A Passion is Rekindled | Mike's Story

As a correctional officer for 25 years, Mike Burton routinely worked long hours in what he describes as a "violent, toxic environment." So, when he began to notice his left hand shaking uncontrollably when he felt stressed or anxious, his concern ran much deeper than his health.

"I was one officer overseeing 60 to 100 inmates at a time, and I was constantly being watched," he says.

Mike's initial reaction was to hide his shaking hand from everyone, including his fellow officers. He kept his hands stuffed in his pockets as much as he could. To open a cell block, he guided the key into the lock with two hands. Once in a while, a colleague would notice him doing it, and Mike would tell them he'd drank too many energy drinks and was feeling amped up.

Mike's concern grew when he was promoted to a specialized unit for which he was frequently required to take a firearm qualification exam. Failing at any point could have jeopardized his job. The left-hander compensated for the shaking, which was worsening, by quickly learning to draw his gun with his dominant hand and then discreetly shifting it to his right hand so he could fire.

Earlier, after his first bouts of shaking, Mike visited a neurology practice near his Delaware home. He was diagnosed with an essential tremor, a type of body tremor that has no known cause. The neurologist started him on the first of what would become multiple medications. Mike returned to work, closely guarding his secret. Only his wife, Diane, and his neurologist knew about his tremor.

Art was Mike's reprieve from his stressful job and progressive tremor. In 2008, he learned how to airbrush, pinstripe, and gold leaf cars under the tutelage of a local artist. In time, he won several national trade contests that helped generate a lot of interest in his work. He opened his own studio, Color Splash Creations, and branched out to designing art on prosthetics. Recipients have told Mike that his creations helped boost their self-esteem.

To do this kind of art, Mike needs a very steady hand and a ton of patience. His tremor eventually eroded both to the point he couldn't continue.

"I couldn't even mix paint without getting it all over the floor and myself," he says.

He wrestled with the decision for a long time before finally deciding to abandon his art.

"It killed me," he says. "That really put me in a dark place."

Mike wasn't just giving up a significant part of his identity, he was also realizing that his tremor was progressing and consuming more and more of his life in the process.

When the neurology practice where Mike had been treated since the onset of his tremor closed in 2023, he was on the verge of losing all hope. "I didn't want to go through everything all over again with somebody new," he says.

Diane, however, wasn't ready to stop trying. She scoured the internet for potential resources, eventually finding her way to neurosurgeon, Iahn Cajigas Gonzalez, MD, PhD, and a procedure he performs for essential tremor called MR-guided focused ultrasound (MRgFUS).

On March 28, 2023, Mike and Diane met with Dr. Cajigas to find out if Mike was a candidate for the procedure.

With experience comes precision

MR-guided focused ultrasound combines two imaging technologies: Magnetic resonance (MR) technology provides precise images of the thalamus, a region of the brain involved in many body functions including control of movement, while highly focused sound waves destroy, or ablate, an area of brain tissue as small as three millimeters. The MR technology also measures the precise temperature of the targeted brain tissue during the treatment, which increases the procedure's safety, according to Dr. Cajigas.

"We can see the area of the brain that we're treating heating up in real time," he says, "so we're able to ablate the targeted tissue with minimal effect to the surrounding tissue."

Over the years, Mike had tried multiple medications, but at no point did any of them curtail his shaking. This history made him a candidate for MR-guided focused ultrasound.

Mike viewed the procedure as his last chance to live the remainder of his life without his left hand constantly shaking, although deep brain stimulation was also a treatment option, Dr. Cajigas notes. Which procedure is best for a particular patient depends on many factors, which are discussed in detail during clinic visits, he says.

On the day of his MR-guided focused ultrasound, Mike and Diane arrived at Pennsylvania Hospital at 5:30 AM.

"From the reception staff to the medical workers who were assigned to me, everyone made us feel comfortable," Mike says of that morning.

Beforehand, he read every article and watched every video about the procedure he could find, but the thought of having it done still scared him.

"I think the prospect of surgery, particularly brain surgery, is scary for everyone," he says. "It's almost natural for your mind to go to the worst-case scenario. But I had total confidence in Dr. Cajigas, so I tried to trust in that."

