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Management of skin erosion following deep brain stimulation

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Abstract

Skin erosion is a hardware-related complication commonly described after deep brain stimulation (DBS). Despite the considerable incidence reported in literature, little is written about the management of this complication. In this report, we describe a case of noninfected device extrusion through the skin; in order to prevent infection and system removal, we performed a scalp reconstruction over the area of system exposure. During the follow-up, no signs of infection or fistula occurred and DBS efficacy was preserved. The paper shows the possibility to treat, in noninfectious cases, this frequent complication avoiding the psychological and clinical consequences related to implant removal.

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Authors and Affiliations

  1. Neurosurgery, Department of Neuroscience, University of Torino, Via Cherasco, 15, 10126, Turin, Italy

    Michele Lanotte, Pier Paolo Panciani & Alessandro Ducati

  2. Neurology, Department of Neuroscience, University of Torino, Turin, Italy

    Maurizio Zibetti & Leonardo Lopiano

  3. Plastic Surgery, Department of Plastic Surgery, San Giovanni Battista Hospital, Turin, Italy

    Giovanni Verna & Antonio Taveggia

Authors
  1. Michele Lanotte
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  2. Giovanni Verna
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  3. Pier Paolo Panciani
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  4. Antonio Taveggia
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  5. Maurizio Zibetti
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  6. Leonardo Lopiano
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  7. Alessandro Ducati
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Corresponding author

Correspondence to Michele Lanotte.

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Comments

Veit Rohde, Goettingen, Germany

Deep brain stimulation (DBS) is on the way to being an accepted therapy in advanced Parkinson’s disease, essential tremor, and dystonia. Most recent articles focused on the clinical effects of DBS, the best target areas, and the optimal location of the lead inside the target [3, 5]. Procedure-related complications barely had been of interest [1, 2, 4]. However, with growing acceptance of DBS and increasing numbers of implantations, complications will be seen more frequently. Thus, communications on complication avoidance and complication management are urgently needed. The case report of Lanotte and coworkers on the management of skin erosions in the area of the burr-hole cap should stimulate further experts in the field to share their experiences in complication management with the neurosurgical community.

References

1. Coenen VA, Gielen F, Rohde I, Fromm C, Kronenbürger M, Dammert S, Rohde V (2004) Subthalamic nucleus stimulation for advanced Parkinson’s disease: how to find a far medial STN. Minim Invas Neurosurg 47:373–377

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4. Temel Y, Ackermans L, Celik H, Spincemaille GH, van der Linden C, Walenkamp GH, van de Kar T, Visser-Vanderwalle V (2004) Management of hardware infections following deep brain stimulation. Acta Neurochir 146:355–361

5. The deep-brain stimulation for Parkinson’s disease study group (2001) deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease. N Engl J Med 345:956–963

Dieter Hellwig, Marburg, Germany, Friedericke Sixel-Döring, Kassel, Germany

Deep brain stimulation has been established as a standardized surgical treatment option for movement and psychiatric disorders in the last decade. The stereotactic implantation of electrodes in the thalamic and subthalamic region as well as in the internal pallidal segment is based on a highly sophisticated operative technology, a well-defined operative technique, and an experienced neurosurgeon. Exact preoperative three-dimensional planning of the approach, using magnetic resonance imaging and stereotactic computed tomography guidance, intraoperative microrecording, and macrostimulation are important prerequisites to place the final electrode in a millimeter range.

Intraoperative and perioperative complications during DBS are rare. In 2007, Seijo et al. [1] reported 2.2% misplaced leads, 3.3% hemorrhage, and 4.7% seizures in a total of 130 patients with 272 procedures. However, there is a considerable amount of postoperative hardware complications in the long-term follow-up reported between 13.9% [2] and 26% [3]. In our own patient group with 286 implanted DBS electrodes, we had 18% of hardware complications, 72% of those occurred in the first year after implantation (data unpublished). Regarding the excellent therapeutic effect of DBS, this is a disastrous fact because in most cases it leads to the removal of the whole stimulation system and the patient has to be referred back to medical treatment.

There are some main factors, which might influence hardware complications in DBS:

1. The shape and size of the implanted material (implantable pulse generator (IPG), connectors, extensions, and burr-hole caps), which lead to skin erosion

2. The lack of a subcutaneous fat tissue as a cover layer

3. Altered microbial colonization at the skin of patients suffering from Parkinson’s disease

4. The implanted material as a foreign body, which leads to rejection

In this paper, Lanotte et al. describe one patient with Parkinson’s disease who developed a skin erosion without infection at the burr-hole cap which fixes the electrode. They use a rotation skin flap, which is vascularized from the temporal artery, to cover the defect and report that the implanted material for DBS had been preserved.

In the literature, there are some other operative techniques which are proposed to reduce or revise hardware-related complications of deep brain stimulation.

Constantoyannis et al. [4] claimed that straight scalp incision instead of curvilinear skin incision at the burr-hole site may lead to an increased rate of erosion or infection. Spiotta et al. [5] focus at the aim to treat scalp erosion to allow for the reimplantation of previously explanted infected hardware or to treat thinned scalp with threatened erosion and prevent the need to remove exposed hardware that was otherwise functioning. Two different approaches were presented: (1) a temporoparietooccipital flap based on the superficial temporal artery with or without scalp expansion and (2) a scalp fasciocutaneous flap with or without cranioplasty.

Today, these proposed operative techniques seem to be very helpful in management of skin erosions after implantation of DBS hardware. However, compared to the minimal invasive approach of DBS, they are a minor solution. To solve the serious problem of hardware complications, new smaller reloadable devices have to be designed, which can be placed directly under the scalp tissue without further connecting extensions to the IPG. Furthermore, the concept of lead fixation using burr-hole caps should be reconsidered. With the refinement of the implantation material hardware, complications can be minimized. Until then, novel approaches need to be developed to save DBS systems and provide symptomatic relief to patients [5].

References

1. Seijo FJ, Alvarez-Vega MA, Gutierrez JC et al. (2007) Complications in subthalamic nucleus stimulation surgery for treatment of Parkinson’s disease. Review of 272 procedures. Acta Neurochir 149(9):867–875

2. Voges J, Waerzeggers Y, Maarouf et al. (2006) Deep brain stimulation: long-term analysis of complications caused by hardware and surgery—experience from a single centre. J Neurol Neurosurg Psychiatry 77(7):868–872

3. Lyons KE, Wilkinson SB, Overman J et al. (2004) Surgical and hardware complications of subthalamic stimulation: a series of 160 procedures. Neurology 63(4):612–616

4. Constantoyannis C, Berk C, Honey CR et al. (2005) Reducing hardware-related complications of deep brain stimulation. Can J Neurol Sci. 32(2):194–200

5. Spiotta AM, Bain MD, Deogoankar M et al. (2008) Methods of scalp revision for deep brain stimulator hardware: case report. Neurosurgery 62(3 Suppl 1):249–250

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Lanotte, M., Verna, G., Panciani, P.P. et al. Management of skin erosion following deep brain stimulation. Neurosurg Rev 32, 111–115 (2009). https://doi.org/10.1007/s10143-008-0158-0

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