Scott Webb (Host): Today, we're getting acquainted with Dr. Jason Gerrard, Director of Regional One Health's Focused Ultrasound Program. Dr. Gerrard is here to explain how focused ultrasound can help patients with hand tremors with no incision or hospital stay. .

This is One-on-One with Regional One Health, your inside look at how we're building healthier tomorrows for our patients and our community. Join us as we get to know some of the individuals who help provide life-saving, life-changing care for our community. I'm Scott Webb. Welcome to the podcast, Dr. Gerrard.

Jason Gerrard, MD: Thank you for having me. It's a pleasure to be here and I'm excited to have this conversation with you.

Host: Yeah, I am too. I'm excited to learn more. I'm sure listeners are as well. So let's just start off here. Want to find out what drew you to the field of neurosurgery and how did you first become involved with the focused ultrasound procedure?

Jason Gerrard, MD: I was always fascinated by the brain. And then, those folks who are old enough will recall that the 1990s was labeled the decade of the brain, by the NIH and the U.S. government at that time. And so I decided that I was going to start studying the brain, which I did as an undergraduate, and I knew I wanted to go to medical school, and I started doing some amazing neuroscience research at the University of Arizona, where I was an undergraduate with Dr. Carol Barnes and Dr. Bruce McNaughton, and I decided I wanted to do both. And so I went to medical school, and I also got a PhD in neuroscience, and decided that I wanted to figure out how the brain works and then try to understand how we can work with it rather than cutting it out, which for the most part, you know, in surgery, that's really what we have to offer.

We can take stuff out, but why not figure out how to work with the brain? And many times I actually put stuff in now and figure out ways to work with the brain to try to fix neurological disorders as best as we possibly can. Part two would be the focused ultrasound. And the focused ultrasound is really, what's old is new again. The interest I had in brain circuits led me to what's called functional neurosurgery. And, you know, the name kind of gives it away. Really what we try to do is restore function. And so we treat a lot of patients with tremors, patients with Parkinson's disease, patients with epilepsy. Patients who have neurodegenerative or neurological disorders where we have a good amount of information about the particular brain circuits that are involved.

And we try to work with those brain circuits. Pretty much what I thought about, you know, 30, 40 years ago. And so I went into functional neurosurgery. We do a lot of deep brain stimulation for tremor, and before we did deep brain stimulation, we made focused lesions in a procedure called a thalamotomy for tremor.

 And the focused ultrasound is basically a new and improved, highly technological way to do a thalamotomy, which is actually a procedure that's been around for decades, since the late 1940s. I think if we were talking economics or field of technology, you would call it a disruptive technology. And I think in medicine, in neurosurgery in particular, the focused ultrasound device is really a disruptive technology. And so here it is, and it's a way for us to do a neurosurgical procedure that's highly effective, that's been around for a long time, but now we can do it without even making an incision, which is really a great step forward. Patients get to go home the same day. We don't have to implant any of our neural stimulators, which of course, you know, I use a lot, but there's certainly people out there that don't want to have these devices implanted. And that's how I got to the focused ultrasound. It was one of the things that drew me to Memphis.

Host: Yeah. Yeah. It's very cool. I teased there that we're going to talk about hand tremors with no incisions or hospital stay, really sort of mind blowing stuff. So let's talk about that. Let's talk about the patients that benefit the most from focused ultrasound, what types of conditions and symptoms they're dealing with.

Jason Gerrard, MD: The Focused Ultrasound is presently FDA approved to treat essential tremor and patients who have what's called tremor predominant Parkinson's disease. So that approval is really focusing on treating tremors and it is quite good at it. So the present time, most of these patients have either essential tremor or they have Parkinson's disease, but you have to be a bit careful in Parkinson's disease because the procedure really only helps the tremors and with Parkinson's disease there's a classic triad of symptoms, which in addition to the tremors, involves things like bradykinesia, which stands for slowness of movement, and also rigidity, which is increased muscle tone, which you can recognize if you know anybody with Parkinson's disease.