Dr. Cajigas tells his patients they can expect the MR-guided focused ultrasound to resolve around 80 percent of their tremor, but the actual amount is usually higher. Penn neurosurgeons, including Dr. Cajigas and Casey H. Halpern, MD, division head of Functional and Stereotactic Neurosurgery, collectively, have performed more than 400 MR-guided focused ultrasounds. Through such experience with a procedure where a fraction of a millimeter can significantly alter the outcome, they've made tremendous gains in controlling tremors while limiting, if not eliminating in many cases, disruptions to other body functions, Dr. Cajigas says.

The most common risks are speech and balance issues. To head off the speech issues, Dr. Cajigas slid Mike out of the MRI scanner at various points during the procedure and asked him some simple questions to test his response to the treatment. (Mike was given a sedative before the procedure, but he remained awake throughout.) Mike was also asked to move his left arm and hand to help Dr. Cajigas gauge the ultrasound's impact on his tremor.

 

Before, during, and after the MR-guided focused ultrasound, Dr. Cajigas has his patients complete a simple worksheet. They need to trace a spiral path and print their name in a large box. Often, the "before" worksheets show wildly erratic attempts at both activities. There's some improvement with the ones completed during the procedure. And the worksheets done after the procedure typically show very little evidence of a tremor; the line follows the middle of the path, and the printing is concise.

"Communication is important during the procedure because as long as I haven't created a lesion, everything is reversible," Dr. Cajigas says. "So, we can always fine tune things."

The balance, however, can't be checked until the conclusion of the procedure.

Mike's MR-guided focused ultrasound lasted about an hour-and-a-half. He was then moved to a recovery room, where he took a series of tests with a physical therapist and an occupational therapist. By midafternoon, he was discharged.

Dr. Cajigas says about one in three patients develop temporary speech and balance issues in the days immediately after the procedure because of swelling in the area around the ablated brain tissue. In almost every case, these issues resolve themselves within 30 days, as the swelling subsides. Mike says he experienced some occasional dizziness after his procedure. It went away after two weeks.

The artist returns to the studio

Mike's tremor was completely gone following his MR-guided focused ultrasound. The realization overwhelmed him.

"Just being able to extend my arm and spread my fingers without any signs of shaking brought tears to my eyes," he says.

When they got home from the hospital, he celebrated by eating a meal with Diane and not spilling food all over himself, something that seemed impossible just 12 hours earlier.

"So many aspects of my daily life–eating, shaving my head, brushing my teeth, even signing my name–had become a struggle," he says.

Eight months later, Mike remains tremor-free.

Dr. Cajigas says that MR-guided focused ultrasound is not a cure for essential tremor. "It disrupts the circuit that leads to the manifestation of the tremor," he says.

Although, the limited data offers reason to be optimistic. Five years after the procedure, about 80 percent of patients still have "very good" control of their tremors, Dr. Cajigas says.

Should Mike's tremor return, which could happen because essential tremor generally worsens over time or the lesion created by Dr. Cajigas has shrunk slightly, he can undergo another MR-guided focused ultrasound without any additional risk to his health. Deep brain stimulation also remains an option.

(Dr. Cajigas notes that for patients who experience tremors in both hands, two separate MR-guided focused ultrasounds can be done safely nine months apart to address the tremor on each side.)

"The key is that he has options," Dr. Cajigas says. "But for most patients, the single treatment is sufficient."

Now retired, Mike, 50, has settled into a low-stress, albeit disciplined, routine. He wakes at 3 AM, hits the gym for an hour-and-half, returns home to eat breakfast with Diane before she leaves for work, takes a short nap, then works on his art for a while before turning to an assortment of household chores.

When he saw Dr. Cajigas in January for a follow-up visit, he presented him with a one-of-a-kind aluminum panel he titled "Neurosurgery, A Mind-Transforming Miracle." The panel is airbrushed and pinstriped with custom automotive candy paints, hand-lettered with gold leaf, and in a frame that Mike also created.

"Dr. Cajigas gave me my life back," Mike says. "I'll never forget that. He's my hero."

The panel now hangs in Dr. Cajigas's office. He says he looks at it every day. It's become a constant reminder of why he pursued medicine in the first place: to help people.

"Mike gave me a little window into his life, and I got to see how much his art means to him," he says. "I feel very fortunate that I was able to have a hand in bringing him back to it. I start to choke up when I think about it."