10.1245/s10434-006-9265-8
Annals of Surgical Oncology 14:1243-1244 (2007)
© 2007 Society of Surgical Oncology
Peroneal Neuropathy due to Ground Pad Burn Injury after a Radiofrequency Ablation Surgery
Murat Kara, MD,
Levent Özçakar, MD,
Özlem Erol, MD and
Bayram Kaymak, MD
Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey
To the editor:
A 55-year-old woman was seen in the surgery ward for her left drop foot that developed immediately after a surgical procedure. She underwent a low anterior abdominal resection for rectal carcinoma and radio-frequency ablation (RFA) of the metastatic lesions in the liver was performed. The medical history was otherwise unremarkable, except for diabetes mellitus in the last 7 years. Physical examination was consistent with a second-degree dermal burn on the posterolateral side of the left knee due to a technical problem with regard to the ground pad (Fig. 1
). Neurological examination revealed a complete left peroneal palsy with no voluntary dorsiflexion and eversion, and sensory loss on the lateral aspect of the left leg and foot. A late electromyography (EMG) was planned and she was started on a rehabilitation program that comprised electrical stimulation and exercises for the left leg. Gabapentine 3
300 mg/day was given as pain medication and a night ankle foot orthosis was prescribed for avoiding ankle contractures. During follow-up, she developed an infection at the burn site. After antibiotic treatment for 2 months, an EMG could be performed, which revealed a total axonal injury of the left common peroneal nerve. In the interim, as she did not benefit significantly from the rehabilitation program, she was referred to the plastic surgeons. They have suggested a surgical repair of the peroneal nerve after her chemotherapy is completed. Currently, she still has a drop foot, but no pain.
RFA has been accepted as a promising and safe technique for the treatment of unresectable hepatic tumors. Nevertheless, the prevalence of major complications after RFA of hepatic tumors has also been reported to be 2.43% and the most common complications were hepatic abscess (0.66%), peritoneal hemorrhage (0.46%), biloma (0.20%), ground pad burn (0.20%), pneumothorax (0.20%) and vasovagal reflex (0.13%).1 Physicians who perform RFA should be aware of this broad spectrum of complications (Table 1).
Proper placement of the ground pad on the patient’s body at a site removed from the surgical field is crucial to the safe operation of electrosurgical instruments. If this pad or its contact with the body is too small, the electrical current will exit over too small an area, either at the ground pad or at other sites, such as electrocardiogram leads, causing burns.2 Moreover, like in our case, if the site of injury is close to peripheral nerves coursing superficially, unforeseen neurological adversities may also ensue. To our best notice, this is the first patient reported in the hitherto literature, who had suffered from a peroneal palsy due to a burn injury as a complication of RFA. This is noteworthy, as other types of peroneal neuropathies due to surgical complications (e.g. related with the lithotomy positioning) can also be seen.3 In our case, although the lithotomy positioning might also be considered to have a contribution to the eventual neural insult, the fact that the problem being unilateral and the presence of an overt burn injury exactly over the superficial course of the peroneal nerve make this possibility less likely. Moreover, the level of peroneal neuropathy was consistent with a lesion proximal to the knee joint rather than being due to a distal lesion that would be caused by the lithotomy stirrups. On the other hand, in relevant patients, one may also recall the possibility of underlying concomitant disorders like diabetes and paraneoplastic
neuropathies that may potentiate the neural injury. Accordingly, it is important that surgeons and the operating personnel should pay enough attention to the electrosurgical system during the operation; and electrolyte solutions, such as lubricating jelly or paste, should generally be employed to improve skin contact and lower electrical resistance between the pad and the skin. Last but not least, we advise that the ground pad should be placed somewhere else other than adjacent to the fibular head, as far as the eventual gait impairment and its likely impact on the patient’s quality of life are concerned.
REFERENCES
- Rhim H, Yoon KH, Lee JM, et al. Major complications after radio-frequency thermal ablation of hepatic tumors: spectrum of imaging findings. Radiographics 2003; 23:123–36.[Abstract/Free Full Text]
- Battig CG. Electrosurgical burn injuries and their prevention. JAMA 1968; 204:1025–9.[Abstract/Free Full Text]
- Erol Ö, Özçakar L, Kaymak B. Bilateral peroneal neuropathy after surgery in the lithotomy position. Aesthetic Plast Surg 2004; 28:254–5.[CrossRef][Medline]
