title: Reoperation for suboptimal outcomes after deep brain stimulation surgery.
abstract: OBJECTIVE
  To examine a case series of reoperations for deep brain stimulation (DBS) leads in which clinical scenarios revealed suboptimal outcome from a previous operation. Suboptimally placed DBS leads are one potential reason for unsatisfactory results after surgery for Parkinson's disease (PD), essential tremor (ET), or dystonia. In a previous study of patients who experienced suboptimal results, 19 of 41 patients had misplaced leads. Similarly, another report commented that lead placement beyond a 2- to 3-mm window resulted in inadequate clinical benefit, and, in 1 patient, revision improved outcome. The goal of the current study was to perform an unblinded retrospective chart review of DBS patients with unsatisfactory outcomes who presented for reoperation.
  
  
  METHODS
  Patients who had DBS lead replacements after reoperation were assessed with the use of a retrospective review of an institutional review board-approved movement disorders database. Cases of reoperation for suboptimal clinical benefit were included, and cases of replacement of DBS leads caused by infection or hardware malfunction were excluded. Data points studied included age, disease duration, diagnosis, motor outcomes (the Unified Parkinson Disease Rating Scale III in PD, the Tremor Rating Scale in ET, and the Unified Dystonia Rating Scale in dystonia), quality of life (Parkinson's Disease Questionnaire-39 in PD), and the Clinician Global Impression scale. The data from before and after reoperation were examined to determine the estimated impact of repeat surgery.
  
  
  RESULTS
  There were 11 patients with PD, 7 with ET, and 4 with dystonia. The average age of the PD group was 52 years, the disease duration was 10 years, and the average vector distance of the location of the active DBS contact was adjusted 5.5 mm. Six patients (54%) with PD had preoperative off medication on DBS Unified Parkinson Disease Rating Scale scores that could be compared with postoperative off medication on DBS scores. The average improvement across this group of patients was 24.4%. The Parkinson's Disease Questionnaire-39 improved in the areas of mobility (28.18), activities of daily living (14.77), emotion (14.72), stigma (17.61), and discomfort (17.42). The average age of the ET group was 66 years, the disease duration was 29 years, and the average adjusted distance was 6.1 mm. Five ET patients (83.3%) in the cohort had a prereplacement on DBS Tremor Rating Scale and a postreplacement on DBS Tremor Rating Scale with the average improvement of 60.4%. The average age of the dystonia group was 39 years, the average disease duration was 7 years, and the average adjusted lead distance was 6.7 mm. Three patients (75%) with dystonia had prereplacement on DBS Unified Dystonia Rating Scale and postreplacement on DBS Unified Dystonia Rating Scale scores. Across these 3 dystonia patients, the improvement was 12.8%. Clinician Global Impression scale scores (1, very much improved; 2, much improved; 3, minimally improved; 4, no change; 5, minimally worse; 6, much worse; 7, very much worse) after replacement revealed the following results in patients with PD: 1, 7 patients; 2, 3 patients; 3, 1 patient); with ET (1, 4 patients; 2, 3 patients); and with dystonia (1, 1 patient; 2, 2 patients; 3, 1 patient). The latency from original lead placement to reoperation (repositioning/revision) overall was 28.9 months (range, 2-104 mo); however, in leads referred from outside institutions (n = 11 patients), this latency was 48 months (range, 12-104 mo) compared with leads implanted by surgeons from the University of Florida (n = 11 patients), which was 9.7 months (range, 2-19 mo). The most common clinical history was failure to achieve a perceived outcome; however, history of an asymmetric benefit was present in 4 (18.2%) of 22 patients, and lead migration was present in 3 (13.6%) of 22 patients.
  
  
  CONCLUSIONS
  There are many potential causes of suboptimal benefit after DBS. Timely identification of suboptimal lead placements followed by reoperation and repositioning/replacement in a subset of patients may improve outcomes.
authors.affiliation: Department of Neurology, Movement Disorders Center, University of Florida, McKnight Brain Institute, Gainesville, Florida, USA.
authors.forename: Tina-Marie
authors.initials: TM
authors.lastname: Ellis
authors.forename: Kelly D
authors.initials: KD
authors.lastname: Foote
authors.forename: Hubert H
authors.initials: HH
authors.lastname: Fernandez
authors.forename: Atchar
authors.initials: A
authors.lastname: Sudhyadhom
authors.forename: Ramon L
authors.initials: RL
authors.lastname: Rodriguez
authors.forename: Pamela
authors.initials: P
authors.lastname: Zeilman
authors.forename: Charles E
authors.initials: CE
authors.lastname: Jacobson
authors.forename: Michael S
authors.initials: MS
authors.lastname: Okun
mesh_terms: D000328:Adult; D000368:Aged; D002648:Child; D046690:Deep Brain Stimulation / Q000009:adverse effects*; D004421:Dystonia / Q000628:therapy*; D004567:Electrodes, Implanted / Q000009:adverse effects; D020329:Essential Tremor / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects; D010300:Parkinson Disease / Q000628:therapy*; D011788:Quality of Life; D012086:Reoperation; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome