Contemporary and evolving perspectives on surgical therapies for essential tremor: deep brain stimulation and focused ultrasound.

INTRODUCTION

Deep brain stimulation (DBS) and focused ultrasound (FUS) are established interventions for medically refractory essential tremor (ET), traditionally targeting the ventral intermediate (Vim) nucleus of the thalamus. Emerging targets such as the dentato-rubro-thalamic tract (DRTT), cerebello-thalamic tract (CTT), and posterior subthalamic (PSA) area offer potential therapeutic advantages.

AREAS COVERED: DBS, with decades of use, offers adjustable, reversible, and often bilateral tremor control through implanted electrodes. FUS is a newer, incisionless MRI-guided technique delivering focused acoustic energy for lesioning, increasingly used in staged bilateral procedures. Evidence shows comparable tremor suppression, though DBS risks relate to hardware and surgery, while FUS more often causes sensory and gait disturbances. Early complication rates are similar. Targeting, while traditionally based on indirect stereotactic coordinates, is increasingly guided by atlas-based and tractography-based approaches, improving precision for both modalities.

EXPERT OPINION: DBS may be preferred for younger patients, those needing long-term modulation, or bilateral therapy. FUS is an appealing option for older individuals or those with surgical contraindications. Directional and closed-loop DBS as well as connectomics-based targeting are likely to define the next generation of ET interventions, offering more personalized, durable, and safer tremor control.