Download Infection Lead migration and breakage

R. Cook, D. Wasson, L. Jones, G. Fracchia, L. Meagher, P. Silburn, P. Silberstein
Sydney Parkinson’s and Movement Disorder Surgery Unit
North Shore Private Hospital, Sydney, Australia
Introduction:
Conclusions:
To date the Sydney Parkinson’s and Movement Disorder Surgery Unit has performed deep brain stimulation
procedures on 144 patients with Parkinson’s disease.
The majority of patients were implanted in the STN (132 patients , 277 electrodes).
Here we present complications data on the first 112 patients treated with STN DBS in our unit. Eight
patients were excluded from the series, either because they had undergone previous surgery (6) [previous
unilateral pallidotomy (4), previous unilateral pallidotomy and contralateral VIM stimulator (1), previous
bilateral pallidal DBS (1)] or had atypical disease (2) [MSA (1), Essential tremor and Parkinson’s disease (1)
– both deceased – latter patient from a myocardial infarct > 12 months post op]. Long term follow up was
unavailable on four patients who lived interstate or overseas. None of the 12 patients excluded suffered
major surgical morbidity (infarction, haemorrhage or seizure) or mortality.
Efficacy data was available for the first 50 patients.
We did not experience any major operative morbidity/mortality, consistent with the widespread experience that
major complications with STN DBS are uncommon.
Methods:
Hardware related complications were more common earlier in the series. Lead fracture was the commonest
complication related to a combination of surgical technique (non-securing of DBS cervical lead connection to
the pericranium) and original design of connector covering boot (bullet shape). Subsequently the connector
shape design has been changed to a flat-sided boot. All fractured leads have been successfully replaced
without subsequent re-fracture.
Neuropsychiatric complications were relatively common.
In many instances symptoms resolved
spontaneously or with adjustment of stimulation and/or medications.
Mild speech disturbance including hypophonia was commonly reported at some time during the follow up
period. Only 4% of patients sought treatment.
Suboptimal lead placement was noted in five patients. These occurred in the first 16 patients consistent with
our learning curve. All leads were successfully re-implanted without morbidity.
Efficacy was formally assessed at a minimum of six months post op. At this time, patients were seen in all
four stimulation/medication states after overnight medication withdrawal. Cabergoline was ceased at least
36 hours prior to assessment in patients taking this medication. Efficacy was determined by comparison of
UPDRS III off medication scores [(pre op off med – post op off med on stim / pre op off med) X 100];
comparison with efficacy of medication (UPDRS III) [(pre op off med – pre op on med/ post op off med on
stim – pre op off med) X 100], UPDRS II scores (pre op off med – post op off med on stim/ pre op off med) X
100; reduction in off duration (UPDRS part 39) medication reduction [(pre op – post op/ pre op) X 100];
reduction in dyskinesia (UPDRS parts 32 & 33) and reduction in l-dopa equivalent dose.
Complications were determined based on retrospective review of the surgical and post operative follow-up
notes and listed in tabulated form by type.
In one patient surgery was abandoned as the nucleus could not be localized on either side (significant CSF
loss). Successful bilateral implantation was per formed two weeks later.
There was one primary surgical infection. The other two infections related to a redo procedure (bilateral
connector wire fracture) or presumed late haematogenous seeding > one year post implant. All have been
successfully managed with antibiotics or explantation / re-implantation.
Hardware complications are dependent on both surgical technique and design. All hardware complications in
this series have been effectively managed with further surgery without morbidity. Infections are rare and can
occur late (>1year) post implantation.
Results
Efficacy cohort: Efficacy data was available on the first 50 patients treated with STN DBS in our unit (12
patients were excluded from this series as outlined above). Mean age at the time of surgery was 58 years
(range 29-77); average time from diagnosis to surgery was 11 years (range 3-26 years). Average time from
surgery to post op assessment was 20 months (range 6-46 months).
Efficacy results are presented in the panels below:
On Meds
Off Meds
30
25
25
20
15
10
5
0
20
15
20
Off Meds
Dyskinesia
Duration (n=44)
30
Off Meds
10
Off Meds
5
0
none
1-25%
25-50%
51-75%
After surgery 1800 1600 Off Duration (n=44)
On Meds
15
40
50
On Meds
10
76-100%
1400 Dyskinesia
severity
1200 1000 40
30
20
10
0
800 1563 600 400 Severely
disabling
5
On Meds
20
Before surgery L‐dopa equivalent dose (mg) After surgery Completely
disabled
0
10
Mean Medication reduction = 78% (20‐100%) Medication ceased post op = 30% Before surgery Mildly
disabling
0
UPDRS 33 How disabling are the dyskinesias? Moderately
disabling
Post-Op
UPDRS 32 What proportion of the waking day are dyskinesias present? Not
disabling
Pre-Op
UPDRS 39 What percentage of the day is the patient “off” on average? 0 = none 1 = 1‐25% 2 = 25‐50% Before surgery 3= 50‐75% 4= 75 – 100% After surgery Mean Off improvement = 54%
UPDRS II Activities of daily living no
ne
1-2
5%
-5
0%
51
-7
5
76 %
-1
00
%
UPDRS III Motor impairment 25
Mean Off improvement = 54% (8-86%)
Mean improvement compared with meds = 87% (11-177%)
200 344 0 Pre‐op Post‐op Complications cohort: Complications data were available on 100 patients (12 patients were excluded from
this series as outlined above). Mean age at time of surgery was 59 (range 29-77). Average time of
completion of complication follow up was 18 months (range 6-46 months).
Complications data by type are summarized in the tables below:
General neurosurgical/neurologic
complications
Demographics n=100
Age at surgery (years)
mean
max
min
sd
sem
0
0
0
0
59
77
18
41
29
9
6
8
Perioperative Confusion
Perioperative Pychosis
18
3
1
1
Depression (not present pre-op)
5
Anxiety (not present pre-op)
0
Hypomania requiring treatment
4
Hedonistic behaviour
10
Cannula infection
3
General Medical
66
52
4
Requiring Botulinum toxin
12
3
Persistent at 6 months
Drooling/ increased salivation
Weight gain
Number
(leads)
Lead Problems
Suboptimal position requiring repositioning
(none last 84 patients)
5
Lead fracture (5 patients)
6
Infections
Onset
Case (post implant)
36
9
cerebral lead (none last 77 patients)
4
connector leads(1 patient post fall)
2
Surgery abandoned (due to brain shift)
1
2 weeks post
revision
Mood elevation
24
Pins and needles
11
Double Vision
8
Common
Common
Hardware
infection
Total
Requiring removal
(successfully replaced)
3
2
Seroma
(self limiting)
2
Battery end of life
13
51
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Organism
Explant
No
5 weeks
IPG pouch Staphylococcus aureus
No
13 months
Connector
wound
Staphylococcus epidermidis
Yes
54
26 months
DBS wire
Yes
Lead migration and breakage
Sydney Parkinson's & Movement Disorders Surgery Unit 2009
Site
IPG pouch Methicillin resistant
Staphylococcus epidermidis
(successfully implanted subsequently)
Transient
Dyskinesia
Infection
Sought treatment
Eyelid opening apraxia
Neuropsychiatric
complications
Hardware related complications
Number
Subjective speech disturbance
including hypophonia
Number
Haemorrhage
Stroke
Epilepsy
Death
Assessment post surgery (months)
Stimulation induced complications
Long term
Major
complications
Propionibacterium acnes