Surgery is not the first option in treating any cause of tremor. It is applied once non-pharmacological and pharmacological therapy fails. Botulinum neurotoxin injections, thalamotomy, deep brain stimulation, magnetic resonance-guided focused ultrasound, and radio-surgical gamma knife thalamotomy are the most common interventional procedures to treat tremors.

• Botulinum neurotoxin injections:
  • It has shown improvement in patients with hand tremor, regardless of the etiology. ^[1]
• Thalamotomy: ^[2]
  • Helpful in medication–resistant essential tremor, cerebellar tremor, or Parkinson’s disease related tremor.
  • Tremor is permanently treated by creating lesions in the thalamus responsible for causing tremors.
  • Most common side effects are dysarthria, cognitive impairment, and imbalance.
  • It is an invasive procedure.
• Deep brain stimulation: ^[3]
  • Parkinson’s disease and essential tremor may benefit from deep brain stimulation.
  • In this non-invasive procedure, electrodes are implanted to send high-frequency electrical signals to the thalamus, substantia nigra, or globus pallidus. The downside of deep brain stimulation is the expense, and long-term benefits are not established. It is reversible.
• Magnetic resonance-guided focused ultrasound (MRgFUS): ^[4]
  • Noninvasive thalamotomy procedure uses thermal ablation.
  • Used in severe medication–resistant essential tremor or Parkinsonian tremor.
  • Most of the side effects reported did not last more than three months.
• Radio-surgical gamma knife thalamotomy: ^[5]
  • It is found to be safe if done unilaterally.
  • Optimum dose from 130 to 150Gy is well tolerated.
  • Most common side effects are mild contralateral numbness and transient hemiparesis.