Spontaneous twiddler's syndrome in a patient with a deep brain stimulator.

BACKGROUND: The subcutaneous placement of IPGs with electrodes to various intracranial and extracranial sites for the purpose of controlling conditions such as essential tremor, epilepsy, Parkinson's disease, and pain is increasing. Experience with similar placement of cardiac pacemakers and defibrillators had revealed the possibility of generator migration and subsequent lead fracture either spontaneously or, more often, through a patient's conscious or subconscious manipulation of the device through the skin. This phenomenon has been termed twiddler's syndrome. CASE DESCRIPTION: An elderly patient's IPG used in the treatment of a debilitating essential tremor had spontaneously rotated during the course of normal physical activities. This resulted in the twisting and fracturing of the leads. Torsional displacement of and tissue stress on subauricular lead connectors caused early discomfort in that region. Recurrent tremors occurred upon device failure. Surgical replacement of the IPG lead and use of a polyester pouch sutured to the surrounding fascia were observed to correct the problem. CONCLUSION: Those caring for patients, especially elderly and obese patients, with an IPG should be aware of the potential of device failure as a result of spontaneous twiddler's syndrome.