A 61‐year‐old right‐handed woman with a 10‐year history of Parkinson's disease was referred to our clinic for motor fluctuations and dyskinesias. She underwent bilateral deep brain stimulation (DBS) surgery with electrodes implanted into the subthalamic nuclei bilaterally with a left dual‐channel implantable pulse generator (IPG). After initial programming, her symptoms of tremor and rigidity were significantly improved. However, at the 2‐week follow‐up, she complained of worsening tremor and rigidity in her right arm. She also complained that her IPG was “twisting” spontaneously while laying on her side. On interrogation of her device, impedances were low at all contacts on the left side. On chest, skull, and neck radiographs, a significant amount of coiling of the DBS extension leads was noted (Figs. 1 and 2). She was scheduled for an emergent revision. The DBS extension leads were replaced, and the IPG was secured underneath the pectoralis fascia. At follow‐up, her tremor was significantly improved, and impedances were normal on interrogation.
FIG 1.
Chest radiograph showing implantable pulse generator and coiling of extension wires.
FIG 2.
Skull radiograph showing coiling of extension wires.
Twiddler's syndrome occurs in about 1% of DBS surgeries. 1 Early identification is crucial because Twiddler's syndrome may cause fracturing of the extensions or the distal part of the electrode and might also cause upward displacement of the lead. 1 Some of the predisposing factors include psychiatric disorders, advanced age, obesity, and female sex. 2 Suturing the device to muscle, limiting pocket size, or dual anchoring of the IPG may limit its occurrence.
Author Roles
(1) Research Project: A. Clinical Assessment of the Patient, B. Execution; (2) Manuscript Preparation: A. Collection of Images, B. Writing of the First Draft, C. Review and Critique.
J.A.: 1B, 2A, 2B
V.S.: 1A, 1B, 2B, 2C
Disclosures
Ethical Compliance Statement
We confirm that an approval of the Institutional review board and patient consent was not necessary for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.
Funding Sources and Conflict of Interest
No specific funding was received for this work. The authors declare that there are no conflicts of interest relevant to this work.
Financial Disclosures for the Previous 12 Months
The authors declare that there are no additional disclosures to report.
Relevant disclosures and conflicts of interest are listed at the end of this article.
References
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