Review Article
Deep Brain Stimulation-Related Surgical Site Infections: A Systematic Review and Meta-Analysis

https://doi.org/10.1111/ner.13354Get rights and content

Abstract

Background

Over the last decades, the increased use of deep brain stimulation (DBS) has raised concerns about the potential adverse health effects of the treatment. Surgical site infections (SSIs) following an elective surgery remain a major challenge for neurosurgeons. Few studies have examined the prevalence and risk factors of DBS-related complications, particularly focusing on SSIs.

Objectives

We systematically searched published literature, up to June 2020, with no language restrictions.

Materials and Methods

Eligible were studies that examined the prevalence of DBS-related SSIs, as well as studies that examined risk and preventive factors in relation to SSIs. We extracted information on study characteristics, follow-up, exposure and outcome assessment, effect estimate and sample size. Summary odds ratios (sOR) and 95% confidence intervals (CI) were calculated from random-effects meta-analyses; heterogeneity and small-study effects were also assessed.

Results

We identified 66 eligible studies that included 12,258 participants from 27 countries. The summary prevalence of SSIs was estimated at 5.0% (95% CI: 4.0%–6.0%) with higher rates for dystonia (6.5%), as well as for newer indications of DBS, such as epilepsy (9.5%), Tourette syndrome (5.9%) and OCD (4.5%). Similar prevalence rates were found between early-onset and late-onset hardware infections. Among risk and preventive factors, the perioperative implementation of intra-wound vancomycin was associated with statistically significantly lower risk of SSIs (sOR: 0.26, 95% CI: 0.09–0.74). Heterogeneity was nonsignificant in most meta-analyses.

Conclusion

The present study confirms the still high prevalence of SSIs, especially for newer indications of DBS and provides evidence that preventive measures, such as the implementation of topical vancomycin, seem promising in reducing the risk of DBS-related SSIs. Large clinical trials are needed to confirm the efficacy and safety of such measures.

Section snippets

INTRODUCTION

Since the 1980s, deep brain stimulation (DBS) has emerged as an efficient and safe modality for the treatment of movement disorders including Parkinson disease (PD), dystonia, and essential tremor, while additional indications, such as neuropsychiatric disorders (i.e., obsessive–compulsive disorder [OCD], Tourette syndrome) and epilepsy are also being explored (1,2). Currently, the indications of DBS implantation include 28 different disorders across 26 brain targets, whereas it is estimated

Data Sources and Search

The present systematic review and meta-analysis adheres to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supporting Information Table S1) (15).

We searched for peer-reviewed original research pertaining to the prevalence of SSIs following DBS surgery, as well as to potential risk and preventive factors associated with the risk of DBS-related SSIs. Two reviewers independently searched the MEDLINE database, and potential discrepancies were resolved by

Study Characteristics and Quality Evaluation

The initial literature search in MEDLINE database retrieved 202 articles, of which 88 were evaluated for eligibility following the titles-first and title-and-abstract approaches as shown in the flow chart of the study selection process (Fig. 1). Twenty-two publications were excluded due to specific reasons (Supporting Information Table S2) (20., 21., 22., 23., 24., 25., 26., 27., 28., 29., 30., 31., 32., 33., 34., 35., 36., 37., 38., 39., 40., 41.). Among these studies, three were excluded due

Principal Findings

To our knowledge, this is the largest comprehensive systematic review and meta-analysis including 66 eligible studies from 27 countries (n = 12,258 participants) that examined the association between different indications of DBS and the risk of SSIs. Overall, the summary prevalence of SSIs was estimated at 5.0% (95% CI: 4.0%–6.0%) with higher rates for dystonia (6.5%), as well as for newer indications of DBS, such as epilepsy (9.5%), Tourette syndrome (5.9%), and OCD (4.5%). Similar prevalence

CONCLUSIONS

The present systematic review summarized to-date evidence and comprehensively quantified the prevalence of SSIs for a wide range of indications of DBS surgery. Furthermore, our aim was to assess any potential risk and preventive factor in relation to SSIs. However, our exhaustive search strategy showed that only few risk and preventive measures have been studied to date. Beyond any potential limitations and biases that may affect the summary effect estimates, the findings from the present

Authorship Statements

Dr. Kantzanou and Dr. Karalexi designed and conducted the study, including the systematic literature search of published peer-reviewed articles, data extraction, and data analysis. Dr. Karalexi performed the statistical analysis (quantitative synthesis of evidence) and prepared the manuscript draft with important intellectual input from Dr. Kantzanou and Dr. Panourias. Dr. Korfias, Panourias and Dr. Sakas had complete access to the study data. All authors critically reviewed the manuscript

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      When compared with the literature, the reported incidences are favorable—intracranial AEs, 3.8%; partial or complete hardware removal, 3.6%; and lead revisions, 4.1%. The most common hardware-related AE following initial implantation was SSI (10%), which is higher than the mean SSI incidence described in large systematic reviews of literature (4.7%–5.12%) but within observed ranges (4.45–11.68; 0–15.2).9,10,25 We found no association of selected variables, ie, obesity, smoking, and diabetes mellitus.

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