A clinical review in Movement Disorders Clinical Practice highlights how surgical management of tremor syndromes continues to evolve, with deep brain stimulation remaining a central treatment while incisionless lesioning approaches expand options for selected patients.
The review examined surgical therapies across essential tremor, Parkinson’s disease tremor, and dystonic tremor, summarizing evidence for neuromodulation and lesioning strategies and factors that may guide treatment selection.
Historically, radiofrequency thalamotomy targeting the ventral intermediate nucleus of the thalamus was the standard treatment for medication-refractory tremor. The development of deep brain stimulation in the early 1990s shifted practice by enabling modulation of neural circuits through implanted electrodes rather than permanent lesions.
Deep brain stimulation (DBS) remains one of the most widely used surgical interventions for tremor syndromes. In essential tremor, the ventral intermediate nucleus continues to be a common target, although the posterior subthalamic area has emerged as an alternative in some cases. In Parkinson’s disease tremor, stimulation of the subthalamic nucleus or globus pallidus internus is often preferred because it may provide broader motor benefits beyond tremor reduction.
Interest in lesioning techniques has re-emerged with the introduction of minimally invasive technologies such as magnetic resonance–guided focused ultrasound. These approaches allow targeted lesioning without surgical incisions and may offer an option for patients who are not candidates for implanted devices or who prefer to avoid hardware.
However, the review emphasizes that treatment effects and supporting evidence vary by tremor syndrome. In essential tremor, both DBS and focused ultrasound have demonstrated strong efficacy, and selection often depends on patient characteristics and preferences. In contrast, DBS remains the preferred surgical option in Parkinson’s disease tremor because of greater and more durable motor benefits, while focused ultrasound approaches are generally reserved for select cases and are not widely recommended outside clinical trials or registries.
Each surgical strategy carries distinct advantages and limitations. DBS allows adjustment of stimulation settings over time as symptoms evolve, whereas lesioning procedures avoid implanted hardware but result in permanent structural changes. The review also highlights that benefits from both approaches may diminish over time, underscoring the importance of long-term management strategies.
Because of these differences, selecting an appropriate surgical approach depends on factors such as tremor type, symptom severity, comorbidities, and patient preferences. Advances in neuroimaging and targeting techniques may improve procedural accuracy, although some methods remain investigational or are not yet widely adopted in clinical practice.
As surgical technologies continue to develop, clinicians may need to consider a broader but more nuanced range of options when managing medication-refractory tremor.
The researchers reported no specific funding for this work; some contributors disclosed relationships with industry.