So those last two don't get better, so you got to make sure in Parkinson's disease that the tremor is really their primary issue.

Host: I see. Yeah, it's really fascinating. Wondering from the patient's perspective, is there anything they need to do to sort of prepare themselves for a focused ultrasound? Is there anything that can be done on their end or are just be a good patient?

Jason Gerrard, MD: Yeah, there's not really much they can do. Sometimes if patients are on blood thinners or, you know, antiplatelet therapy, we do have to hold that for a few days. One of the things that's nice is if you look at all of the cases of focused ultrasound that have been done, there's, never been a hemorrhage, a big hemorrhage, big enough to cause trouble, so, it really is quite safe on that front, but we still, to be super safe, we still do hold antiplatelet and anticoagulation therapy, so you have to get approval from that perspective.

The one thing they do have to do, and this is the joke I crack with my patients in clinic, um, is that you can't be too thick headed, you can be hard headed, but you can't be thick headed.

Host: Can't be thick headed. Okay.

Jason Gerrard, MD: And the reason for that is because the way the system works is it's actually calculating exactly how all the various beams, and there's up to 1,024 beams, are going to be refracted, and they are mostly refracted by the patient's skull, so passing through the skull can kind of bend the beam a little bit, and so it predicts exactly how that's going to happen for every beam, and if your skull is really thick, it tends to have a low density material in it, kind of like bone marrow, and then it gets very difficult and even impossible to predict how that beam's going to refract.

So, I always crack that same joke with my patient every time, well, if you're too thick headed, we can't do this. And so, we have to get a high resolution CT scan, and we send it off. And it gets evaluated to make sure that what's called their skull density ratio falls within the range that makes it possible for us to do focused ultrasound.

The statistics here in the US suggests that about 85 percent of the population are candidates. So most people can, but every once in a while we get a skull density ratio that's too low for us to do the procedure.

Host: Yeah. I was going to ask you, you must've read my mind because I was going to ask you, is there anybody that this isn't appropriate for? And you say it's about 15 percent or so, whose heads are too thick, you know, and it's unfortunate, I'm sure, and maybe there's some other treatment options. Focusing on focused ultrasound and that procedure, and we probably would need longer than we have in this podcast, but can you just generally tell us how it works and how you use it to treat hand tremors?

Jason Gerrard, MD: In clinic, I will often give what I call my short five minute version of the history of tremor surgery, but it probably takes more than five minutes. But just briefly, a surgical procedure called the thalamotomy has been around for many decades and it's very effective. And what that procedure involves is a targeted lesion made at an exact location in the part of the brain called the thalamus, which is right in the middle of the head. And we can do this with open surgery. We've been doing it for decades. And then today, most people who have what we call open surgery or brain surgery are going to have deep brain stimulation done where we put the electrode in, but the target's the same.

So focused ultrasound, what it does is we use that same target and my understanding of the physics of this are that each of these beams is focused, hence the focused ultrasound.

Host: Sure.

Jason Gerrard, MD: And we're using ultrasound beams, and they collide at the target that you make in the head. And they collide in phase, and what happens when ultrasound waves are in phase is it generates actual heat.

So when we do these procedures, what's happening is that we're turning the beams on, and they're colliding at the target, and they're on for about anywhere from 12 to 30 seconds only at a time, and we're generating heat at that target, which is in the thalamus in the brain. The other cool piece of technology is that we do this in an MRI scanner and we've developed what's called MRI thermography, which means that while I'm generating this heat with the focused ultrasound beams, I can see in real time where in the brain it's getting hot.

And so that needs to be, of course, right in the target that we made and not in other places. So that's like this really nice safety feature that this has built into it. So for the first time, we can literally see where we're generating heat in real time as we do it. And so we do usually a series of anywhere from six or seven to 12 or 13 of these, what are called sonications, where the beams are on for that you know, 12 to 30 seconds, as I said.

