Outcomes following surgical management of vagus nerve stimulator–related infection: a retrospective multi-institutional study

View More View Less
  • 1 Departments of Neurologic Surgery and
  • | 2 Neurology, Mayo Clinic, Rochester, Minnesota;
  • | 3 Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan;
  • | 4 Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; and
  • | 5 Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

Surgical site infection (SSI) is a rare but significant complication after vagus nerve stimulator (VNS) placement. Treatment options range from antibiotic therapy alone to hardware removal. The optimal therapeutic strategy remains open to debate. Therefore, the authors conducted this retrospective multicenter analysis to provide insight into the optimal management of VNS-related SSI (VNS-SSI).

METHODS

Under institutional review board approval and utilizing an institutional database with 641 patients who had undergone 808 VNS-related placement surgeries and 31 patients who had undergone VNS-related hardware removal surgeries, the authors retrospectively analyzed VNS-SSI.

RESULTS

Sixteen cases of VNS-SSI were identified; 12 of them had undergone the original VNS placement procedure at the authors’ institutions. Thus, the incidence of VNS-SSI was calculated as 1.5%. The mean (± standard deviation) time from the most recent VNS-related surgeries to infection was 42 (± 27) days. Methicillin-sensitive staphylococcus was the usual causative bacteria (58%). Initial treatments included antibiotics with or without nonsurgical procedures (n = 6), nonremoval open surgeries for irrigation (n = 3), generator removal (n = 3), and total or near-total removal of hardware (n = 4). Although 2 patients were successfully treated with antibiotics alone or combined with generator removal, removal of both the generator and leads was eventually required in 14 patients. Mild swallowing difficulties and hoarseness occurred in 2 patients with eventual resolution.

CONCLUSIONS

Removal of the VNS including electrode leads combined with antibiotic administration is the definitive treatment but has a risk of causing dysphagia. If the surgeon finds dense scarring around the vagus nerve, the prudent approach is to snip the electrode close to the nerve as opposed to attempting to unwind the lead completely.

ABBREVIATIONS

GR = generator removal; MSS = methicillin-sensitive staphylococcus; NTR = near-total removal; SSI = surgical site infection; TR = total removal; VNS = vagus nerve stimulator; VNS-SSI = VNS-related SSI.

Artist’s illustration of the classic mulberry appearance of a cavernoma. This illustration represents the Seven Cavernomas series by Dr. Michael Lawton, a collection of articles defining the tenets and techniques for the treatment of cavernous malformations, a taxonomy for classifying these lesions, and the nuances of their surgical approaches. Artist: Peter M. Lawrence. Used with permission from Barrow Neurological Institute, Phoenix, Arizona. See the article by Garcia et al. (pp 671–682).

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Wheless JW , Gienapp AJ , Ryvlin P . Vagus nerve stimulation (VNS) therapy update . Epilepsy Behav . 2018 ;88S :2 10 .

  • 2

    Spencer S , Huh L . Outcomes of epilepsy surgery in adults and children . Lancet Neurol . 2008 ;7 (6 ):525 537 .

  • 3

    DeGiorgio CM , Schachter SC , Handforth A , et al. Prospective long-term study of vagus nerve stimulation for the treatment of refractory seizures . Epilepsia . 2000 ;41 (9 ):1195 1200 .

    • Search Google Scholar
    • Export Citation
  • 4

    Usami K , Kawai K , Sonoo M , Saito N . Scalp-recorded evoked potentials as a marker for afferent nerve impulse in clinical vagus nerve stimulation . Brain Stimul . 2013 ;6 (4 ):615 623 .

    • Search Google Scholar
    • Export Citation
  • 5

    Amar AP , Heck CN , Levy ML , et al. An institutional experience with cervical vagus nerve trunk stimulation for medically refractory epilepsy: rationale, technique, and outcome . Neurosurgery . 1998 ;43 (6 ):1265 1280 .

    • Search Google Scholar
    • Export Citation
  • 6

    Englot DJ , Rolston JD , Wright CW , et al. Rates and predictors of seizure freedom with vagus nerve stimulation for intractable epilepsy . Neurosurgery . 2016 ;79 (3 ):345 353 .

    • Search Google Scholar
    • Export Citation
  • 7

    Elliott RE , Morsi A , Tanweer O , et al. Efficacy of vagus nerve stimulation over time: review of 65 consecutive patients with treatment-resistant epilepsy treated with VNS > 10 years . Epilepsy Behav . 2011 ;20 (3 ):478 483 .

