Neurologic injury from electrocautery equipment is a known complication that occurs infrequently. These rare surgical mishaps can be potentially devastating to the patient, causing permanent morbidity. We report the case of a 43-year-old female who presented with a permanent neurologic injury following the use of electrocautery during an elective gynecologic procedure.
A 43-year-old right hand dominant female presented to our orthopaedic hand clinic with left hand clawing following an elective gynecologic procedure. Six months earlier, she was in her normal state of health when her gynecologist recommended a Loop Electrosurgical Excision Procedure (LEEP) for the treatment of her cervical dysplasia. This common procedure uses looped electrocautery to remove the transformation zone of the cervix. During the course of her procedure, the patient stated that she felt an electric shock go through her body while an electrocautery device was being operated. Furthermore, she described a burning sensation in her neck and left arm. She did not recall being grounded during the procedure. Following the surgery, the patient developed weakness of her left hand and leg. Subsequently, she was referred to physical therapy for treatment of her left-sided motor weakness, however she noted no improvement.
The patient was eventually referred to our orthopedic clinic to evaluate a claw hand deformity. On presentation, she was a well-developed, well-nourished female who was in no apparent distress. Her chief complaint was that of left hand weakness and discomfort. Her symptoms were also accompanied with weakness of the left leg. The patient denied any loss of control of her bowels or bladder at the time of examination. Her pain score was self-reported as 7/10 on the visual analog scale.
The patient's past medical history was significant for depression and anxiety disorder. She denied previous stroke or neurologic or orthopedic injuries. The patient denied having any previous spine or extremity surgeries.
Physical exam was remarkable for claw hand deformity upon inspection. She had significant weakness of her left hand intrinsic muscles, and she had diminished sensation in the left small finger to light touch. Her hand was not discolored or edematous and had good capillary refill. No allodynia or hyperesthesia was noted upon exam. Her deep tendon reflexes were 2+ and symmetric. The remainder of her neurologic examination was unremarkable except for an obvious limp on her left leg.
Following her initial evaluation, the patient was referred for electrodiagnostic testing of her left upper extremity to evaluate for possible ulnar neuropathy. EMG/NCV failed to reveal evidence of peripheral nerve injury, brachial plexopathy, or cervical radiculopathy. However, there was evidence of reduced (interference) recruitment, which was consistent with a central neurologic process. After her upper extremity EMG/NCV study, she was sent for an additional electrodiagnostic study to evaluate her left leg weakness. This EMG/NCV study of the lower extremities revealed similar findings of central nerve lesion without evidence of peripheral nerve injury or radiculopathy.
At her follow-up visit with the hand service, the patient was offered tendon transfers to correct her claw hand deformity, and she consented to the procedure. Subsequently, she underwent flexor digitorum superficialis lasso procedures to the small and ring fingers. The metacarpophalangeal joints were tensioned in 40 degrees of flexion. Post-operatively, she had no complications and demonstrated improvement in her claw deformity.
The LEEP is a common outpatient gynecologic procedure that occurs thousands of times daily in this country.1 Cervical Loop Electrosurgical Excision Procedures have been a very effective way to treat cervical intraepithelial neoplasia since the 1990s.1,2,3,4 Known complications of this procedure include: infection, post-op bleeding, vaginal laceration, cervical stenosis, urinary tract infections, and bladder perforation amongst others.1 Evidence of spinal injury from a LEEP has not been previously been published in the medical literature.
Our patient sustained neurologic injuries to her left arm and leg most likely secondary to an indirect thermal injury that occurred during her LEEP.5 Brill, et. al postulated that this type of injury results when an electrical current travels along an unintended pathway and burns a non-targeted tissue. Furthermore, they concluded that these injuries occurred by three mechanisms: insulation failure, direct coupling, and/or capacitive coupling. In our case, the patient was informed that the injury occurred because she was not properly grounded, i.e. an insulation error.
The patient's neurologic presentation most closely represents an incomplete spinal cord injury known as central cord syndrome. It was initially described by Schneider, et. al in 1954 and is the most common incomplete spinal cord injury.6,7,8 Patients typically exhibit greater impairment of the upper extremities than of the lower extremities. Bladder dysfunction and sensory loss may also occur in central cord patients.
In conclusion, we present this case as a cautionary tale to clinicians who perform medical procedures with electrocautery. Utmost vigilance and strict adherence to standard operating room safety procedures must be followed to prevent potentially devastating injuries when using electrosurgical equipment.
The authors have no relevant disclosures.
Theodore Conliffe, MD, is a Clinical Assistant Prof. at Thomas Jefferson University Hospital in the Dept. of Physical Medicine and Rehabilitation, and an Attending Physician, Rothman Institute of Orthopedics, Philadelphia, PA.
Zach Broyer, MD, is a Clinical Instructor at Thomas Jefferson University Hospital, in the Dept. of Physical Medicine and Rehabilitation, and an Attending Physician at the Rothman Institute of Orthopedics in Philadelphia, PA.
Jonas Matzon, MD, is a Clinical Asst. Prof. at Thomas Jefferson University Hospital in the Dept. of Orthopedics, and an Attending Physician at the Rothman Institute of Orthopedics, Philadelphia, PA.
Lisa Marino, DO, is an Attending Physician at the Rothman Institute of Orthopedics in Philadelphia, PA.
Pedro Beredjiklian, MD, is an Associate Professor at Thomas Jefferson University Hospital in the Dept. of Orthopedic Surgery, and Director of the Division of Hand & Wrist Surgery at the Rothman Institute, Philadelphia, PA.
Jeremy Simon, MD, is a Clinical Instructor at Thomas Jefferson University Hospital in the Dept. of Physical Medicine and Rehabilitation, and an Attending Physician at the Rothman Institute of Orthopedics in Philadelphia, PA.
Michael Mehnert, MD, is a Clinical Instructor at Thomas Jefferson University Hospital in the Dept. of Physical Medicine and Rehabilitation, and an Attending Physician at the Rothman Institute of Orthopedics, Philadelphia, PA.
- Siegler, E & Bornstein, J. Loop electrosurgical excision procedures in Israel. Gynecol Obstet Invest. 2011; 72: 85-89.
- Bigrigg MA, Haffenden DK, Sheehan AL, Codling BW, Read MD: Efficacy and safety of large-loop excision of the transformation zone. Lancet. 1994; 343: 32-34.
- Naumann RW, Bell MC, Alavarez RD, Edwards RP, Partridge EE, Helm CW, Shingleton HM, McGee JA, Higgins RV, Hall JB: Large loop excision of the transitional zone is an acceptable alternative to diagnostic cold knife conization. Gynecol Oncol. 1994; 55:224-228.
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- Brill AI, Feste JR, Hamilton TL, et al. Patient safety during laparoscopic monopolar electrosurgery – principles and guidelines. JSLS. 1998; 2:221–225.
- Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury. J Neurosurg. Nov. 1954; 11(6): 546-77.
- McKinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007; 30(3):215-24.
- Aito S, D'Andrea M, Werhagen L, et al. Neurologicical and functional outcome in traumatic central cord sydrome. Spinal Cord. Apr. 2007; 45(4): 292-7.