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Neurosurgeon Answers: DBS or Focused Ultrasound for Tremor? · Tremor & Parkinson's Surgery Explained with Dr. Wu

• 0:00
  SPEAKER_00: If you're dealing with essential tremor or tremor from Parkinson's disease, you may be hearing about two different surgical procedures, focused ultrasound and deep brain stimulation or DBS.
• 0:11
  SPEAKER_00: I'm Dr.
• 0:11
  SPEAKER_00: Chun Yanwu.
• 0:12
  SPEAKER_00: I'm a neurosurgeon that performs both of these procedures.
• 0:15
  SPEAKER_00: And I think that matters because I don't think the right question is which procedure is better, but which procedure is right for you.
• 0:24
  SPEAKER_00: Now, because it's newer, there's a lot of excitement around focused ultrasound and for good reason.
• 0:29
  SPEAKER_00: It gives us an incisionless way to treat symptoms that can be extremely disabling.
• 0:34
  SPEAKER_00: But with any newer technology, we have to follow the data and not necessarily get caught up in all the hype.
• 0:40
  SPEAKER_00: There's a time and a place for focused ultrasound, and there's a time and a place for deep brain stimulation.
• 0:45
  SPEAKER_00: The goal is really to understand where each treatment works best, what risks come with it, and which trade-offs make sense for you.
• 0:52
  SPEAKER_00: To start, we need to understand when does treatment move beyond medication?
• 0:57
  SPEAKER_00: When should we start thinking about these sorts of surgeries as something to augment what we're already doing with medication?
• 1:03
  SPEAKER_00: Now, there's no rule that says you need to have tremor for five years, ten years, or really any specific amount of time before you can talk about the procedure, either of the procedures.
• 1:13
  SPEAKER_00: The bigger question is what the tremor is doing to your life and your quality of life.
• 1:18
  SPEAKER_00: Can you sign your name?
• 1:19
  SPEAKER_00: Can you carry a cup?
• 1:21
  SPEAKER_00: Are you okay eating in front of other people without planning around the shaking?
• 1:25
  SPEAKER_00: Can you use your phone or button a shirt, go to work, cook, or continue doing the hobby you've done for years?
• 1:31
  SPEAKER_00: Ultimately, everyone is different.
• 1:33
  SPEAKER_00: A mild tremor may be a major problem for a surgeon or a musician, while a clearly visible, obvious tremor may bother someone else far less.
• 1:42
  SPEAKER_00: So we don't make this decision based on how dramatic a tremor looks.
• 1:47
  SPEAKER_00: Instead, we look at how much it interferes with your quality of life.
• 1:51
  SPEAKER_00: Then we look at medication.
• 1:52
  SPEAKER_00: Have the medications prescribed to treat your tremor stop giving you enough control?
• 1:57
  SPEAKER_00: Do you need more of it than you used to?
• 1:59
  SPEAKER_00: Or perhaps are the side effects becoming almost as disruptive as the tremor used to be?
• 2:04
  SPEAKER_00: When the medications stop working and your day-to-day activities are suffering, focused ultrasound and DBS may both become reasonable to discuss.
• 2:12
  SPEAKER_00: When the medications stop working and your day-to-day activities are suffering, things like focused ultrasound and DBS may both become reasonable to discuss.
• 2:20
  SPEAKER_00: So what are these two treatments?
• 2:22
  SPEAKER_00: In short, DBS requires a surgical procedure and uses thin electrodes placed into a very small target in the brain.
• 2:28
  SPEAKER_00: They connect to a battery under the skin, usually just under the collarbone, and the system delivers electrical stimulation that we can adjust over time to help improve your symptoms.
• 2:38
  SPEAKER_00: Focused ultrasound does not leave a device in the body, but instead it uses MRI-guided sound waves to heat, create a lesion, and permanently treat that same tiny area in the brain.
• 2:49
  SPEAKER_00: So a key difference between the two options is that one does it with an adjustable implanted system and the other does it with a permanent treatment and no implant.
• 2:58
  SPEAKER_00: Before choosing either procedure, we still have to make sure we are treating the right problem in the right patient.
• 3:03
  SPEAKER_00: That means looking at the type of tremor that you have, which symptoms affect you most, your overall health, your balance, your thinking and memory, your brain imaging, and what you want the treatment to improve.