    • Search Google Scholar
    • Export Citation
  • 8

    Connor DE Jr , Nixon M , Nanda A , Guthikonda B . Vagal nerve stimulation for the treatment of medically refractory epilepsy: a review of the current literature . Neurosurg Focus . 2012 ;32 (3 ):E12 .

    • Search Google Scholar
    • Export Citation
  • 9

    Giordano F , Zicca A , Barba C , et al. Vagus nerve stimulation: surgical technique of implantation and revision and related morbidity . Epilepsia . 2017 ;58 (suppl 1 ):85 90 .

    • Search Google Scholar
    • Export Citation
  • 10

    Kawai K , Tanaka T , Baba H , et al. Outcome of vagus nerve stimulation for drug-resistant epilepsy: the first three years of a prospective Japanese registry . Epileptic Disord . 2017 ;19 (3 ):327 338 .

    • Search Google Scholar
    • Export Citation
  • 11

    García-Pallero MA , García-Navarrete E , Torres CV , et al. Effectiveness of vagal nerve stimulation in medication-resistant epilepsy. Comparison between patients with and without medication changes . Acta Neurochir (Wien) . 2017 ;159 (1 ):131 136 .

    • Search Google Scholar
    • Export Citation
  • 12

    Kawai K , Shimizu H , Maehara T , Murakami H . Outcome of long-term vagus nerve stimulation for intractable epilepsy . Neurol Med Chir (Tokyo) . 2002 ;42 (11 ):481 490 .

    • Search Google Scholar
    • Export Citation
  • 13

    Conway CR , Sheline YI , Chibnall JT , et al. Cerebral blood flow changes during vagus nerve stimulation for depression . Psychiatry Res . 2006 ;146 (2 ):179 184 .

    • Search Google Scholar
    • Export Citation
  • 14

    Conway CR , Sheline YI , Chibnall JT , et al. Brain blood-flow change with acute vagus nerve stimulation in treatment-refractory major depressive disorder . Brain Stimul . 2012 ;5 (2 ):163 171 .

    • Search Google Scholar
    • Export Citation
  • 15

    Zobel A , Joe A , Freymann N , et al. Changes in regional cerebral blood flow by therapeutic vagus nerve stimulation in depression: an exploratory approach . Psychiatry Res . 2005 ;139 (3 ):165 179 .

    • Search Google Scholar
    • Export Citation
  • 16

    Conway CR , Xiong W . The mechanism of action of vagus nerve stimulation in treatment-resistant depression: current conceptualizations . Psychiatr Clin North Am . 2018 ;41 (3 ):395 407 .

    • Search Google Scholar
    • Export Citation
  • 17

    Révész D , Rydenhag B , Ben-Menachem E . Complications and safety of vagus nerve stimulation: 25 years of experience at a single center . J Neurosurg Pediatr . 2016 ;18 (1 ):97 104 .

    • Search Google Scholar
    • Export Citation
  • 18

    Ramsay RE , Uthman BM , Augustinsson LE , et al. Vagus nerve stimulation for treatment of partial seizures: 2. Safety, side effects, and tolerability . Epilepsia . 1994 ;35 (3 ):627 636 .

    • Search Google Scholar
    • Export Citation
  • 19

    Ben-Menachem E . Vagus nerve stimulation, side effects, and long-term safety . J Clin Neurophysiol . 2001 ;18 (5 ):415 418 .

  • 20

    Patel NC , Edwards MS . Vagal nerve stimulator pocket infections . Pediatr Infect Dis J . 2004 ;23 (7 ):681 683 .

  • 21

    Patwardhan RV , Stong B , Bebin EM , et al. Efficacy of vagal nerve stimulation in children with medically refractory epilepsy . Neurosurgery . 2000 ;47 (6 ):1353 1358 .

    • Search Google Scholar
    • Export Citation
  • 22

    Yu C , Ramgopal S , Libenson M , et al. Outcomes of vagal nerve stimulation in a pediatric population: a single center experience . Seizure . 2014 ;23 (2 ):105 111 .

    • Search Google Scholar
    • Export Citation
  • 23

    Kabir SM , Rajaraman C , Rittey C , et al. Vagus nerve stimulation in children with intractable epilepsy: indications, complications and outcome . Childs Nerv Syst . 2009 ;25 (9 ):1097 1100 .

    • Search Google Scholar
    • Export Citation
  • 24

    Galbarriatu L , Pomposo I , Aurrecoechea J , et al. Vagus nerve stimulation therapy for treatment-resistant epilepsy: a 15-year experience at a single institution . Clin Neurol Neurosurg . 2015 ;137 :89 93 .

