Objective: Orthostatic tremor was first described in 1977 (Pazzaglia et al.); they described three patients with lower body tremor during standing. Tremor with a frequency of 13–18 Hz can be measured in the muscles of the legs and trunk muscles and are typical finding in orthostatic tremor patients. Medical therapy (Gabapentin, Primidon,Clonazepam) may be helpful in patients with orthostatic tremor (OT), but many patients symptoms do not improve.

Background: Deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (VIM) is a well established therapy for movement disorders like essential tremor. Even less common types of tremor like Holmes tremor can be treated with VIM-DBS successfully. There are some case reports with small numbers of patients with OT treated with VIM-DBS. The results are varying from excellent to absent effect of the stimulation therapy following to the operation.

Methods: We report on the case of a 65 years old male Patient, with a ten year history of orthostatic tremor. Trials with medication including Rivotril, Clonazepam, Primidon, Propanolol and Gabapentin failed to improve the symptoms or were not tolerated. The implantation of DBS leads to the VIM was considered. After informed consent the Patient was operated. Under local anesthesia segmented leads were implanted in a stereotactic procedure using awake microelectrode recording and test stimulation. The electrodes were connected to a Saint Jude Medical Infinity 7.0 IPG. Pre- and postoperative neurological finding and nine months follow up were evaluated. Surgery with MRI based targeting and postoperative CT-scan for the verification of the lead postioning are described.

Results: The surgical procedure was well tolerated. There were no complications. The postoperative cranial CT showed the electrodes in the correct Position. The preoperative standing time was about 30 seconds til the onset of severe tremor of the legs forcing the patient to sit down. The early postoperative microlesioneffect was remarkable with an increase of standing time to about five minutes. The first stimulation with low amplitude did not show any stimulation side effects. The standing time prolonged up to ten minutes. Though there was no complete remission of the symptoms the patient was very satisfied with the stimulation’s effect and described a significant increase of quality of life.

Conclusions: The implantation of DBS-electrodes into the VIM (ventral intermediate nucleus of the thalamus) is a safe surgical procedure and can be very effective in the treatment of the orthostatic tremor when medication therapy failed. Because OT is a rare disease, meta analyses of case series are needed to find out, why some patients benefit from dbs and some fail to stimulation therapy or why there is only a limited duration of symptoms relief.

References: McManis PG1, Sharbrough FW. Orthostatic tremor: clinical and electrophysiologic characteristics. Muscle Nerve. 1993 Nov;16(11):1254-60. Merola A, Fasano A et al. Thalamic deep brain stimulation for orthostatic tremor: A multicenter international registry. Mov Disord. 2017 Aug;32(8):1240-1244. doi: 10.1002/mds.27082. Epub 2017 Jun 20.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/bilateral-deep-brain-stimulation-of-the-ventral-intermediate-thalamic-nucleus-for-orthostatic-tremor-a-case-report/