title: Aim for the Suprasternal Notch: Technical Note to Avoid Bowstringing after Deep Brain Stimulation.
abstract: BACKGROUND
  Bowstringing may occur when excessive fibrosis develops around extension cables in the neck after deep brain stimulation (DBS) surgery. Though the occurrence of this phenomenon is rare, we have noted that it tends to cause maximal discomfort when the cables cross superficially over the convexity of the clavicle. We hypothesise that bowstringing may be avoided by directing the extension cables towards the suprasternal notch.
  
  
  METHODS
  When connecting DBS leads to an infraclavicular pectoral implantable pulse generator (IPG), tunnelling is directed towards the suprasternal notch, before being directed laterally towards the IPG pocket. In previously operated patients with established fibrosis, the fibrous tunnel is opened and excised as far cranially as possible, allowing medial rerouting of cables. Using this approach, we reviewed our series of patients who underwent DBS surgery over 10 years.
  
  
  RESULTS
  In 429 patients, 7 patients (2%) with cables tunnelled over the convexity of the clavicle complaining of bowstringing underwent cable exploration and rerouting. This eliminated bowstringing and provided better cosmetic results. When the cable trajectory was initially directed towards the suprasternal notch, no bowstringing was observed.
  
  
  CONCLUSIONS
  The tunnelling trajectory appears to influence postoperative incidence of fibrosis associated with DBS cables. Modifying the surgical technique may reduce the incidence of this troublesome adverse event.
authors.affiliation: Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, UK.
authors.forename: Harith
authors.initials: H
authors.lastname: Akram
authors.forename: Patricia
authors.initials: P
authors.lastname: Limousin
authors.forename: Jonathan
authors.initials: J
authors.lastname: Hyam
authors.forename: Marwan I
authors.initials: MI
authors.lastname: Hariz
authors.forename: Ludvic
authors.initials: L
authors.lastname: Zrinzo
mesh_terms: D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D046690:Deep Brain Stimulation / Q000009:adverse effects / Q000379:methods*; D020821:Dystonic Disorders / Q000503:physiopathology / Q000628:therapy; D004567:Electrodes, Implanted; D005260:Female; D005355:Fibrosis; D006261:Headache / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D010300:Parkinson Disease / Q000503:physiopathology / Q000628:therapy; D012189:Retrospective Studies