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Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis–associated tremor

Acta Neurochirurgica volume 155, pages 2359–2364 (2013)Cite this article

Abstract

Background

Tremor is an important cause of disability and poor quality of life amongst multiple sclerosis (MS) patients. We assessed the outcomes of ventral intermediate (VIM) nucleus deep brain stimulation for the treatment of multiple sclerosis (MS)–associated tremor at a single centre in a prospective fashion.

Methods

Sixteen patients (9 female, 7 male) with a mean age of 41.7 years (range 24–59) underwent surgery. The median duration of MS prior to surgery was 6.5 years and median duration of tremor prior to surgery was 4 years. Case selection was by multidisciplinary assessment with carers, therapists, neurosurgeons and movement disorder neurologists. Tremor was scored pre-operatively and at 6 to 12 months post operatively using Bain and/or Fahn–Tolosa–Marin systems. The Euro-Qol 5D tool was used to assess quality of life before and after surgery.

Results

The mean tremor reduction was 39 % with a range between 0 and 87 %. Five of 16 patients achieved at least 50 % tremor reduction and 11 of 16 achieved at least 30 % tremor reduction at last follow up, mean 11.6 months (range 3–80). Tremor was significantly reduced as rated by Bain scores (Wilcoxon matched pairs, Z = 3.07, p = .002) and tended to significance as rated by Fahn scores (Wilcoxon matched pairs, Z = 1.85, p = 0.06). Sub-analysis of activities of daily living measures from the Fahn system showed post operative improvement in feeding (statistically significant), hygiene, dressing, writing and working. Mean visual analogue scores (0–100) of patient reported well-being increased from 54.6 to 57.4 post operatively with a trend to significance (Student’s t-test, t = 1.26, p = 0.2). Euro-Qol 5D utility values increased following surgery with a trend to significance which was greater in the group with at least 50 % tremor reduction than in those with none or at least 30 % tremor reduction.

Conclusions

VIM DBS may reduce severe, disabling tremor in patients with MS. This tremor reduction tends to be associated with improved quality of life and function in those who respond. Patient reported outcome measures may not correlate with physician rated clinical outcome such as tremor scoring systems and more subtle assessment of these patients is required.

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Acknowledgments

With thanks to Ms P Byrne, theatre nurse, and Ms B Hammersley, clinical nurse specialist

Conflicts of interest

None.

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Authors and Affiliations

  1. Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK

    Rasheed Zakaria, Leanne Westmoreland, Paul Eldridge & Jibril Osman-Farah

  2. Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK

    Nick Fletcher & Sundus Alusi

  3. The Wessex Neurological Centre, Southampton, UK

    Giresh Vajramani

Authors
  1. Rasheed Zakaria
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  2. Giresh Vajramani
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  3. Leanne Westmoreland
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  4. Nick Fletcher
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  7. Jibril Osman-Farah
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Corresponding author

Correspondence to Rasheed Zakaria.

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Comment

Tremor is a very common and disabling problem in multiple sclerosis (MS). Charcot described tremor as a part of a triad of characteristic symptoms in MS, together with nystagmus, and scanning speech. In MS, tremor can be "postural", namely present whilst voluntarily maintaining an antigravity position or "intention" tremor, occurring during voluntary and visually guided movement directed towards a target object. On the other hand, a true resting tremor present in a body part that is supported against gravity and not voluntarily activated, is unusual in patients with MS.

The pathophysiology of tremor in MS is not entirely known, also because MS is a multifocal disease and tremor cannot always be linked to a specific lesion site. The predominance of action tremors (postural and intention) suggests that the cerebellum and its connections play a main role in tremor production, whereas the rarity of rest tremor argues against an involvement of the basal ganglia. It is likely that lesions of the dentate nucleus or superior cerebellar peduncle may determine the activation of thalamic nuclei, which are the main producers of intention tremor.

Ventral intermediate nucleus (VIM) deep brain stimulation (DBS) is commonly used to treat essential or rubral tremor and has been proposed to treat also tremor in MS. The study of Zakaria and colleagues is a very interesting and well-balanced study on this modern, but controversial topic of functional neurosurgery. Similarly to few other relevant series on this issue, authors recorded a significant early post-operative reduction of tremor, particularly the postural and intentional aspects, but very limited durability of relief and modest impact on quality of life in all patients. This and other studies suggest that the duration of benefit may be as short as 3 months, raising concerns about the cost/benefit ratio of this procedure. Furthermore, as stated by the authors themselves, tremor reduction may sometimes occur spontaneously as a serendipitous consequence of a disease progression, perhaps induced by thalamic lesioning.

Alfredo Conti

Messina, Italy

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Zakaria, R., Vajramani, G., Westmoreland, L. et al. Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis–associated tremor. Acta Neurochir 155, 2359–2364 (2013). https://doi.org/10.1007/s00701-013-1848-0

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  • DOI: https://doi.org/10.1007/s00701-013-1848-0

Keywords

  • Deep brain stimulation
  • Multiple sclerosis
  • Tremor
  • Quality of life