Management of skin erosion following deep brain stimulation

Periosteal Turnover Flap for Coverage and Salvage of Exposed Deep Brain Stimulation Device

Implanted deep brain stimulation (DBS) devices are crucial in the treatment of movement disorders. Hardware extrusion is among the most frequent complications of the implantation process and requires reconstruction with well-vascularized tissues. The authors present a case of periosteal turnover flap for coverage of an exposed DBS device. An 11-year-old female patient with spastic cerebral palsy presented with an exposed DBS device located in the right parietal area. The exposed device was covered by a proximally based periosteal flap. Postoperative evaluations at months 1, 2, 3, and 8 revealed no signs of infection or dehiscence. This brief clinical study shows that reconstruction with periosteal turnover flaps is both an easy and excellent choice for secondary closure of exposed DBS devices.

Hardware-Related Skin Erosion in Deep Brain Stimulation for Parkinson's Disease: How Far Can We Go? An Illustrative Case Report

Skin erosion is a hardware-related complication commonly described after deep brain stimulation (DBS). Hardware exposure is often associated with the development of infection that can lead to implant removal. However, in selected cases, it is possible to manage skin erosion without having to remove the hardware. This article presents the case of a patient with recurrent skin erosions above the IPG, who underwent multiple surgeries. Given the failure of less invasive approaches, a more complex surgery with the employment of a pedunculated flap of pectoralis major in order to cover the IPG was attempted. Nevertheless, the IPG removal was finally unavoidable, resulting in a rapid decline in clinical performance. This illustrative case suggests how, in patients with sustained stimulation who benefit from a good degree of autonomy, it may be useful to use invasive surgical techniques to resolve skin erosions and save the DBS system. In spite of everything, sometimes complete or partial removal of the implant still becomes unavoidable, but this can lead to a severe worsening of PD symptoms. Definitive removal of the system should therefore be considered only in cases of frank infection or after failure of all other approaches.

The wandering ventriculoperitoneal shunt and the scope of its salvage

PURPOSE

Distal shunt tube migration following ventriculoperitoneal (VP) shunt placement in children is mostly managed by an initial shunt diversion/removal and subsequent replacement. Lately, shunt salvage is being used as an alternative in certain conditions. We have focused on the situations where one can consider or disregard shunt salvage in such cases.

METHOD

A retrospective study of children treated for distal shunt migration following VP shunt placement between January 2013 and December 2019.

RESULT

Seventeen children were managed for over 7 years. These included cutaneous extrusions (n = 4), hollow viscus perforation (n = 6), inguinal hernias (n = 5), and umbilical extrusion (n = 2). The surgical treatment varied from a cutaneous wound closure (with a tube in situ), temporary external shunt diversion, and laparotomy with shunt reposition into the peritoneal cavity. Shunt salvage was possible in three cases, whereas in 2 cases even though shunt salvage was possible, it was not feasible due to a short residual shunt length.

CONCLUSION

VP shunt salvage is possible in certain cases of distal shunt migration with a functional uninfected shunt. Small cutaneous extrusions can be covered by a local skin flap. Also, one should consider the residual intraperitoneal shunt length before its salvage in small children.

Is It Possible to Save the Deep Brain Stimulation Hardware when Presenting with Wound Dehiscence or Hardware Infection?

INTRODUCTION

Deep brain stimulation (DBS) hardware complications have been traditionally managed by removal of the entire system. Explantation of the system results in prolonged interruption to the patient's care and potential challenges when considering reimplantation of the cranial leads. The purpose of this study was to understand whether complete explantation can be avoided for patients initially presenting with wound dehiscence and/or infection of hardware.

METHODS

We performed a retrospective study that included 30 cases of wound dehiscence or infection involving the DBS system. Patients underwent reoperation without explantation of the DBS system, with partial explanation, or with complete explantation as initial management of the complication.

RESULTS

A total of 17/30 cases were managed with hardware-sparing wound revisions. The majority presented with wound dehiscence (94%), with the scalp (n = 9) as the most common location. This was successful in 76.5% of patients (n = 13). Over 11/30 patients were managed with partial explantation. The complication was located at the generator (91%) or at the scalp (9%). Partial explantation was successful in 64% of patients (n = 7). In cases that underwent a lead-sparing approach, 33% of patients ultimately required removal of the intracranial lead, and 2/30 cases of hardware infection were managed initially with total explantation.