    • Search Google Scholar
    • Export Citation
  • 25

    Fernandez L , Gedela S , Tamber M , Sogawa Y . Vagus nerve stimulation in children less than 3 years with medically intractable epilepsy . Epilepsy Res . 2015 ;112 :37 42 .

    • Search Google Scholar
    • Export Citation
  • 26

    Wozniak SE , Thompson EM , Selden NR . Vagal nerve stimulator infection: a lead-salvage protocol . J Neurosurg Pediatr . 2011 ;7 (6 ):671 675 .

    • Search Google Scholar
    • Export Citation
  • 27

    Air EL , Ghomri YM , Tyagi R , et al. Management of vagal nerve stimulator infections: do they need to be removed? J Neurosurg Pediatr . 2009 ;3 (1 ):73 78 .

    • Search Google Scholar
    • Export Citation
  • 28

    Ortler M , Luef G , Kofler A , et al. Deep wound infection after vagus nerve stimulator implantation: treatment without removal of the device . Epilepsia . 2001 ;42 (1 ):133 135 .

    • Search Google Scholar
    • Export Citation
  • 29

    Liechty PG , Tubbs RS , Blount JP . The use of a sump antibiotic irrigation system to save infected hardware in a patient with a vagal nerve stimulator: technical note . Surg Neurol . 2006 ;65 (1 ):48 50 .

    • Search Google Scholar
    • Export Citation
  • 30

    Elliott RE , Morsi A , Kalhorn SP , et al. Vagus nerve stimulation in 436 consecutive patients with treatment-resistant epilepsy: long-term outcomes and predictors of response . Epilepsy Behav . 2011 ;20 (1 ):57 63 .

    • Search Google Scholar
    • Export Citation
  • 31

    Murphy JV , Hornig GW , Schallert GS , Tilton CL . Adverse events in children receiving intermittent left vagal nerve stimulation . Pediatr Neurol . 1998 ;19 (1 ):42 44 .

    • Search Google Scholar
    • Export Citation
  • 32

    Smyth MD , Tubbs RS , Bebin EM , et al. Complications of chronic vagus nerve stimulation for epilepsy in children . J Neurosurg . 2003 ;99 (3 ):500 503 .

    • Search Google Scholar
    • Export Citation
  • 33

    Rychlicki F , Zamponi N , Cesaroni E , et al. Complications of vagal nerve stimulation for epilepsy in children . Neurosurg Rev . 2006 ;29 (2 ):103 107 .

    • Search Google Scholar
    • Export Citation
  • 34

    Aalbers MW , Rijkers K , Klinkenberg S , et al. Vagus nerve stimulation lead removal or replacement: surgical technique, institutional experience, and literature overview . Acta Neurochir (Wien) . 2015 ;157 (11 ):1917 1924 .

    • Search Google Scholar
    • Export Citation
  • 35

    Ortler M , Unterhofer C , Dobesberger J , et al. Complete removal of vagus nerve stimulator generator and electrodes . J Neurosurg Pediatr . 2010 ;5 (2 ):191 194 .

    • Search Google Scholar
    • Export Citation
  • 36

    Vassilyadi M , Strawsburg RH . Delayed onset of vocal cord paralysis after explantation of a vagus nerve stimulator in a child . Childs Nerv Syst . 2003 ;19 (4 ):261 263 .

    • Search Google Scholar
    • Export Citation
  • 37

    Couch JD , Gilman AM , Doyle WK . Long-term expectations of vagus nerve stimulation: a look at battery replacement and revision surgery . Neurosurgery . 2016 ;78 (1 ):42 46 .

    • Search Google Scholar
    • Export Citation
  • 38

    McGregor A , Wheless J , Baumgartner J , Bettis D . Right-sided vagus nerve stimulation as a treatment for refractory epilepsy in humans . Epilepsia . 2005 ;46 (1 ):91 96 .

    • Search Google Scholar
    • Export Citation
  • 39

    Navas M , Navarrete EG , Pascual JM , et al. Treatment of refractory epilepsy in adult patients with right-sided vagus nerve stimulation . Epilepsy Res . 2010 ;90 (1-2 ):1 7 .

    • Search Google Scholar
    • Export Citation
  • 40

    Spuck S , Nowak G , Renneberg A , et al. Right-sided vagus nerve stimulation in humans: an effective therapy? Epilepsy Res . 2008 ;82 (2-3 ):232 234 .

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 279 279 77
Full Text Views 87 87 9
PDF Downloads 116 116 13
EPUB Downloads 0 0 0