Revision of deep brain stimulator for tremor - Technical note

The treatment of essential tremor with thalamic deep brain stimulation (DBS ) is considered to be more effective and to cause less morbidity than treat ment with thalamotomy. Nonetheless, implantation of an indwelling electrode , connectors, and a generator is associated with specific types of morbidit y. The authors describe three patients who required revision of their DBS s ystems due to lead breakage. The connector between the DBS electrode and th e extension wire, which connects to the subclavicular pulse generator, was originally placed subcutaneously in the cervical region to decrease the ris k of erosion through the scalp and to improve cosmesis. Three patients pres ented with fractured DBS electrodes that were located in the cervical regio n near the connector, necessitating reoperation with stereotactic retargeti ng and placement of a new intracranial electrode. At reoperation, the conne ctors were placed subgaleally over the parietal region. Management of these cases has led to modifications in the operative procedu re designed to improve the durability of DBS systems. The authors recommend that surgeons avoid placing the connection between the DBS electrode and t he extension wire in the cervical region because patient movement can cause microfractures in the electrode. Such microfractures require intracranial revision, which may be associated with a higher risk of morbidity than the initial operation. The authors also recommend considering prophylactic relo cation of the connectors from the cervical area to the subgaleal parietal r egion to decrease the risk of future DBS electrode fracture, which would ne cessitate a more lengthy procedure to revise the intracranial electrode.