DISCUSSION/CONCLUSION

Wound dehiscence can be successfully managed without complete removal of the DBS system in most cases. In cases of infection, removing the involved component(s) and sparing the intracranial leads may be considered. Wound revision without removal of the entire DBS system is safe and can improve quality of life by preventing or shortening the withdrawal of DBS treatment.

Skin erosion in deep brain stimulation procedures: Using the temporalis muscle to treat this complication - A technical note

Background:

Skin erosion is a common complication after deep brain stimulator procedures. Despite being a relatively common event, there is no standard surgical technique or a widely accepted guideline for managing this kind of complication.

Methods:

We describe a case of cutaneous erosion in the connector’s site of deep brain stimulation case, surgically managed with anterior displacement of the connectors and overlapping and wrapping the connections within the temporal muscle.

Results:

Postoperatively, the patient did well and achieved complete resolution of the skin erosion, with no signs of infection or new skin lesions.

Conclusion:

This technique demonstrated to be effective in this case in the long-term follow-up.

Reconstruction of chronic scalp erosion after deep brain stimulation surgery

OBJECTIVE

To investigate the reconstructive effectiveness for chronic scalp erosion after deep brain stimulation (DBS).

BACKGROUND

Deep brain stimulation (DBS) is an effective treatment for Parkinson's disease. However, this surgery is not exempt from hard-ware related complications, especially scalp erosions on scalp. Scalp erosions usually accompanied with chronic infection and wound contamination. If not arrested, infections may spread through the entire equipment which would endanger the patient's life. Along with review of previous literatures, we summarized our experience in the management of scalp erosion and implemented a systemic treatment plan for reconstruction.

METHODS

We retrospectively analyzed the clinical data of patients with chronic scalp erosion after DBS in the past 40 months. The treatment plan was composed of three sequential major steps, including wound care and conservative methods, debridement and local flap, and revaluation of the wound. In each of the cases, wound debridement and local scalp flap repair were conducted, and assisted by negative pressure wound therapy (NPWT) device and double cannula irrigation.

RESULTS

The local scalp flap survived in all 6 patients. The chronic scalp erosions all healed without refractory. The DBS devices still functioned properly after the treatments in all patients. The average follow-up period was 13.33 months (range: 4 to 23 months), and no infection recurrence or re-erosion of the scalp flap was reported.

CONCLUSION

A combination of wound debridement, local scalp flap repair, the use of NPWT device and double cannula irrigation provides effective treatment method for chronic erosion post DBS surgery.

Experience Reduces Surgical and Hardware-Related Complications of Deep Brain Stimulation Surgery: A Single-Center Study of 181 Patients Operated in Six Years

Objective

Deep brain stimulation (DBS) surgery has increasingly been performed for the treatment of movement disorders and is associated with a wide array of complications. We aimed to present our experience and discuss strategies to minimize adverse events in light of this contemporary series and others in the literature.

Methods

A retrospective chart review was conducted to collect data on age, sex, indication, operation date, surgical technique, and perioperative and late complications.

Results

A total of 181 patients (113 males, 68 females) underwent DBS implantation surgery (359 leads) in the past six years. Indications and targets were as follows: Parkinson's disease (STN) (n=159), dystonia (GPi) (n=13), and essential tremor (Vim) (n=9). Mean age was 55.2 ± 11.7 (range 9-74) years. Mean follow-up duration was 3.4 ± 1.6 years. No mortality or permanent morbidity was observed. Major perioperative complications were confusion (6.6%), intracerebral hemorrhage (2.2%), stroke (1.1%), and seizures (1.1%). Long-term adverse events included wound (7.2%), mostly infection, and hardware-related (5.5%) complications. Among several factors, only surgical experience was found to be related with overall complication rates (early period: 31% versus late period: 10%; p=0.001).

Conclusion

The rates of both early and late complications of DBS surgery are acceptably low and decrease significantly with cumulative experience.

Management of exposed ventriculoperitoneal shunt on the scalp in pediatric patients

PURPOSE

The exposure of a ventriculoperitoneal shunt on the scalp is a serious complication. There are limited studies evaluating this complication's management in the literature. The aim of this study is to define the management of shunt salvage and the reconstruction of the scalp.

METHODS

This retrospective study included seven pediatric patients with ventriculoperitoneal shunts that were exposed on the scalp for various reasons. The demographic characteristics of the patients and the medical and surgical treatments used were recorded. The patient follow-up durations and complications associated with these methods were determined.

