Objective: The objective of this report is to describe the effect of both unilateral and bilateral Gamma Knife thalamotomy (GKT) on axial tremor. Methods: Sixty-eight patients with essential tremor (ET) either only or predominantly affecting axial structures, including the head and neck, voice or lower jar, underwent staged bilateral GKT using previously described methods. A single lesion was made during each GKT procedure in the ventral intermediate (VIM) thalamic nucleus using one 4-mm collimator isocenter, and a maximum radiosurgical dose of 140 Gy. All patients had failed prior medical management. Tremor was graded on a five step scale [0-4] by a comprehensive movement disorder team before treatment, after unilateral thalamotomy and again after bilateral thalamotomy.

Results: There were statistically significant improvements in head, voice and lower jaw tremor after bilateral GKT (P. Keywords: Gamma Knife; thalamotomy; axial tremor Submitted Aug 08, 2014.

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Developing a Deep Brain Stimulation Neuromodulation Network for Parkinson Disease, Essential Tremor, and Dystonia: Report of a Quality Improvement Project. Fahn-Tolosa-Marin Tremor Rating. Jun 25, 2015 - Various clinical rating scales are used to quantify resting, postural, and action tremors such as the Fahn-Tolosa-Marin Tremor Rating Scale.

Accepted for publication Oct 17, 2014. Doi: 10.3978/j.issn.2218-676X.2014.11.01 Introduction Essential tremor (ET) is most frequently marked by tremor of the upper extremities but in some patients either in addition to extremity tremor or in isolation, tremor of the axial portions of the body including the head, voice and lower jaw may be disabling and require intervention. Primidone (mysoline) and beta blockers are the usual pharmacological treatments of ET and other anticonvulsant medications may also be used. In some patients however medical treatment fails, either because it is ineffective after a time or side effects prevent the use of adequate doses. In such circumstances surgical intervention may be considered. Patients with significant head tremor may be embarrassed in public or in more severe cases may be unable to read, use a computer, watch television or movies, drive a motor vehicle safely and may also develop neck pain due to constant head and neck movement. Voice tremor may interfere with communication via telephone or in severe cases even in face to face conversation.

The voice handicap associated with ET has multiple dimensions including physical, functional and emotional (). Hobbies or in some cases an individual’s livelihood may be impaired due to inability to sing or speak. Tremor of the lower jaw, although less common than head or voice tremor, may be extremely embarrassing in public and may interfere with eating, chewing and speaking. In some patients combinations of two or even three of these types of axial tremor may be severely disabling. A number of reports have described small numbers of patients treated for axial tremor by deep brain stimulation (DBS) usually in the ventral intermediate (VIM) thalamic nucleus (-).

The reports are rather conflicting in terms of a determination of the effectiveness of unilateral versus bilateral stimulation with some authors having reported excellent relief of axial tremor with unilateral stimulation and others indicating that bilateral stimulation provided the most effective treatment. A recent report suggests that the trajectory of electrode placement may influence the outcome (). Unfortunately, not all patients are candidates for DBS due to factors such as advanced age, chronic use of anticoagulants, multiple medical conditions (e.g., diabetes, severe coronary artery disease, severe pulmonary disease) or simply a refusal to undergo an open neurosurgical operation or to deal with implanted hardware with its long term problems (e.g., lead fracture, lead displacement, wearing off of effectiveness, and infection) including the need for programming and battery changes at varying intervals. In such patients, thalamotomy of the VIM nucleus with the Leksell Gamma Unit, the so-called “Gamma Knife” may be considered. In this report we describe our experience with bilateral Gamma Knife thalamotomy (GKT) for treatment of axial tremor. Materials and methods Sixty-eight patients with ET either predominantly or only affecting axial structures including head and neck, voice and lower jaw underwent staged bilateral GKT between 2006 and 2012.