Objective: To describe 2 patients with orthostatic tremor (OT) who responded to deep brain stimulation (DBS).

Background: OT is a rare movement disorder, characterized by a 13-18 Hz tremor when standing, causing unsteadiness on standing, relieved by walking, sitting or lying. Medical treatment is often unsatisfactory. There are few studies of invasive therapies suggested long-term benefit from DBS. Spinal cord stimulation was reported to improve the symptom in 2 patients. There are some reports of response to DBS targeting Vim thalamus. We report clinical and electrophysiology findings of two patients with medically intractable OT who were first treated with spinal cord stimulation and subsequently underwent DBS.

Methods: Case report.

Results: Patient 1 is a 74-year-old woman with the onset symptoms of unsteadiness and leg tremor at age 50. Combination therapy with gabapentin, levodopa and clonazepam provided modest improvement. At age 69, an assiduous trial of spinal cord stimulation was performed but failed to relief her symptoms despite producing paraesthesiae in the legs. Subsequent bilateral ventralis intermedius medialis (Vim) DBS provided satisfying benefit. Four years after the operation, she was able to stand with feet together for 108 seconds with the stimulator turned on but only 58 seconds with it turned off. Surface electromyography (sEMG) study showed similar frequency but smaller amplitude with the stimulator turned on than off. Patient 2 is a 73-year-old man with the onset of symptoms of unsteadiness and leg tremor at age 65. Gabapentin, clonazepam, propranolol and primidone were tried but were ineffective. He underwent spinal cord stimulation placement at age 72, which did not improve his symptoms despite appropriate paraesthesiae. Subsequent bilateral subthalamic area/zona incerta DBS improved his symptoms. He could stand for less than 30 seconds and more than 5 minutes with the stimulator off and on respectively. sEMG study also showed similar frequency but smaller amplitude EMG bursting with the stimulator turned on than off.

Conclusions: In these two patients, DBS gave partial but clinically worthwhile improvement in OT despite failed spinal cord stimulation. Bilateral Vim or subthalamic/zona incerta DBS should be considered as a treatment option in patients with medically refractory OT. Systematic control trials are needed.

« Back to 2016 International Congress

MDS Abstracts - https://www.mdsabstracts.org/abstract/orthostatic-tremor-is-deep-brain-stimulation-better-than-spinal-cord-stimulation/