RESULTS

Four female and three male patients with an average age of 5.7 were followed for an average of 9.4 months. All but one of these patients were treated without removing the shunt. While one skin flap was used in one patient, successful repairs were made with double skin flaps in five patients. There were no complications during follow-up for the patients treated with these methods.

CONCLUSION

In this study, the appropriate management of shunt exposure, which is common in pediatric cases, has been revealed. Given appropriate infection prevention, the reconstruction of the scalp is possible without the removal of the shunt.

Technical Note: Preemptive Surgical Revision of Impending Deep Brain Stimulation Hardware Erosion

BACKGROUND

While deep brain stimulation (DBS) is a relatively safe procedure, skin erosion is a commonly reported hardware complication that can threaten the DBS system. Patients with Parkinson disease are especially at risk for this complication due to their autonomic dysregulation and impaired nutrition. Early detection of impending skin erosion allows for intervention that may prevent hardware destruction. Here we report a novel technique to address this complication preemptively. We describe the use of an acellular dermal matrix to prevent skin erosion in 20 patients with Parkinson disease who were treated with DBS and showed signs of impending skin erosion.

METHODS

Twenty patients with signs of impending hardware erosion were identified. An acellular dermal matrix was surgically placed under the at-risk skin overlying the DBS lead.

RESULTS

None of the 20 patients treated with this technique went on to require further revision surgery or removal of hardware.

CONCLUSIONS

Surgical placement of acellular dermal matrix in patients identified as having impending hardware erosions is a safe and cost-effective way to prevent hardware complications.

Surgical Management of Deep Brain Stimulator Scalp Erosion without Hardware Removal

BACKGROUND

Scalp erosion in patients with deep brain stimulation (DBS) hardware is an uncommon complication that lacks a clearly defined management strategy. Previous studies have described various therapies including conservative treatment with antibiotics and surgical debridement with or without hardware removal.

OBJECTIVES

The aim of this study was to review the efficacy of a hardware-sparing management strategy for the treatment of scalp erosion.

METHODS

Five patients with previous DBS implantation presented with scalp erosion and visible hardware exposure at the calvarial burr hole site, and underwent tension-free, vascularized, rotational scalp flap, with preservation of the leads under the pericranium. Two of the procedures were performed after an unsuccessful attempt at primary closure and 3 as a primary procedure. Each patient was followed clinically for at least 14 months postoperatively to evaluate for wound-healing and adverse effects.

RESULTS

The median duration from initial DBS hardware implantation to erosion and revision surgery was 12 months (range 1.5-62 months). Three patients were documented to have positive intraoperative cultures in spite of the absence of purulence. At the last follow-up, all patients were noted to have complete wound-healing and no evidence of infection or erosion.

CONCLUSIONS

DBS scalp erosion can be managed by rotational scalp flap without hardware removal, even in cases where infection is identified.

Changing of the guard: reducing infection when replacing neural pacemakers

OBJECTIVE

Infection of deep brain stimulation (DBS) hardware has a significant impact on patient morbidity. Previous experience suggests that infection rates appear to be higher after implantable pulse generator (IPG) replacement surgery than after the de novo DBS procedure. In this study the authors examine the effect of a change in practice during DBS IPG replacements at their institution.

METHODS

Starting in January 2012, patient screening for methicillin-resistant Staphylococcus aureus (MRSA) and, and where necessary, eradication was performed prior to elective DBS IPG change. Moreover, topical vancomycin was placed in the IPG pocket during surgery. The authors then prospectively examined the infection rate in patients undergoing DBS IPG replacement at their center over a 3-year period with at least 9 months of follow-up.

RESULTS

The total incidence of infection in this prospective consecutive series of 101 IPG replacement procedures was 0%, with a mean follow-up duration of 24 ± 11 months. This was significantly lower than the authors' previously published historical control group, prior to implementing the change in practice, where the infection rate for IPG replacement was 8.5% (8/94 procedures; p = 0.003).

CONCLUSIONS

This study suggests that a change in clinical practice can significantly lower infection rates in patients undergoing DBS IPG replacement. These simple measures can minimize unnecessary surgery, loss of benefit from chronic stimulation, and costly hardware replacement, further improving the cost efficacy of DBS therapies.

Occipital-device-related pain as a complication of deep brain stimulation

Deep brain stimulation is an established treatment for movement disorders. We reported 4 patients (1.3%) of post-operative occipital headache related to the placement of the connection among 309 patients from 1998 to 2008. The patients were treated successfully by repositioning the connector into a groove created in the bone.