• 3:15
  SPEAKER_00: What are your goals?
• 3:16
  SPEAKER_00: The two treatments also share something important.
• 3:18
  SPEAKER_00: For a central tremor, both commonly target the same tremor network in a small area of the thalamus called the Vim or VIM, motor thalamus, different names for it.
• 3:28
  SPEAKER_00: So they're not trying to solve two different problems, but instead both are trying to modulate or modify the abnormal circuit causing the tremor.
• 3:37
  SPEAKER_00: The difference is how they do it.
• 3:39
  SPEAKER_00: One with stimulation with electrodes, the other with heating the target and creating a lesion.
• 3:45
  SPEAKER_00: And this really highlights the difference of an adjustable treatment versus a permanent one.
• 3:50
  SPEAKER_00: With DBS, if the tremor changes, we have the ability to change the stimulation settings through reprogramming the device.
• 3:56
  SPEAKER_00: And that's done wirelessly without another surgery.
• 3:59
  SPEAKER_00: If the stimulation causes a side effect, we can reduce it or change the settings to avoid that side effect or even turn the stimulation off at worst case.
• 4:07
  SPEAKER_00: And that's an important idea because DBS side effects may be stimulation related.
• 4:12
  SPEAKER_00: If you have side effects like balance issues or numbness or tickling, and if they come from the stimulation, they are often reversible, going away when the stimulation is turned off or adjusted appropriately.
• 4:25
  SPEAKER_00: Focused ultrasound is different.
• 4:26
  SPEAKER_00: Focused ultrasound uses converging beams of focused energy to generate enough heat to burn and create a permanent lesion.
• 4:33
  SPEAKER_00: So once it's created, it cannot be reprogrammed or turned off.
• 4:36
  SPEAKER_00: Now that doesn't make focused ultrasound bad necessarily.
• 4:39
  SPEAKER_00: It just means that you're choosing no implanted device in exchange for treatment that is relatively fixed once it is completed.
• 4:46
  SPEAKER_00: Adjustability matters even more when tremor is part of Parkinson's disease, since tremor may not be the only symptom to treat.
• 4:53
  SPEAKER_00: So we really need to ask which symptoms are you trying to treat with the surgery?
• 4:58
  SPEAKER_00: And this is where essential tremor and Parkinson's disease really start to separate.
• 5:01
  SPEAKER_00: For essential tremor, the comparison is fairly direct.
• 5:04
  SPEAKER_00: Tremor is the main condition we are treating, and focused ultrasound has the strongest and most mature track record as a tremor-focused therapy, especially with essential tremor.
• 5:14
  SPEAKER_00: Now, DBS also has a long and strong track record for treating essential tremor.
• 5:20
  SPEAKER_00: So when it comes to people with essential tremor and the decision to go between deep brain stimulation or focused ultrasound, it really comes down to thinking about treating one side versus both, having a permanent lesion versus an adjustable device, having a device or no device at all, and which risk profile fits your personality.
• 5:41
  SPEAKER_00: For Parkinson's disease, the question is more complicated.
• 5:45
  SPEAKER_00: Focused ultrasound of the usual tremor target is really only for treating tremor.
• 5:50
  SPEAKER_00: If the tremor is your main problem, that may be exactly what you need and all you need.
• 5:54
  SPEAKER_00: But Parkinson's can cause many other symptoms like stiffness, slowness, dynesia, dystonia, and medication fluctuations.
• 6:03
  SPEAKER_00: Now, DBS can target areas of the brain that treat that tremor, but also a broader range of those motor symptoms and has very good literature, very good long-term data on the ability to do that.
• 6:15
  SPEAKER_00: More recently, focused ultrasound is also being used with newer targets for some Parkinson's motor complications beyond tremor, things like the stiffness and slowness.
• 6:24
  SPEAKER_00: And yeah, that's very exciting, but the outcomes and the data are more recent, so we have to take them a little bit with a grain of salt.
• 6:31
  SPEAKER_00: So the way I think about the evidence is this focused ultrasound has its strongest track record for tremor.
• 6:37
  SPEAKER_00: First essential tremor, then tremor-predominant Parkinson's disease, and early data on treating other symptoms of Parkinson's disease showing promise.
• 6:46
  SPEAKER_00: Meanwhile, DBS has a mature track record of at least 30 years for tremor and for broader Parkinson's motor symptoms.
