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Primary orthostatic tremor: is deep brain stimulation better than spinal cord stimulation?
  1. Han-Lin Chiang1,2,
  2. Yi-Cheng Tai1,3,
  3. Jacqueline McMaster4,
  4. Victor SC Fung1,
  5. Neil Mahant1
  1. 1Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia
  2. 2Department of Neurology, Taipei Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
  3. 3Department of Neurology, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
  4. 4Department of Neurosurgery, Westmead Hospital, Sydney, Australia
  1. Correspondence to Dr Neil Mahant, Movement Disorders Unit, Department of Neurology, Westmead Hospital, Cnr. Darcy Rd & Hawkesbury Rd, Westmead NSW 2145, Australia; nmahant{at}gmail.com

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Introduction

Primary orthostatic tremor (POT) is a rare movement disorder characterised by a tremor of 13–18 Hz in the legs with female preponderance. POT typically causes severe unsteadiness on standing which, when severe, may persist during walking. This can greatly impact day-to-day functions, including activities that require prolonged standing, such as showering. The response to medications is often limited. There are few data on medications for POT. Clonazepam and gabapentin are probably the two most efficacious medications to treat POT, whereas other medications such as levodopa may also have a role.1 On the other hand, case studies have shown favourable outcomes in patients treated with ventralis intermedius medialis (VIM) thalamic nucleus deep brain stimulation (DBS). Blahak et al also reported that four patients responded well to chronic spinal cord stimulation (SCS), at the cost of stimulation-induced paraesthesias.2 Here, we report the surgical treatment response and electrophysiology findings of two additional patients with severe POT.

Case report

Case 1

The patient is a 74-year-old woman who developed progressive unsteadiness and tremor in the legs when standing at age 50. The symptoms improved when she leant on something to support and disappeared when she walked. There was also low-amplitude, high-frequency tremor of the outstretched hands. Surface electromyography (sEMG) showed a short duration (<50 ms), ~16 Hz sEMG bursting in all the …

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