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BMJ. 2007 July 21; 335(7611): 114–115.
PMCID: PMC1925158

Neurosurgeons told to watch for signs of “twiddler's syndrome”

Neurosurgeons need to watch out for signs of “twiddler's syndrome” in their patients, a new report warns.

With the increasing use of implanted stimulation devices, there have been a number of reports where patients have consciously, subconsciously, or unintentionally moved wires attached to the device.

“With the advent of implanted pulse generators in the treatment of epilepsy, Parkinson's disease, essential tremor, and pain those caring for patients with such a device should be aware of this potential complication,” says the report in Surgical Neurology (doi: 10.1016/j.surneu.2006.10.062).

It says, “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.”

Power for such stimulation devices comes from an implanted pulse generator, usually located in a pocket in the chest underneath the skin. In the latest case, twiddler's syndrome, defined as the spontaneous, subconscious, inadvertent, or deliberate rotation of the generator, occurred in a 65 year old woman with a history of disabling essential tremor. A deep brain stimulator was implanted, which initially resulted in almost complete resolution of her symptoms, and she was able to carry out activities involving repetitive movements that she had previously avoided, including housework and gardening.

But after six months she developed a pain behind her left ear and uncontrolled tremor of her right hand. Tests showed a lack of current getting through to the implant, and it was later found that the wires to the generator had several twists, reducing power supply and putting stress on tissue, causing the ear pain.

“The patient adamantly denied manipulation of the IPG [implanted pulse generator] in a twisting or twirling fashion,” says the report, which states that the device apparently moved within the pocket spontaneously. “This case suggests that twiddler's syndrome can occur in patients with no known history of manipulating their IPGs and that it should be considered in patients with either device related complaints or device malfunctions.”

A commentary on the case says that many centres have had similar cases. Konstantin Slavin, of the department of neurosurgery at the University of Illinois at Chicago, wrote: “I have observed a similar problem myself—and for sure most busy places have had one or two patients who compulsively manipulate an implanted device. Unfortunately, there is no easy solution for it. Even placing the device in a Dacron pouch does not make it completely attached.”

Two other case reports, in Der Chirurg (doi: 10.1007/s00104-007-1319-3) and Cardiology (2007;17:220-2), described movement in pacemaker wires that resulted in problems for an adult male patient and a boy.


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