• 6:53
  SPEAKER_00: The tremor-only treatment may leave the other major symptoms unchanged if that's all we're going after.
• 6:58
  SPEAKER_00: Now I want to come back to the idea of treating one side versus both sides because again, focused ultrasound treats one side at a time.
• 7:06
  SPEAKER_00: One side of the brain treats the opposite side of the body.
• 7:09
  SPEAKER_00: So if both hands shake, the untreated hand may still limit you after the first procedure.
• 7:14
  SPEAKER_00: That said, there's an opportunity to treat the other side with a second focused ultrasound treatment, but it has to wait and be staged at least nine months for safety reasons.
• 7:23
  SPEAKER_00: DBS, however, can often treat both sides during the same operation.
• 7:27
  SPEAKER_00: And there's an important point about how effective each treatment can be.
• 7:30
  SPEAKER_00: Because DBS treats both sides, the outcomes sometimes look much better on paper.
• 7:34
  SPEAKER_00: When we compare one-sided treatments, so unilateral or one-sided DBS with focused ultrasound, they ultimately show that they provide similar tremor improvement in the treated hand.
• 7:45
  SPEAKER_00: But if both hands need treatment, bilateral DBS generally provides more complete overall tremor control than treating only one side with focused ultrasound.
• 7:53
  SPEAKER_00: Now, that doesn't mean that everyone needs bilateral treatment.
• 7:57
  SPEAKER_00: If one hand is causing nearly all the problems, and the main reason for difficulty with day-to-day tasks, treating that one side may make an enormous difference and be all that someone really needs.
• 8:08
  SPEAKER_00: So the real question you have to ask yourself is how much would the untreated side continue to limit your life, your daily activity, if it remained the way it was without any improvement in its tremor?
• 8:19
  SPEAKER_00: Now, what does each procedure actually look like?
• 8:22
  SPEAKER_00: This is another area where patients sometimes have a little bit of an outdated picture of DBS.
• 8:27
  SPEAKER_00: In my practice, DBS is perform under general anesthesia, so with the patient entirely asleep.
• 8:32
  SPEAKER_00: My preference is also to shave a minimal amount of hair so that within a week or so you may not look any different than before surgery.
• 8:40
  SPEAKER_00: It is image guided and electrode locations are verified with interoperative imaging before the surgery is considered to be complete.
• 8:46
  SPEAKER_00: The electrodes, extension wires, and battery are all implanted on the same day in a single stage in my practice.
• 8:52
  SPEAKER_00: And most patients stay overnight being able to go home the next day.
• 8:56
  SPEAKER_00: In some select patients, I've even discharged them on the same day.
• 9:00
  SPEAKER_00: So ultimately, DBS is still invasive, but it is really a minimally invasive procedure that has evolved over time.
• 9:07
  SPEAKER_00: It still means brain surgery, anesthesia, and living with implanted hardware.
• 9:11
  SPEAKER_00: And I don't want to minimize any of that, but the practical gap in recovery between the way we perform DBS today and the way we perform focused ultrasound is smaller than many patients expect.
• 9:22
  SPEAKER_00: Focused ultrasound is incisionless and leaves no device behind, but the patient remains awake.
• 9:26
  SPEAKER_00: Your head is shaved completely and a frame is attached, and the patient then lies inside an MRI scanner connected to the ultrasound helmet.
• 9:34
  SPEAKER_00: In the focused ultrasound procedure, we deliver controlled treatments, check the tremor, and check for side effects before creating the final lesion.
• 9:42
  SPEAKER_00: So focused ultrasound avoids the incision but requires staying awake and still in the MRI for an extended period of time.
• 9:49
  SPEAKER_00: So we really have to consider things like claustrophobia, anxiety, and even back pain when it comes to thinking about candidacy for the focused ultrasound procedure.
• 9:59
  SPEAKER_00: Before we move forward with focused ultrasound, we obtained a specialized CAT scan of the skull.
• 10:03
  SPEAKER_00: And that CAT scan is used to calculate what we call a skull density ratio or SDR.
• 10:09
  SPEAKER_00: In simple terms, it tells us the relative amount of dense cortical bone compared to the more spongy cancellus bone inside the skull.
• 10:17
  SPEAKER_00: And that ratio matters because ultrasound energy does not travel through every skull equally well.
