Neurosurgical conundrum: Better to fix it or cut it out?

Neurosurgical conundrum: Better to fix it or cut it out?

Neurosurgical conundrum: Better to fix it or cut it out?


Neuro-augmentation vs neuro-destruction in the treatment of tremor.


Neurosurgeons become involved in the treatment of certain tremors (such as those caused by Parkinson’s Disease or Benign Essential Tremors) as a last resort (after non-surgical treatments, such as medication, no longer provide benefit). Two types of minimally invasive treatments are available, neuro-destructive and neuro augmentative.


Neuro-destructive treatment, also called neural-ablation, involves destruction of a small part of the thalamus (the main relay hub for the central nervous system). The method of destruction, also called thalamotomy, has changed over the years. 


Initially, the procedure involved a wire, which was threaded deep into the brain. Electrical energy was applied to the tip of the wire to burn the neural tissue.  


Later on, researchers developed less invasive methods to ablate the target. In 2020, Spanish researchers reported on their results using Stereotactic Radiosurgery ((SRS) multiple pencil thin beams of radiation, guided by computer algorithm and MRI or CT to coalesce and destroy a target within the brain) for tremors. The scientists reported that, when aimed at the ventral-intermediate nucleus of the thalamus (VIM), SRS provided long term control of tremors.


In 2016, the FDA approved a novel method to create a thalamotomy. Ultrasound energy, rather than radiation, may be used to destroy the VIM. Israeli researchers, in 2018, reported that the procedure was effective in reducing tremors.


Neuro-augmentative methods, such as Deep Brain Stimulation (DBS) rely on enhancement of  brain circuitry to achieve tremor alleviation. As in electro-mechanical thalamotomy, DBS begins with a wire being inserted into the brain. But instead of destroying the target, the wire is hooked up to a pacemaker-like device, which changes the electrical rhythm of the neurons (brain cells). The target for neuro-augmentation is slightly different from thalamotomy. A different section of the thalamus (subthalamic nucleus) or the internal part of the globus pallidus (a part of the brain that smooths out movement) is frequently targeted in DBS. 


Those are the facts. 


So back to the question, if there’s something broken in the brain, is it better to cut it out or fix it? As for many things, the answer is: it depends. But, as a general rule, I think destructive procedures, over time, will head towards extinction (in the same way that frontal lobectomy for psychiatric disease has flown over the cuckoo’s nest).


Pérez-Sánchez JR, Martínez-Álvarez R, Martínez Moreno NE, Torres Diaz C, Rey G, Pareés I, Del Barrio A A, Álvarez-Linera J, Kurtis MM. Gamma Knife® stereotactic radiosurgery as a treatment for essential and parkinsonian tremor: long-term experience. Neurologia (Engl Ed). 2020 Sep 8:S0213-4853(20)30217-6. English, Spanish. doi: 10.1016/j.nrl.2020.05.014. Epub ahead of print. PMID: 32917436.


Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M, Schlesinger I. Magnetic resonance-guided focused ultrasound thalamotomy for tremor: a report of 30 Parkinson’s disease and essential tremor cases. J Neurosurg. 2018 Jan;128(1):202-210. doi: 10.3171/2016.10.JNS16758. Epub 2017 Feb 24. PMID: 28298022.


Wong JK, Cauraugh JH, Ho KWD, Broderick M, Ramirez-Zamora A, Almeida L, Wagle Shukla A, Wilson CA, de Bie RM, Weaver FM, Kang N, Okun MS. STN vs. GPi deep brain stimulation for tremor suppression in Parkinson disease: A systematic review and meta-analysis. Parkinsonism Relat Disord. 2019 Jan;58:56-62. doi: 10.1016/j.parkreldis.2018.08.017. Epub 2018 Aug 28. PMID: 30177491.