Technical NoteLong-Term Effect of Modified Incision to Prevent Related Complications in Deep Brain Stimulation
Introduction
Deep brain stimulation (DBS) is applied broadly for movement disorders that are difficult to manage medically.1, 2 The U.S. Food and Drug Administration approved DBS as a treatment for essential tremor in 1997, for Parkinson disease in 2002, and for dystonia in 2003.2 The main advantage of DBS is that its effects are safe and reversible, with less neurologic morbidity and mortality.1 This procedure is well tolerated but still not free of complications; a variety of hardware-related complications have been reported including infection, lead migration or misplacement, skin erosion, and lead fracture.3, 4, 5 Skin-related complications are the most common hardware-related complications and vary from 1% to >15% per patient.6 Most infections (75%) occurred within 3 months after DBS surgery, but they also occurred 21 months after DBS surgery.7, 8, 9 Some retrospective analyses reported that skin complications, such as infections or erosions, always occur in skin overlying implanted foreign material.10, 11 The implantable pulse generator pocket was the most common site, followed by the extension cable at the level of the postauricular area and scalp area. In addition, it has been reported that the infection rate was higher in those with a straight scalp incision compared with those with a curvilinear incision.12 Skin-related complications usually need surgical revision of the implants or device removal, compromising long-term benefits and increasing health care costs.6 What is noteworthy is that the number of DBS hardware implants will continue to increase along with new technology and low cost. Therefore it is urgent to decrease the rate of skin complications and other hardware-related complications. Various techniques have been investigated to prevent hardware erosion including countersinking the DBS cap and using C-shaped incisions, sine-wave-shaped incisions, and adjusted burr holes.13 In this study, we describe a modified skin incision procedure that takes advantage of a C-shaped incision and a ventriculoperitoneal shunt, avoiding the placement of hardware directly under the suture line, which we assume may effectively prevent postoperative skin infection or erosion.
Section snippets
Patients
We retrospectively analyzed the incidence of skin-related complications before and after the modified skin incision. Between September 2013 and December 2014, DBS electrodes were implanted in 30 patients with the common bilateral linear scalp and postauricular incision. Between January 2015 and April 2018, DBS electrodes were implanted in 103 patients with the adjusted incision at the Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, China. Informed consent was obtained
Clinical Characteristics of Subjects
The clinical characteristics of the study subjects are summarized in Table 1. In total, 30 patients (18 male/12 female) underwent traditional incisions: 29 patients with Parkinson disease and 1 patient with dystonia. The mean age at surgery was 59.20 ± 2.08 years (range, 22–27 years), and the mean duration was 11.12 ± 0.71 years (range, 5.5–19 years). There were 103 patients (51 male/52 female) with the modified incision at our center who underwent DBS electrode implantation: 101 patients with
Discussion
DBS has become a vital therapeutic method for movement disorders since its introduction in 1987. However, with the promotion of DBS, there are some common complications observed in many studies. Hardware-related complications are a major concern for physicians and patients.5 With regard to hardware-related complications, skin complications including erosion and infection are the major complication type reported in all series. Although many interventions have been adopted to prevent infection,
Conclusions
We describe a modified surgical incision that avoided the placement of hardware directly under the suture line. Our modified incision successfully reduced the incidence of skin complications compared to the traditional surgical incision. Our conclusion still needs to be further defined and explored in future studies with larger sample sizes and a longer follow-up period.
References (16)
- et al.
Long-term evaluation of changes in operative technique and hardware-related complications with deep brain stimulation
Neuromodulation
(2015) - et al.
Systematic review of hardware-related complications of deep brain stimulation: do new indications pose an increased risk?
Brain Stimulation
(2017) - et al.
Infection related to deep brain stimulation in patients with Parkinson disease: clinical characteristics and risk factors
J Neurol Sci
(2017) - et al.
Technical note: preemptive surgical revision of impending deep brain stimulation
World Neurosurg
(2018) - et al.
Deep brain stimulation hardware complications in patients with movement disorders: risk factors and clinical correlations
Stereotact Funct Neurosurg
(2012) - et al.
Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature
Acta Neurochir (Wien)
(2010) - et al.
Delayed complications of deep brain stimulation: 16-year experience in 249 patients
Acta Neurochir (Wien)
(2017) - et al.
Management of device-related wound complications in deep brain stimulation surgery
J Neurosurg
(2012)
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Rongsong Zhou and Yu Ma contributed equally to this work.