• 10:23
  SPEAKER_00: If the skull composition does not transmit enough energy, we may not be able to heat the target safely and effectively.
• 10:29
  SPEAKER_00: So this is not just a routine head CT.
• 10:31
  SPEAKER_00: The scan has to be obtained and analyzed specifically for the focused ultrasound procedure and for planning purposes.
• 10:38
  SPEAKER_00: And we need that information before deciding that the procedure is technically feasible.
• 10:42
  SPEAKER_00: Now another difference between the two different procedures is how quickly you may see the result.
• 10:47
  SPEAKER_00: Focused ultrasound can produce a visible result during the procedure itself.
• 10:51
  SPEAKER_00: You may draw a spiral before the treatment, repeat it during your treatment, and see the tremor change while you're still in the MRI scanner.
• 10:58
  SPEAKER_00: It's really remarkable.
• 10:59
  SPEAKER_00: DBS takes longer to optimize, so I always say patience is key here in that you have to be patient and wait for that period of time for optimization.
• 11:09
  SPEAKER_00: With deep brain stimulation, the initial programming visit is generally about four weeks after the surgery, after everything has healed both inside and out.
• 11:17
  SPEAKER_00: And the first programming visit is not always that final answer.
• 11:21
  SPEAKER_00: It may take several reprogramming and refinement visits to really adjust the setting.
• 11:26
  SPEAKER_00: So on average, I usually say it can take three to six months before programming is optimized.
• 11:32
  SPEAKER_00: So as you can see, focused ultrasound may give you a faster visible result.
• 11:36
  SPEAKER_00: For better or worse, DBS gives us the ability to continue adjusting the treatment over time and requires a little more patience.
• 11:42
  SPEAKER_00: Unfortunately, neither procedure guarantee that the tremor control will remain identical forever because symptoms can change over time, especially if we're talking about tremor-predominant Parkinson's disease.
• 11:52
  SPEAKER_00: Now, what about after the surgery?
• 11:54
  SPEAKER_00: What are the differences in the recovery between the two procedures?
• 11:57
  SPEAKER_00: Well, focused ultrasound usually has a shorter physical recovery, simply because there are no incisions to care for and no implanted hardware to manage.
• 12:06
  SPEAKER_00: DBS, on the other hand, requires incision care and some activity restrictions while you heal.
• 12:10
  SPEAKER_00: Then comes the main long-term practical difference, having a device implanted.
• 12:15
  SPEAKER_00: With DBS, you have to be comfortable living with and managing an implanted system.
• 12:19
  SPEAKER_00: That means programming visits, charging the battery, or eventually replacing the battery, being aware of possible electromagnetic interference like security systems and MRIs, and the possibility of hardware problems over time.
• 12:33
  SPEAKER_00: Focus ultrasound is a lot more straightforward and requires less ongoing device management.
• 12:38
  SPEAKER_00: In fact, there's no device management, whereas DBS requires more follow-up but is more adjustable.
• 12:44
  SPEAKER_00: And that's the real advantage of focus ultrasound for the right patient.
• 12:48
  SPEAKER_00: Now, if we consider the risk profile, there are differences there too.
• 12:51
  SPEAKER_00: And for me, this may be the most important difference.
• 12:54
  SPEAKER_00: DBS has surgical risks.
• 12:56
  SPEAKER_00: The ones we worry about most are bleeding and infection, just like any other kind of surgery.
• 13:00
  SPEAKER_00: There can also be hardware complications over time.
• 13:02
  SPEAKER_00: But if a problem is caused by the stimulation itself, we can often improve it or avoid it altogether by changing the programming.
• 13:10
  SPEAKER_00: And that's the beauty of deep brain stimulation.
• 13:12
  SPEAKER_00: Focused ultrasound avoids an incision and implanted hardware and really minimizes the surgical risks.
• 13:18
  SPEAKER_00: But because it effectively burns a small part of the brain, it permanently treats the area that is responsible for tremor, which is near pathways that are potentially involved in sensation, coordination, walking, speech, and swallowing.
• 13:32
  SPEAKER_00: So possible side effects of focus ultrasound include numbness and tinkling, unsteadiness, coordination problems, speech changes, and swallowing problems.
• 13:41
  SPEAKER_00: Fortunately, most improve as the swelling settles down, but unfortunately, some may persist.