Host: Yeah. You know, Doctor, I often learn from the experts, quite often when I host these, and then every once in a while I run into an expert like you and I'm just shaking my head. If, if listeners could see me just shaking my head, it sounds like you're describing a video game or something, but it's not. It's you and someone's head and their brain and ultrasound, and it makes me wonder, you know, you said this, a form of this technology goes all the way back to the 40s.

It makes me wonder if you could show them, what they were doing in the 40s, what you're doing now, and just how, really pun intended, mind blowing it is. It's unbelievable, right?

Jason Gerrard, MD: It is mind blowing. Yeah. And you know, what is the same as the target in the brain. But back then, you know, they didn't have CT scans or MRI scans and they had to go find this location in the brain basically by using a coordinate target system and then putting electrodes down in the brain and recording from the brain and doing test stimulations until they were in the right spot.

And then they would put a different electrode down there and make the tip of it hot, 70 degrees Celsius, and they would make a targeted lesion. They're burning a little hole, as I tell my patients, but we don't like to say that in medicine, so we call it a thalamotomy.

Host: Sure. Right. That sounds much more scientific.

Jason Gerrard, MD: Sounds much more scientific.

Host: Well, as you say, today it's no incisions or hospital stay. It's really amazing. Just want to finish up today and just talk about results, outcomes, and how ultimately what you're doing for folks impacts their lives.

Jason Gerrard, MD: So we'll start with the results. So the best data that we have on the results comes from the original trial that got the FDA to approve this therapy. And there was a number of patients in that trial and what they did, I think the best thing to go over to understand that is on average, how much benefit in the tremor did patients experience?

And that was essentially about 75% improvement in the tremor. So if we take, you know, some variety of tremor scores that are available to us, and then we score the patient's tremor, let's say they're right handed and they have a bad tremor in their right hand. And then after the procedure, we score their tremor in that hand, say six months after the procedure, then we compare the two.

You can, you'll see a 75 percent improvement in their tremor on average. So this is a significant improvement in the tremor. Some patients experience more. Some patients experience less. Of course, there's going to be a distribution around that average. But yeah, it's 75 percent is a really nice improvement.

There were other devices, some that still exist today that we could do this type of procedure with without doing surgery, but they did not show the same level of tremor improvement that the focused ultrasound does. So it's nice. This is a huge improvement in the quality of lives. And I know it sounds rudimentary, but I just never get tired of hearing people laugh and sometimes even cry because they just wrote their name on a piece of paper for the first time in a decade, or they can eat with a fork you know, in their right hand, or they can paint again. Things that we take for granted, buttoning buttons, brushing your teeth without sticking the toothbrush up your nose accidentally because of the tremor, writing your name, all these things that you don't think about.

 Patients with severe tremors have difficult time doing and some people have to use two hands to say drink out of a glass of water and some and sometimes they still spill it and you know our favorite trick in the recovery room is to hand them a bottle of water and watch them drink out of it. It really is life changing for these patients and the day that I do these procedures I always tell my patients you guys make my day because I skip out of here smiling ear to ear. Just watching the change in these people's quality of lives and how happy it makes them.

Host: I'm sure, as you say, some laughter, some tears, maybe both, but all those things, those rudimentary things that so many of us take for granted, just the simple, like just trying to brush your teeth, as you say, without going up your nose. I mean, it's really amazing. I have learned so much today and it is just, you used the word cool earlier, and it's just undeniably cool. So, thank you so much for your time. Really appreciate it.

Jason Gerrard, MD: You're welcome. Anytime. Happy to come back and, you know, talk some more if you'd like.

Host: Focused Ultrasound is available at Regional One Health's East Campus Imaging Center, 6555 Quince Road. To learn more and find out if Focused Ultrasound is right for you, go to regionalonehealth.org/FUS/.

 And thanks for making One-on-One with Regional One Health, part of your journey to better health. Join us next time as we introduce you to another member of the Regional One Health Family. I'm Scott Webb. Stay well.