Wire in the brain to help hands that won’t stop shaking

AROUND 650,000 people in Britain suffer from essential tremor. Tonia Walsh, 53, a mother-of-three from Essex, controls her hand tremor with a remote control that operates a brain implant, as she tells RACHEL HALLIWELL

THE PATIENT

As a girl I used to dread it being stew for school lunch because by the time I’d carried my tray to the table my shaking hands meant I’d have spilt it all down me. My hands started trembling when I was nine and only got worse.

at 15 our GP prescribed valium, saying I was suffering from anxiety and the pills would help settle my hands. They only left me feeling spaced out so I came off them. a year later I went to hospital for tests.

various specialists scratched their heads, and one doctor suggested giving me alcohol, which can steady body trembles. My horrified father took me home.

The shaking became something I learned to live with. But it left me shy and reclusive. I was too embarrassed to eat or drink in public.

Motherhood was difficult — even holding my baby was tricky. Imagine trying to give a spoonful of medicine to a child when you can’t feed yourself without spilling food.

It wasn’t until I was 32 that I got a diagnosis. I went to my GP who referred me to a neurologist who diagnosed essential tremor.

He explained this is caused by faulty electrical impulses in the thalamus — an area deep in the brain that controls movement. The condition tends to get worse.

He tried me on beta-blockers and then anti- epilepsy medication. My Neither worked.

TreMor meant I couldn’t work, so I volunteered for t he National Tremor Foundation. There I learned about a new technique called deep brain stimulation (DBs) — where electrodes are i mplanted under the thalamus.

These emit electrical pulses that block the faulty signals.

However, the thought of brain surgery frightened me and it took me until my late 40s to take it further, by which time my voice had started to shake as well.

I got a referral with Mr Hu Liang Low, a neurosurgeon at Queen’s Hospital in romford, essex, who felt that DBs would help.

He told me the procedure would take a day and I would need to be conscious when he inserted the electrode to make sure my speech and vision, also controlled by the thalamus, weren’t damaged.

He explained I would be able to change the level of electrical current with a remote control at home. This is new — previously patients had to go back to their consultant to have settings readjusted.

I had the operation two years ago. The night before I was nervous — especially as I’d be awake for some of it. But I knew it was my only hope of a cure. In the event, hearing Mr Low drill into my skull just felt uncomfortable. I know he asked me questions and did tests to check I was oK, but it passed in a dreamlike blur.

What I do recall is the moment the probe reached the correct part of my brain, because my hands suddenly stopped trembling.

My next memory is waking up in bed. Two days later I was home, with the system set on low. For the first time in my life I could drink tea without a straw. My sons, now 28, 27 and 25, were overwhelmed.

over the next month I returned to the hospital to have the stimulator that controls the electrode gradually turned up and was shown how to control it using a remote the size of a mobile phone that I hold against my chest.

The difference has been lifechanging — I can brush my teeth properly, write and fill out forms, I’ve taken up yoga, and enjoy meals out without being embarrassed.

I also sound like me again, which is wonderful. at home I keep the system set on low, and live with a small tremor, because the higher I have it the more tired I feel and I have to work harder at remembering things.

I knew this would be a sideeffect; dealing with all this electrical interference is very tiring for the brain. But if I’m going out I turn it up so I stop shaking completely.

That’s when I feel the greatest benefit, because then I know that I feel and look just like everyone else. and that’s all I ever wanted.

THE SURGEON

Hu liAng loW is a consultant neurosurgeon at Queen’s Hospital in Romford, essex. esseNTIaL tremor affects at least 1 per cent of the population and it can be utterly debilitating.

as well as the hands, the arms, head, eyelids, lips and other muscles can also be affected. a tremor in the voice box may cause a shaky voice.

First-line treatment is medication, the main options are beta blockers and anti-epilepsy drug primidone, which alter activity in the brain, but the side-effects can be serious and for some patients these drugs bring no relief.

The only other option is surgery. We started carrying out deep brain stimulation surgery, which is also licensed for Parkinson’s and dystonia (which causes muscle spasms), at Queen’s in 2007.

The devices have become smaller, so less apparent under the skin, and more sensitive to adjustment.

The device I fitted in Tonia, made by Medtronic, consists of an electrode that goes into the brain, and a neurotransmitter t hat’s implanted under the collar bone.

The electrode is a wire 1.2mm in diameter with four platinum ‘contacts’ at the end (they look a bit like tiny cylindrical beads, not much thicker than the wire).

The electrode is put inside the brain and the other end is attached to an extension cable, which in turn is attached to a neurostimula- tor, about the size of a matchbox. This has two parts: a small computer that allows us to programme how strong or how frequent the current is, and a battery.

The battery lasts up to six years, and can be replaced under local anaesthetic as a day case.

We put Tonia to sleep at 8.30am, when I attached a surgical frame to her skull using four small pins, before sending her down for an MrI scan of her brain.

The frame keeps the head stable while we insert the electrode to ensure placement is accurate — an error of more than 1mm is the difference between success and failure. I used the MrI results to locate the target tissue in the brain just under the thalamus — an area measuring less than 1cm — and plot my route.

Then we woke Tonia and made two incisions the size of 5p coins in her skull and put a temporary micro- electrode into her brain, which guides me to the correct part by measuring electrical activity and converting that into patterns EacH and sounds.

part of the brain speaks a different ‘language’ and I know which part I’m in by what I hear. It suddenly becomes quiet when the microelectrode reaches the right area. It’s often enough for symptoms to dampen. In Tonia’s case she stopped shaking completely.

We needed Tonia awake for this to see the impact on her tremor. We checked she didn’t have any difficulties speaking or moving her arms and legs. Her vision was also fine, so I was able to remove the micro-electrode and replace it with the permanent wire.

Tonia was sent for another MrI scan to confirm the electrode was fitted correctly. all was satisfactory, so at 3.30pm we put her back to sleep and I connected the wiring to an extension cable channelled under the skin in her neck down to her chest and attached to t he neurostimulator, implanted under her left collarbone.

apart from some post-operative checks and a lesson in using the device, Tonia could now largely forget all about the implant.

THe operation costs the nHs £25,000. Privately, it costs £30,000.