Elsevier

World Neurosurgery

Volume 117, September 2018, Pages 280-283
World Neurosurgery

Technical Note
Long-Term Effect of Modified Incision to Prevent Related Complications in Deep Brain Stimulation

https://doi.org/10.1016/j.wneu.2018.05.224Get rights and content

Highlights

  • A novel modified incision in deep brain stimulation.

  • Long-term results in patient with novel modified incision.

  • Our surgical incision successfully reduces the incidence of skin complications.

Background

Skin complications are a frequent type of complication of deep brain stimulation (DBS) neurosurgical procedure and are always observed in the postauricular area, scalp area, and implantable pulse generator pocket. Modifications to the surgical techniques for DBS have been proposed as therapeutic options. To prevent skin complications, we modified the surgical incisions.

Methods

At our center, we retrospectively analyzed the complications associated with traditional surgical incisions and then adjusted the double C-shaped incision and changed the postauricular incision from vertical to horizontal in patients undergoing DBS for movement disorders.

Results

Skin complications were observed in 4 patients among 30 patients who underwent traditional surgical incisions. In 102 consecutive patients who underwent operations with modified surgical incisions, we did not encounter any skin complications such as skin infection or erosion related to our modified incision. A single patient experienced pain and was cured after a week of local antiinflammatory treatment.

Conclusion

By trying to avoid placing hardware directly under the suture line, our modified surgical incision successfully reduces the incidence of skin complications.

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)

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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.

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