Incisionless surgery

Gene Freund after his procedure at St. Mary's Hospital in Nebraska City to treat his essential tremor. He was able to write legibly for the first time in years.

The first thing Gene Freund did after undergoing an incisionless brain procedure intended to still the tremors in his right hand was reach for a flimsy Styrofoam cup on a hospital side table.

After jokingly advising bystanders to ready a mop, he grabbed the cup, took a long drink and set the cup back down without spilling a drop.

He also wrote his name legibly for the first time in years and, after being discharged, ate a bowl of soup at a hotel restaurant without spilling.

“It’s like most disabilities,” said Freund, 73, of Fernandina Beach, Florida. “You learn to cope and adapt, and when you have the opportunity to remove that disability or at least a big portion of it, it’s absolutely amazing.”

In Freund’s case, the disability is essential tremor, the most common movement disorder and one that affects an estimated 10 million Americans alone. Actress Katharine Hepburn reportedly was one of them. By comparison, roughly 1 million Americans have Parkinson’s disease.

Medications, such as beta blockers and epilepsy drugs, reduce tremors by about 60% in half of patients, by one calculation. But even those patients can develop resistance over time. In Freund’s case, medications never stilled his shaking hands entirely.

But a Nebraska hospital was able to help him. St. Mary’s Hospital, a CHI Health facility in Nebraska City, is one of 16 places in the country offering a relatively new procedure called MR-guided focused ultrasound. Patients like Freund have been coming from all over the country to be treated there.

As the name implies, the procedure is performed with the patient in an MRI, or magnetic resonance imaging machine. The focused ultrasound device, which resembles a salon hairdryer helmet, encircles the patient’s head, said Dr. Travis Tierney, the neurosurgeon performing the procedure at St. Mary’s.

Inside the dome are 1,000 speakers, which deliver ultrasonic or high-frequency sound waves. During treatment, the sound waves overlap in an area in the brain measuring about 3 square millimeters, heating it to about 130 degrees Fahrenheit. The heat kills the cells responsible for the tremor, which lie in what’s known as the ventral intermediate nucleus of the thalamus.

Before turning up the heat, however, doctors first map the brain with MRI and then with low-energy sound. Patients are awake and talking the whole time, Tierney said, allowing practitioners to check for side effects such as tingling in the hands or face that indicate that they’re off target.

“The patient’s really working with me the whole time,” he said. The MRI also allows doctors to make sure they’re generating the right amount of heat.

There are no incisions or holes in either the scalp or the skull. The procedure usually takes two to three hours. It’s currently approved only on one side of the body, which targets the tremor on the opposite side.

Tierney said the tremors typically improve right away. Like Freund, many patients can write their names legibly for the first time in years afterward or drink a bottle of water without spilling. In such cases, physicians often are treating not just the tremors but also the social ills that come with them, he said. Some patients may avoid going out, particularly to restaurants.

“This is one where immediately afterward everyone is crying,” Tierney said. “It’s one of the happy things (that) you can do as a neurosurgeon.”

St. Mary’s began offering the treatment in May. According to CHI, it’s now done more than any other center — 54 by the end of October. Next in line, Tierney said, is a group at Brigham and Women’s Hospital, a teaching hospital of Harvard Medical School, which had done 48 procedures. The most active sites have long waiting lists, which might explain why St. Mary’s has drawn so many out-of-state patients. Only four have been local residents.

Tierney previously worked at a children’s hospital in Florida, which wasn’t interested in expanding a program for adults. So he approached leaders at Creighton and CHI Health about offering it here. An Omaha native and Creighton University graduate, he got his medical degree at Johns Hopkins and trained in neurosurgery at Massachusetts General Hospital.

St. Mary’s just happened to have the model of MRI machine the system is designed to work with. It’s also the model Tierney used in Boston while participating in a clinical trial of the procedure.

That multi-center trial, results of which were published in the New England Journal of Medicine, led to Food and Drug Administration approval of focused ultrasound for essential tremor in 2016. The procedure now is covered by Medicare in 38 states, including Nebraska, according to Insightec, the Israel-based company that developed the technology. The FDA more recently approved the technique for use in a type of Parkinson’s disease in which tremor is the main symptom.

St. Mary’s also offers another advantage: Its MRI machine isn’t as busy as those at larger hospitals.

“We have a steady stream of patients and the time to do it,” Tierney said.

Currently, the more common surgical treatment for patients whose tremors don’t respond to medication is deep brain stimulation. It involves implanting an electrical probe into the same region of the brain targeted by focused ultrasound. A wire under the skin connects the electrode to a pacemaker-like device that’s implanted in the chest. Deep brain stimulation is the preferred surgical procedure for Parkinson’s and is likely to remain so, Tierney said.

But that procedure comes with a 1% risk of stroke and a 4% risk of infection, said Tierney, who estimated that he’s performed about 1,000 of them. Not only is focused ultrasound less invasive, the stroke risk is lower, with no strokes reported so far among the several thousand cases performed.

“It’s the safety aspects that I really like as a treatment for essential tremor,” he said.

About 5% of patients have side effects such as numbness in the face or hand, he said. There also can be other temporary effects, including difficulty sleeping and walking, during the up to six weeks it takes the lesion created in the brain to heal. Those usually peak three days after the procedure.

Tierney, who is working on a consultant basis for CHI Health, said he isn’t aware of any serious detractors. But the treatment is newer than deep brain stimulation and many neurologists haven’t yet trained in it.

“No one’s saying it’s a bad idea, but some say (deep brain stimulation) is the way to go,” Tierney said.

Insightec’s website indicates that the tremor control remains at up to 90% after several years in the patients the company was able to follow.

Patrick McCartney, executive director of the International Essential Tremor Foundation, based in Overland Park, Kansas, said focused ultrasound has “created a lot of buzz” in the essential tremor community, given that it’s the first new therapy to come along since deep brain stimulation nearly 20 years ago.

That treatment has many years of data behind it, he said, although early indications for focused ultrasound are positive. Unlike focused ultrasound, however, deep brain stimulation is reversible and can be used on both sides of the body, he said. Researchers apparently are exploring using focused ultrasound on both sides as well.

But part of the struggle with essential tremor is that treatment results vary from patient to patient. “We’d caution that no one thing works for everyone,” McCartney said.

Tierney said he next wants to work with Creighton researchers to study the treatment’s use in epilepsy and tumors.

Freund, a semi-retired college professor, said he had some numbness in his lip and tongue after the procedure, but that’s virtually gone. The tremor in his right hand, his dominant one, is more than 90% gone as well.

Before coming to Nebraska, he had kept tabs on treatments for some time. He wasn’t comfortable with deep brain stimulation. In May, he checked with a contact at the University of Virginia Health System, but that hospital had a two-year wait for focused ultrasound. His contact suggested St. Mary’s. He traveled to Nebraska in June.

Now he can eat without spilling, handle barbecue ribs and wings and take a shower without dropping the soap a half a dozen times.

He’s ready to try the metal detector his wife bought him. Before, the tremors were so bad he couldn’t really control the wand. He’s also thought about giving cowboy action shooting, a former pastime, another try. He stopped competing and sold his gear about seven years ago when he no longer felt safe handling the pistols.

“I had high expectations,” Freund said, “but I was really surprised and amazed how well it did work out. It was awesome.”