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Delayed vagal nerve compressive neuropathy following placement of vagal nerve stimulator: case report

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Abstract

Vagal neuropathy causing vocal fold palsy is an uncommon complication of vagal nerve stimulator (VNS) placement. It may be associated with intraoperative nerve injury or with device stimulation. Here we present the first case of delayed, compressive vagal neuropathy associated with VNS coil placement which presented with progressive hoarseness and vocal cord paralysis. Coil removal and vagal neurolysis was performed to relieve the compression. Larger 3 mm VNS coils were placed for continuation of therapy. Coils with a larger inner diameter should be employed where possible to prevent this complication. The frequency of VNS-associated vagal nerve compression may warrant further investigation.

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Abbreviations

VNS:

Vagal nerve stimulator

VHI-10:

Voice handicap index-10

EMG:

Electromyography

CMAPs:

Compound motor action potentials

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Acknowledgements

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Authors and Affiliations

  1. Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA

    Hari McGrath, Zach Pennington & Jamie J. Van Gompel

  2. Department of Neurology, Mayo Clinic, Rochester, MN, USA

    Madeline R. Cross, Ernest M. Hoffman & Nicholas M. Gregg

  3. Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA

    Kendall K. Tasche & Semirra L. Bayan

Authors
  1. Hari McGrath
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  2. Zach Pennington
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  3. Madeline R. Cross
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  4. Ernest M. Hoffman
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Correspondence to Jamie J. Van Gompel.

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Comments

The authors of this case report present an interesting case of intraoperatively documented constriction of the vagus nerve by a long-ago implanted electrode in a patient who experienced symptomatic improvement after the electrode was replaced with a larger version of the same device. Although very unusual, the finding is not completely unexpected as the nerve malfunctions and excessive fibrosis in the vicinity of implanted electrodes have been a known issue during the last several decades, ever since the peripheral nerve stimulation became an established therapeutic modality. As a matter of fact, I would venture to suspect this to be one of the main sources of voice alteration in VNS patients—just as the authors suggest here.

With all this, I want to congratulate the authors with their ability to preserve the vagus nerve functionality following their corrective surgery. One of the reasons such approach (electrode revision or replacement) is rarely considered is the remarkable fragility of the vagus nerve and serious risk of development of complete—and irreversible—vocal cord paralysis with any attempt to mobilize or remove the electrodes that are strongly attached to the nerve after being in place for a prolonged period of time.

As with everything else in medicine, it is better to prevent the problem than deal with it post-factum; perhaps development of softer and more pliable electrodes—or replacing them with non-invasive alternative options—would be an optimal solution for the future.

Konstantin Slavin

Chicago, USA

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McGrath, H., Pennington, Z., Cross, M.R. et al. Delayed vagal nerve compressive neuropathy following placement of vagal nerve stimulator: case report. Acta Neurochir 166, 193 (2024). https://doi.org/10.1007/s00701-024-06087-x

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