Intraoperative Trombone Playing during Awake Deep Brain Stimulator Placement

In this case, a 65-yr-old man with bilateral essential tremor underwent awake deep brain stimulator placement targeted to the ventral intermediate nucleus for symptom management and improved quality of life. The patient’s primary complaint was that the tremor affected his ability to play the trombone.

Initially his tremor was managed with oral medications, but, as their effects waned, he struggled to hold his horn steady and felt as though his hands were fighting each other. Because his ability to play the trombone was a key factor in his decision to pursue deep brain stimulator placement, the patient asked if he could bring his trombone to the procedure, to ensure there was symptom improvement after lead placement. After consultation, this was approved by the neurosurgical and anesthesia teams.

Intraoperatively, monitored anesthesia care with sedation and local anesthesia was used for scalp incision and burr hole placement. Remifentanil (0.05 to 0.12 μg · kg^–1 · min^–1) was titrated to sedation and nicardipine (5 to 15 mg/h) was used to maintain systolic blood pressure less than 150 mmHg. The remifentanil infusion was stopped 15 min before the start of microelectrode recording to ensure adequate neuronal firing. All medications known to cause excessive sedation or interfere with electrode recording, specifically midazolam, propofol, and labetalol, were avoided. 

Once fully awake, lead placement began using microelectrode recording and motor testing that uses variations in spontaneous firing rates and movement-related firing rates to localize the specific brain target. After electrode placement was confirmed, the patient requested to play his trombone intraoperatively.

Due to both the increased risk of bleeding secondary to elevated intracranial pressure during Valsalva maneuver as well as the risk of venous air embolism with deep inspiration, the patient was instructed not to blow with force but to instead go through the motions of moving the main slide and adjusting his mouth position (fig. 1). As he began “playing,” the deep brain stimulator was turned on and he noted that his tremor nearly vanished and his hands were once again working in sync (supplemental video, https://links.lww.com/ALN/D359). The patient was satisfied, because his specific concern was addressed, and the effective treatment was demonstrated intraoperatively.