Bruce Bush, 66, first noticed a tremor in his hands in 2008. What started out as barely perceptible grew to become debilitating. Bush struggled to get dressed, use a fork and knife, sign his name.
A movement disorder neurologist prescribed medications, but none worked for Bush.
In 2012, he was diagnosed with essential tremor in both hands. The diagnosis may not have been a surprise – but it was gut-wrenching. “My father had essential tremor, and it was such a stress to him that he dealt with severe depression for the rest of his life,” Bush said. “I knew that, because I’m a different person, I wouldn’t react that way. But I also knew it was going to be life-changing.”
It was. But so was the INSIGHTEC focused ultrasound procedure performed by Dr. Charles Munyon. The neurosurgeon at Novant Health Brain & Spine Surgery - Cotswold, performed the incisionless surgery – no scalpel, only sound waves – on Bush in August 2021. And the results were more or less instantaneous: The majority of the tremor vanished.
Munyon, whose grandfather had essential tremor, treats patients from all over the country at Novant Health Mint Hill Medical Center. And the results are often similar.
Do you have tremors? Ask your doctor about seeing a neurologist.
“It used to be that people just had to live with this diagnosis,” said Cynthia Lang, vice president of neurosciences at Novant Health. “We don’t like to talk about ‘miracles’ in health care, but this is as close to a miracle as anything I’ve ever witnessed.” Munyon is on track to perform his 500th procedure by the end of 2023.
The procedure is FDA-approved for one side at a time. Bush had his right side – his dominant side – done first. Earlier this year, the FDA approved the procedure for patients’ other side. Patients can now have the two procedures closer together, but they must wait nine months after the first to have the second.
Bush was originally referred to Munyon in 2018 to discuss deep brain stimulation. Munyon told him a new procedure might fit his needs even better. But it wasn’t available in Charlotte yet. Bush was willing to wait.
The wait turned out to be longer than he’d imagined. His insurance wouldn’t cover the procedure, and he had to wait about two years before he was eligible for Medicare, which did cover it.
Bush, who was a system administrator in the computer industry before he retired, has always had interesting hobbies. He plays the autoharp – bluegrass, specifically – and since 2000, he’s been a prolific chronicler of his own life by keeping a journal.
By the time of Bush’s diagnosis, he “couldn’t reliably put pen to paper.” He had to give up playing music, too.
But he didn’t feel defeated. “Because I’m a computer guy, I’ve always been a problem-solver,” he said. “I took it on as a challenge instead of an inevitable sentence of doom.” He figured out some workarounds, but it was still a constant challenge.
“Take dressing myself, for instance. If you can't get a button to go in a buttonhole, you can’t put on a dress shirt. Eating had been difficult, too.”
After the first procedure, eating got easier. Bush could deftly use a fork in his right hand. But holding a knife in his left hand was impossible. One workaround he devised: He’d often eat at Asian restaurants where the food is usually served in bite-size pieces, making a knife unnecessary.
How incisionless brain surgery works
The patient, wearing a domed helmet, is awake during the procedure. No general anesthesia is necessary. Patients are flat on their back, and they’re rolled inside an MRI, where they’ll remain for up to two to three hours, though they’re rolled back out between each administration of the treatment.
The doctor uses high-energy ultrasound waves to target the areas of the brain that control fine-motor movement. The sound waves cause enough vibration that it translates into heat, Munyon said. When the neurological circuit is misfiring, the surgeon can “burn” brain tissue at the source of the tremor, thereby restoring function.
Because Bush had a diagnosis of essential tremor and tried – and failed – multiple different medications, he was a good candidate for ultrasound. It’s not right for everyone, though. Good candidates for ultrasound treatment include adults with a confirmed diagnosis of essential tremor who are ineligible for, or have failed, at least two standard-of-care medications. It can also be used to treat tremors that accompany some form of Parkinson’s.
The procedure has a high success rate on essential tremor, with tremor severity improving 76.5% over baseline at the three-year follow-up. There are potential risks associated with focused ultrasound, as there are with any surgery. The most common include imbalance/gait disturbance, numbness/tingling and headache.
Most of these events were classified as mild or moderate, and 48% of all adverse events resolved on their own within 30 days. Complications that persisted at three years were all mild or moderate. A small percentage of patients – about 2 to 3% – may require a revision. (Of the 400%20 INSIGHTEC procedures Munyon has performed, only about 10 patients have needed a revision.)
Bush realized early into the procedure that it was working. Techs pulled him partially out of the MRI a few times for a test of his ability to write legibly. He relishes showing people the “before” and “after” photos. “Everyone is amazed,” he said.
During an interview, he pulled out his phone to display his handiwork. “This was my first ‘MRI art class,’” he said, pointing to a photo. “They’ll pull you partially out of the MRI just long enough to ask you to trace this circle and try to write your name.”
It looks like a child’s scribbles.
But then he pulls up another photo. It’s the same test – but taken about an hour after the first one. This time, he had traced the round labyrinth accurately and written his name with perfect penmanship.
“They did three ins and outs from the MRI,” he said. “I could see the changes every time. And it was just breathtaking to be part of that.”
Once he was home after the first procedure in 2021, Bush pulled out his journal from 2012 and started to write. His handwriting looked just as it did then.
A few weeks after that procedure, a little of Bush’s tremor came back. But he estimates that it’s still 80% improved. Bush expects the same thing will happen with his left hand.
Bush had been warned the procedure could affect his balance for up to a month. He felt a little unsteady for a few days, but his balance returned within a week.
A year later, Bush wrote to Munyon to ask when he could have the procedure for his other side.
A lesson in empathy
Bush and his wife, Midge, traveled from their home in Niagara Falls, New York to the Charlotte area for the second procedure in late July 2023. While closer facilities were available, Bush already trusted Munyon. “Why mess up the formula for success?” he asked.
The procedure took even less time than the first – about an hour. And once again, there was tremendous improvement in his handwriting almost immediately.
Since he’s been home, he’s been enjoying doing things he hasn’t been able to do for years. “I have a four-year-old grandson, and we were out in the yard playing with a little toy rocket launcher,” Bush said. “I was able to put the rocket into the launcher using my left hand.” And as he “rediscovers” his left hand, he marvels at how huge a simple pleasure can be.
Bush’s faith helped him endure the years he lived with essential tremor. And it continues to be a source of strength.
“My faith told me that God is in charge of this tremor,” he said. “I believe nothing has come into my life without God being aware of it and having a purpose for it. I may not appreciate having it, but it’s there for a reason. I was able to experience a tiny taste of what people with serious disabilities go through – having to ask for help to write something, feeling a little awkward in restaurants. I’m more empathetic because of my experience.”
Bush can’t help but think of his father and how different things might have been if this procedure had been available to him.
“To anyone who’s currently dealing with tremors, I'd like them to know that, if they are a good candidate for this surgery, it’s amazing how helpful it is,” he said. “If the ultrasound procedure is right for you, it’s a long road, but it’s worth it.”
