia. Distal limb dystonia (hand and foot dystonia) requires the intervention of the ventro-oral (Vo) nucleus of the thalamus. Vo-thalamotomy using radiofrequency, gamma knife, and focused ultrasound has been reported to have long-term effects on focal hand dystonia.