• 13:46
  SPEAKER_00: And if a persistent side effect comes from a permanent lesion, we cannot simply program it away.
• 13:52
  SPEAKER_00: Interestingly, these are some of the same side effects that we see with DBS, but again, when we do see them, they are usually the result of direct stimulation and can be avoided with reprogramming the device.
• 14:02
  SPEAKER_00: So when we get into some of the details, the idea that DBS is invasive and focused ultrasound is safe is a far oversimplification, is not an accurate way to frame this.
• 14:12
  SPEAKER_00: Both treatments carry risk.
• 14:14
  SPEAKER_00: The risks are just different between the two options.
• 14:17
  SPEAKER_00: And those differences should matter when we choose the procedure.
• 14:20
  SPEAKER_00: So which one may fit you better?
• 14:22
  SPEAKER_00: I don't want this discussion to make focused ultrasound sound like the procedure we use only when DBS is not an option.
• 14:29
  SPEAKER_00: I don't think that's necessarily how we should think about it.
• 14:32
  SPEAKER_00: Focused ultrasound can be an excellent option when tremor is the main problem, when one side is driving most of the disability, and avoiding an implanted device is important to you.
• 14:42
  SPEAKER_00: That is particularly relevant for many patients with essential tremor and some patients with tremor-predominant Parkinson's disease.
• 14:48
  SPEAKER_00: It can be especially valuable for someone who is a poorer surgical candidate who may not be able to tolerate general anesthesia well, or in some patients for whom interrupting blood-thinning medication may be a problem in terms of treating their other comorbidities.
• 15:04
  SPEAKER_00: DBS becomes especially attractive when both sides need treatment, when Parkinson's symptoms extend beyond tremor, or when we want the ability to adjust treatment as symptoms change.
• 15:14
  SPEAKER_00: So when I help patient decide, I focus on a few questions.
• 15:17
  SPEAKER_00: What symptoms are we really trying to improve?
• 15:20
  SPEAKER_00: What really matters in your day-to-day life?
• 15:22
  SPEAKER_00: Is one side causing most of the problem, or do we really need to treat both sides for us to see a meaningful improvement in your quality of life?
• 15:30
  SPEAKER_00: Is a tremor the main problem or only one part of a more complicated picture of Parkinson's disease?
• 15:35
  SPEAKER_00: How important is avoiding an implanted device?
• 15:38
  SPEAKER_00: And how valuable would future adjustability be?
• 15:41
  SPEAKER_00: And which procedure and which side effect profile fit you best?
• 15:45
  SPEAKER_00: Once we answer those questions, the better fit is usually fairly clear.
• 15:48
  SPEAKER_00: So to wrap things up, I really think that focused ultrasound is an exciting technology.
• 15:53
  SPEAKER_00: And as new targets are developed, we may find more and more ways to use it.
• 15:58
  SPEAKER_00: But I also think it's important that the excitement should not get ahead of the data.
• 16:02
  SPEAKER_00: What I really emphasize in my practice is performing evidence-based medicine.
• 16:06
  SPEAKER_00: If the data will lead me somewhere, I will follow it.
• 16:09
  SPEAKER_00: For now, for a central tremor, focused ultrasound has strong and increasingly mature track record in terms of treating tremor.
• 16:17
  SPEAKER_00: For tremor-predominant Parkinson's, it can also be very effective, although long-term durability is less certain.
• 16:23
  SPEAKER_00: And for Parkinson's symptoms beyond tremor, the focused ultrasound data are promising, but much newer.
• 16:29
  SPEAKER_00: So this does not mean that we should avoid focused ultrasound.
• 16:32
  SPEAKER_00: It means we should use it thoughtfully in patients for whom the evidence and the trade-offs make sense.
• 16:37
  SPEAKER_00: I perform both procedures because there is a time and place for each of them.
• 16:41
  SPEAKER_00: And my goal is to help you understand the options well enough to make an informed decision about which treatment best matches your symptoms, your priorities, and your risk tolerance.
• 16:51
  SPEAKER_00: And if you're still wondering whether your symptoms have reached the point where a procedural treatment should even be part of the conversation, watch my video next about when to consider surgery for Parkinson's disease or tremor.
• 17:03
  SPEAKER_00: Until next time, bye.