Vagus nerve stimulation: Surgical technique of implantation and revision and related morbidity
Open accessAbstract
Summary: Indications for vagus nerve stimulation ( VNS ) therapy include focal, multifocal epilepsy, drop attacks (tonic/atonic seizures), Lennox‐Gastaut syndrome, tuberous sclerosis complex ( TSC )–related multifocal epilepsy, and unsuccessful resective surgery. Surgical outcome is about 50–60% for seizures control, and may also improve mood, cognition, and memory. On this basis, VNS has also been proposed for the treatment of major depression and Alzheimer's' disease. The vagus nerve stimulator must be implanted with blunt technique on the left side to avoid cardiac side effects through the classic approach for anterior cervical discectomy. The actual device is composed of a wire with three helical contacts (two active contacts, one anchoring) and a one‐pin battery. VNS is usually started 2 weeks after implantation with recommended settings of stimulation (1.0–2.0 mA; 500 μs pulse width; 20–30 Hz; 30 s ON , 5 min OFF ). The complications of VNS therapy are early (related to surgery) and late (related to the device and to stimulation of the vagus nerve). Early complications include the following: intraoperative bradycardia and asystole during lead impedance testing, peritracheal hematoma, infections (3–8%), and vagus nerve injury followed by hoarseness, dyspnea, and dysphagia because of left vocal cord paralysis. Delayed morbidity due to the device includes late infections or problems in wound healing; other more rare events are due to late injury of the nerve. Late complications due to nerve stimulation include delayed arrhythmias, laryngopharyngeal dysfunction (hoarseness, dyspnea, and coughing), obstructive sleep apnea, stimulation of phrenic nerve, tonsillar pain mimicking glossopharyngeal neuralgia, and vocal cord damage during prolonged endotracheal intubation. The laryngopharyngeal dysfunction occurs in about 66% of patients and is usually transitory and due to the stimulation of the inferior (recurrent) laryngeal nerve. A true late paralysis of the left vocal cord is often partial and rare (1–2.7%), and usually transitory, and may be caused by previous surgical trauma (i.e., damage of nerve fibers and/or of their blood supply) or to a supposed chronic denervation during stimulation. Surgery for complete removal or revision and replacement of the device is to be considered in cases of device malfunction (4–16.8%), failure of VNS therapy, intolerable side effects, or because of patient's specific request. As described in the literature, the surgical techniques of lead revision and replacement are two: sharp and blunt dissection of helical electrodes and replacement; and blunt dissection combined with ultrasharp low‐voltage cautery dissection. The incidence of left vocal cord palsy after vagus nerve stimulator replacement/revision is slightly higher than that of first implantation (4.9% vs. 3.8%). A de novo implantation in a naive segment of the left or right vagus nerve may be considered in specific cases; the use of the right vagus nerve is a rare exception that may be chosen with an acceptable result.
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Complications of helical electrode vagal nerve stimulation include late infections, wound dystrophy, and rare permanent vocal cord paralysis and twiddler's syndrome.
“Complications of this procedure include late infections, wound dystrophy, and rare incidents such as permanent vocal cord paralysis and twiddler’s syndrome, which involves the dislodgement of the electrode causing stimulation of unintended nerves [53].”
From Interfaces with the peripheral nervous system for the control of a neuroprosthetic limb: a review (2020) · cites this paper as [53]
The Key Points section (page not available) lists late infections, wound dystrophy, rare permanent left vocal cord paralysis, and device tampering called “twiddler’s syndrome” as complications. It does not say that twiddler’s syndrome dislodges the electrode or causes stimulation of unintended nerves, as the citing sentence adds. (LLM, conf=0.86)
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- Authors
- Giordano, F., Zicca, A., Barba, C., Guerrini, R., & Genitori, L.
- Affiliations
- University of Florence (IT)
- Meyer Children's Hospital (IT)
- Corresponding author
- Giordano, Flavio
- Venue
- Epilepsia
- Publisher
- Wiley
- Published
- 2017-04
- Volume
- 58
- Issue
- S1
- Pages
- 85-90
- ISSN
- 0013-9580 (ISSN-L)
- 1528-1167
- OpenAlex
- W2604957510
- Cited by
- 258
- References
- 53
- Citations by year
- 2026: 32 · 2025: 32 · 2024: 45 · 2023: 36 · 2022: 20 · 2021: 23 · 2020: 25 · 2019: 27 · 2018: 14 · 2017: 3
- FWCI
- 1.81
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Epilepsia (publishedVersion)
- PubMed (publishedVersion)
- Florence Research (University of Florence) (submittedVersion)
- Topics
- Life Sciences › Neuroscience › Neurology › Vagus Nerve Stimulation Research
- Health Sciences › Medicine › Psychiatry and Mental health › Epilepsy research and treatment
- Health Sciences › Medicine › Neurology › Neurological disorders and treatments
- Keywords
- vagus nerve stimulation, surgical technique, device revision, postoperative complications, vocal cord paralysis, phrenic nerve stimulation, epilepsy, Lennox-Gastaut syndrome, tuberous sclerosis complex, major depressive disorder, Alzheimer's disease, anterior cervical approach
- MeSH terms
- Adolescent, Adult, Arrhythmias, Cardiac, Bradycardia, Electrodes, Implanted, Epilepsy, Equipment Failure, Female, Humans, Male, Vocal Cords, Vagus Nerve Stimulation, Young Adult
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