One-step tunneling of DBS extensions--a technical note

BACKGROUND

Infection constitutes a serious adverse event in deep brain stimulation (DBS) surgery, being responsible for difficult therapeutic decisions that may ultimately involve the removal of implanted material. Some cases begin with skin erosion and wound dehiscence of the retroauricular incision, which is one of the most fragile points. Several techniques of rotation flaps and skin reconstruction, as well as prolonged antibiotic regimens, have been proposed as therapeutic options. To prevent the onset of this complication, the authors propose a one-step tunneling technique of DBS extensions, avoiding the opening of the retroauricular space.

METHODS

We describe a surgical technique of a one-step tunneling of DBS extensions in 20 patients submitted to subthalamic DBS for Parkinson's disease, avoiding the opening of the retroauricular space.

RESULTS

After implantation of the extensions using this technique, we had no erosions of the retroauricular skin, with a consequent reduction in the number of infections.

CONCLUSIONS

The authors describe an easy surgical technique that allows reduction of wound and erosion complications, with great benefits for DBS patients.

Drug-induced dyskinesia in Parkinson's disease. Should success in clinical management be a function of improvement of motor repertoire rather than amplitude of dyskinesia?

BACKGROUND

Dyskinesia, a major complication in the treatment of Parkinson's disease (PD), can require prolonged monitoring and complex medical management.

DISCUSSION

The current paper proposes a new way to view the management of dyskinesia in an integrated fashion. We suggest that dyskinesia be considered as a factor in a signal-to-noise ratio (SNR) equation where the signal is the voluntary movement and the noise is PD symptomatology, including dyskinesia. The goal of clinicians should be to ensure a high SNR in order to maintain or enhance the motor repertoire of patients. To understand why such an approach would be beneficial, we first review mechanisms of dyskinesia, as well as their impact on the quality of life of patients and on the health-care system. Theoretical and practical bases for the SNR approach are then discussed.

SUMMARY

Clinicians should not only consider the level of motor symptomatology when assessing the efficacy of their treatment strategy, but also breadth of the motor repertoire available to patients.

Diagnosis and treatment of complications related to deep brain stimulation hardware

Deep brain stimulation is a therapeutic technique increasingly used in the treatment of a variety of neurological, psychiatric, and pain disorders. Although beneficial, it carries the immediate and long-term risks associated with implanted hardware in the brain parenchyma and subcutaneous tissue. The most common hardware complications include electrode migrations or misplacements, wire fractures, skin erosion, infections, and device malfunction. We systematically reviewed the literature on deep brain stimulation-related complications and propose a diagnostic and therapeutic algorithm. Our aim is to provide a guide for clinicians and medical staff involved in the treatment of patients with deep brain stimulation for rapid recognition and efficient management of these complications.

Surface characteristics of biomaterials used for space maintenance in a mandibular defect: a pilot animal study

PURPOSE

The purpose of the present study was to evaluate the effect of implant porosity on wound healing between solid and porous implants placed within a bony mandibular defect with intraoral exposure.

MATERIALS AND METHODS

Solid poly(methyl methacrylate) (PMMA) implants similar to those used currently in clinical space maintenance applications in maxillofacial surgery were compared with poly(propylene fumarate) implants that contained a porous outer surface surrounding a solid core. A 10-mm diameter nonhealing bicortical defect with open communication into the oral cavity was created in the molar mandibular region of 12 adult male New Zealand white rabbits. Of the 12 rabbits, 6 received the hybrid poly(propylene fumarate) implants and 6 received the solid PMMA implants. At 12 weeks, the rabbit mandibles were harvested and sent for histologic staining and sectioning.

RESULTS

Gross inspection and histologic examination showed all 6 poly(propylene fumarate) implants to be intact within the defect site at the termination of the study period, with 3 of the 6 specimens exhibiting a continuous circumferential soft tissue margin. In contrast, 5 of the 6 PMMA-implanted specimens were exposed intraorally with an incomplete cuff of soft tissue around the implant. One of the PMMA-implanted specimens exhibited complete extrusion and subsequent loss of the implant. Fisher's exact test was used to compare the occurrence of oral cavity wound healing between the 2 groups (P = .09).

CONCLUSIONS

Although statistically significant differences between the 2 groups were not seen, our results have indicated that advantages might exist to using porous implants for space maintenance. Additional study is needed to evaluate these findings.