An antibiotic envelope to reduce infections in deep brain stimulation surgery

Published:November 19, 2022DOI:


      • Surgical site infections in neurosurgery can result in significant morbidity.
      • Retrospective review conducted of all Deep Brain Stimulation surgeries.
      • An antibiotic envelope can prevent the onset of surgical site infections.
      • An antibiotic envelope is therefore a safe and well-tolerated adjunct.
      • No implant removal was required.


      The therapeutic benefits of Deep Brain Stimulation (DBS) surgery in patients with movement disorders such as Parkinson’s Disease are life-altering. Surgical site infections (SSI), however, can result in increased hospitalisations, prolonged antibiotics and neurological sequelae. We performed a retrospective review to evaluate the effectiveness of an antibiotic envelope to reduce SSI in DBS surgeries. This study included all DBS surgeries performed between August 2020 to May 2022 using a single-use, multifilament, antibiotic-coated mesh envelope wrapped around the DBS implantable pulse generator (IPG) (TYRX™ Absorbable Antibacterial Envelope, Medtronic Fridley, MN, USA). Standardised infection-prevention measures were applied and various patient-specific and surgery-specific factors were analysed. 44 patients were analysed with 26 (59.1 %) primary implantations and 18 (40.9 %) revision surgeries. The median age was 65 years old with an average follow-up of 13.5 months (range 3–24 months). The mean Body Mass Index was 24.0 (range 16.7–35.6). 8 (18.2 %) patients had underlying diabetes mellitus. There were only 2 (4.5 %) SSIs reported with neither involving the subcutaneous IPG and antibiotic envelope. 1 superficial-incisional SSI (2.3 %) was from a prior retro-auricular abscess around a lead-wire requiring antibiotics and subcutaneous implant transposition. The other was a deep-incisional SSI (2.3 %) from repetitive trauma causing delayed scalp wound dehiscence and lead-wire extrusion, requiring antibiotics and wound revision. Both subjects were discharged well with no implants removed. The antibiotic envelope therefore appears to be a safe and well-tolerated adjunct that may reduce SSIs in DBS surgery. Further prospective work with larger sample sizes in a multi-institution setting is required.


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        • Benabid A.L.
        Deep brain stimulation for Parkinson's disease.
        Curr Opin Neurobiol. 2003; 13: 696-706
        • Hubble J.P.
        • Busenbark K.L.
        • Wilkinson S.
        • Penn R.D.
        • Lyons K.
        • Koller W.C.
        Deep brain stimulation for essential tremor.
        Neurology. 1996; 46: 1150-1153
        • Koller W.C.
        • Lyons K.E.
        • Wilkinson S.B.
        • Troster A.I.
        • Pahwa R.
        Long-term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor.
        Mov Disord. 2001; 16: 464-468
        • Houeto J.L.
        • Karachi C.
        • Mallet L.
        • Pillon B.
        • Yelnik J.
        • Mesnage V.
        • et al.
        Tourette's syndrome and deep brain stimulation.
        J Neurol Neurosurg Psychiatry. 2005; 76: 992-995
        • Lee D.J.
        • Lozano C.S.
        • Dallapiazza R.F.
        • Lozano A.M.
        Current and future directions of deep brain stimulation for neurological and psychiatric disorders.
        J Neurosurg. 2019; 131: 333-342
      1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-78; quiz 79-80.

        • Fenoy A.J.
        • Simpson Jr., R.K.
        Management of device-related wound complications in deep brain stimulation surgery.
        J Neurosurg. 2012; 116: 1324-1332
        • Fenoy A.J.
        • Simpson Jr., R.K.
        Risks of common complications in deep brain stimulation surgery: management and avoidance.
        J Neurosurg. 2014; 120: 132-139
        • Beric A.
        • Kelly P.J.
        • Rezai A.
        • Sterio D.
        • Mogilner A.
        • Zonenshayn M.
        • et al.
        Complications of deep brain stimulation surgery.
        Stereotact Funct Neurosurg. 2001; 77: 73-78
        • Hamani C.
        • Lozano A.M.
        Hardware-related complications of deep brain stimulation: a review of the published literature.
        Stereotact Funct Neurosurg. 2006; 84: 248-251
      2. Oh MY, Abosch A, Kim SH, Lang AE, Lozano AM. Long-term hardware-related complications of deep brain stimulation. Neurosurgery 2002;50:1268-74; discussion 74-6.

        • Chen T.
        • Mirzadeh Z.
        • Lambert M.
        • Gonzalez O.
        • Moran A.
        • Shetter A.G.
        • et al.
        Cost of Deep Brain Stimulation Infection Resulting in Explantation.
        Stereotact Funct Neurosurg. 2017; 95: 117-124
        • Wetzelaer P.
        • Vlis T.
        • Tonge M.
        • Ackermans L.
        • Kubben P.
        • Evers S.
        • et al.
        Management of Hardware Related Infections after DBS Surgery: A Cost Analysis.
        Turk Neurosurg. 2018; 28: 929-933
        • Bernstein J.E.
        • Kashyap S.
        • Ray K.
        • Ananda A.
        Infections in Deep Brain Stimulator Surgery.
        Cureus. 2019; 11: e5440
        • Tarakji K.G.
        • Mittal S.
        • Kennergren C.
        • Corey R.
        • Poole J.E.
        • Schloss E.
        • et al.
        Antibacterial Envelope to Prevent Cardiac Implantable Device Infection.
        N Engl J Med. 2019; 380: 1895-1905
      3. Hagedorn JM, Canzanello N, Bendel MA, T PP, T JL. Antibacterial Envelope Use for the Prevention of Surgical Site Infection in Spinal Cord Stimulator Implantation Surgery: A Retrospective Review of 52 Cases. J Pain Res 2021;14:2249-54.

        • Mittal S.
        • Wilkoff B.L.
        • Kennergren C.
        • Poole J.E.
        • Corey R.
        • Bracke F.A.
        • et al.
        The World-wide Randomized Antibiotic Envelope Infection Prevention (WRAP-IT) trial: Long-term follow-up.
        Heart Rhythm. 2020; 17: 1115-1122
        • Li J.
        • Zhang W.
        • Mei S.
        • Qiao L.
        • Wang Y.
        • Zhang X.
        • et al.
        Prevention and Treatment of Hardware-Related Infections in Deep Brain Stimulation Surgeries: A Retrospective and Historical Controlled Study.
        Front Hum Neurosci. 2021; 15707816
        • Urban M.V.
        • Rath T.
        • Radtke C.
        Hydrogen peroxide (H2O2): a review of its use in surgery.
        Wien Med Wochenschr. 2019; 169: 222-225
        • Tatnall F.M.
        • Leigh I.M.
        • Gibson J.R.
        Comparative study of antiseptic toxicity on basal keratinocytes, transformed human keratinocytes and fibroblasts.
        Skin Pharmacol. 1990; 3: 157-163
        • Lu M.
        • Hansen E.N.
        Hydrogen Peroxide Wound Irrigation in Orthopaedic Surgery.
        J Bone Jt Infect. 2017; 2: 3-9
      4. Huntingdon Life Sciences Study TR-2013-001. (Data on file with Medtronic, PLC).

      5. TYRX™ Absorbable Antibacterial Envelope, Medtronic, Fridley, MN, USA.