The authors report the results of a long-term follow-up study of the effects of the physiologically defined selective VIM (nucleus ventralis intermedius)-thalamotomy on tremor of Parkinson's disease in 27 patients and essential tremor in 16 patients. The follow-up period ranged from 3.25 to 10 years (mean 6.58 years). In 43 patients a total of 50 operations (including four bilateral operations and three reoperations) were carried out. The early (2 to 4 weeks after surgery) and late effects on the tremors were determined clinically and electromyographically. Fourteen parkinsonian cases were treated with minimal lesions (about 40 cu mm). Their late results were very similar to the early results: in 10, the tremors were completely abolished, three had a slight residual tremor, and one underwent reoperation 3 months after the first surgery. Eleven essential tremor cases were treated with minimal lesions. Six of these tremors were completely abolished, four patients had slight residual tremors, and one patient with a recurrence underwent reoperation 2 years after the initial surgery. In these 23 successful operations with minimal lesions (excluding two cases with reoperation), the tremor was abolished without discernible long-lasting side effects. The other 23 operations on 16 patients with Parkinson's disease (including one reoperation) and on seven with essential tremor (one of whom also had a minimal lesion on the other side) involved relatively large lesions. In this group, the surgery was successful in almost every case. It was concluded that radiographically and physiologically monitored selective VIM-thalamotomy for parkinsonian and essential tremor is effective even when lesioning is minimal. Moreover, the beneficial effect is maintained over a long period of time.

GK thalamotomy is an alternative treatment for intractable tremors of PD as well as for ET. Less invasive intervention may be beneficial to patients.

In 51 cases (6 cases with bilateral operations) with various kinds of tremor, stereotaxic ventralis intermedius (Vim) thalamotomies were performed using Leksell's apparatus and the results of operation evaluated. Several characteristics of the tremor, including clinical features and EMG, were correlated with the assumed location and volume of the coagulative lesion. In 54 of the 57 operations, the thalamic Vim nucleus was identified physiologically and a therapeutic lesion placed at a site that included the Vim neurons. In all these cases, except one in which the lesion was estimated to be too small, tremor was immediately abolished by a relatively small lesion. The estimated volume of the lesion was about 40 to 200 mm3 and the effect persisted over a long follow-up period (maximum ten years). The size of the lesion that was necessary apparently depended on several features of the tremor. A larger lesion was required in cases of movement type tremor, tremor with a low rate (less than 4 Hz), tremor of high amplitude (more than 600 microV), and tremor involving proximal muscles or with a wide distribution. Tremor following a cerebrovascular lesion and post-traumatic tremor were characterized by coarse oscillation (high amplitude and low frequency) involving proximal muscles. A relatively larger coagulative lesion was therefore necessary to relieve this type of tremor. In contrast, parkinsonian and essential tremor were usually of low amplitude and distal in distribution. For the relief of such tremor, the lesion could be very small: if aided by electrophysiological methods to identify Vim neurons, the minimal effective volume of the lesion was estimated as about 40 mm3 and restricted to the Vim nucleus. Based on these results, the importance of the Vim nucleus in tremor mechanisms is discussed.

1. During the course of stereotaxic thalamotomy for 56 cases with tremor mainly due to Parkinson's disease and essential tremor, extracellular recordings were made from the thalamic ventralis intermedius (Vim) nucleus under local anesthesia. These procedures have been justified as an essential technique to achieve the best therapeutic results by a selective coagulation. These physiological observations provide important information about the functional organization of the ventrolateral thalamic mass in humans. 2. Using Leksell's stereotaxic apparatus, a pair of semimicroelectrodes was introduced simultaneously to the thalamic ventral lateral region from the prefrontal area. The Vim nucleus was identified tentatively by characteristic high background activity which contrasted to that found in its rostral part and by superimposed large amplitude spontaneously active units. 3. In this high activity zone, 135 units (approximately 1/5 of the recorded units) responded to natural stimulation applied to contralateral body parts. Among them, approximately 90% responded to a passive or active movement of a joint. Several lines of evidence suggested that probably muscle receptors were responsible. 4. The rest of units (approximately 10%) responded to light touch applied to contralateral skin surface. Convergent responses between kinesthetic and tactile units were never encountered. Also, kinesthetic and tactile neurons were geographically separated. The latter were found always at the end of our oblique trajectory, following the kinesthetic neurons. 5. Neurons with sensory responses were clustered mostly within the confines of the Vim nucleus, probably extending caudally to the ventrocaudalis externus anterior of Hassler. Evidence for a somatotopic representation in the Vim nucleus was obtained. 6. Electrical stimulation of the appropriate peripheral nerve produced responses of the same thalamic unit(s) that responded to natural stimulation. The latency to upper limb nerve stimulation was between approximately 10 and 20 ms. It was almost fixed in a given case. 7. It is concluded that the Vim nucleus receives kinesthetic afferent input from the contralateral body parts (mainly from the muscle receptor) and may be concerned with muscle sense. This may explain why a small, selective coagulation of the physiologically identified Vim has such a constant effect on several different kinds of tremor.

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