© 1999 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0521/99/$14.00/0 • Dermatol Surg 1999;25:415–417

BOOK REVIEWCASE REPORT

Cutaneous Electrosurgery in a Patient with a DeepBrain Stimulator

Jeffrey Weaver, DO, Susan J. Kim, MD, and Abel Torres, MD, JD

Department of Dermatology, Loma Linda University Medical Center, Loma Linda, California

background.

Deep brain stimulators are implantable deviceswith electrical activity used to treat certain movement disorderssuch as essential tremor and Parkinson’s disease. Similar to im-plantable cardiac devices, use of electrosurgery on patients withthese devices may produce adverse effects.

case report.

We describe the effects of electrosurgery on a pa-tient with essential tremor and an implantable deep brain stim-ulator who required Mohs micrographic surgery to excise abasal cell carcinoma.

The patient experienced immediate lancinating “electrical

shock” using electrosurgery in the monopolar mode. The patientexperienced no discomfort when a bipolar electrosurgical devicewas used or when his deep brain stimulator was “turned off.”Appropriate positioning of the dispersive plate also reduced ad-verse effects.

conclusion.

Dermatologic surgeons should be aware of pa-tients with devices implanted in the CNS with electrical activityand proceed with caution when using electrosurgery. Differentapproaches can be utilized to help reduce adverse effects.

ESSENTIAL TREMOR is the most common move-ment disorder, and Parkinson’s disease affects approx-imately 500,000 people in the United States alone.

1

The magnitude of the problem of movement disorderscan be very great resulting in a lower quality of life forpatients suffering the severest symptoms.

2

In August 1997, the FDA approved the treatment ofdisabling essential tremor refractory to medical man-agement and the tremor associated with Parkinson’sdisease by deep brain stimulation utilizing an implantedelectrical device called Medtronic Activa.

3

Deep brainstimulation was initially used to determine the best lo-cation to place a surgical lesion in the thalamus to con-trol tremor not amenable to drug therapy.

4

Since deepbrain stimulation controlled tremor intraoperatively, itwas hypothesized that a device could be implanted forlong-term control, avoiding the complications of a de-structive surgical lesion.

5,6

The deep brain stimulator device has 4 contact elec-trodes, which are stereotactically placed in the ventralintermediate nucleus of the thalamus contralateral tothe side with the severest symptoms. The electrodesare connected to the pulse generator by a wire that istunneled down to the pulse generator from the brain.The pulse generator typically is placed in the subcuta-neous tissue of the chest, much the same as a cardiacpacemaker. Adjustable stimulation parameters includeelectrode selection, stimulation pulse amplitude, fre-

quency, and pulse width. The electrical pulses blockfaulty brain signals that induce tremor. The device canbe turned off or switched between high and low set-tings by the patient using an external magnet. Patientscan control their individual therapy with the magnetto meet the needs for tremor suppression. The manu-facturer, Medtronics, Inc. recommends that patientsturn off the device at night when sleeping to conservethe life span of the battery.

3

However, like the implantable cardiac devices suchas pacemakers and defibrillators, the deep brain stim-ulator generates electrical impulses and has the poten-tial for interference when subjected to external electro-magnetic forces such as electrosurgery.

7

We present acase that exemplifies this issue.

Case Report

JP is an 81-year-old male who was treated with Mohsmicrographic surgery to excise a basal cell carcinomaof the left cheek. He had an Activa deep brain stimula-tor tremor control system implanted 5 years earlierunder an investigational protocol for treatment of se-vere essential tremor. The deep brain stimulator leadwas located in his right ventral intermediate nucleusand the pulse generator implanted subcutaneously onhis right anterior chest wall. He had experienced markedimprovement of his tremor with only the mild side ef-fects of transient and mild parathesia at the time of re-programming of his device.

During the surgical procedure, a Birtcher Hyfrecatorin the monopolar mode (electrofulguration type wave-form) without a dispersive plate was used to controlbleeding. Our patient experienced immediate lancinat-

Address correspondence and reprint requests to: Abel Torres, MD, JD,Loma Linda University Dermatology Medical Group, Inc., FacultyMedical Offices, 11370 Anderson St. Suite 2600 Loma Linda, CA92354.

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ing “electric shock” sensations down his left arm andleft leg. He described this as similar to what he felt dur-ing reprogramming, except much more severe. A bat-tery-operated heat generating handheld device (oph-thalmic cautery) was used for the rest of the procedurewithout discomfort to the patient. Soon after this pro-cedure, the patient reported for his regularly scheduledmonitoring and programming of his deep brain stimu-lator. No discernable changes in the device’s adjustableparameters had occurred.

He required additional surgical procedures on theleft side of his face and cheek at a later date. Two differ-ent electro-surgical methods were used. When treatinga left preauricular lesion, a Valley Labs Surgistat devicewith a monopolar pencil lead with a dispersive plate onthe right posterior calf was used to divert the circuitaway from the implanted device. This arrangement re-sulted in electric shock sensations in the left arm and leg,even with the device on very low power settings. Next, asecond lesion on his chin was treated with the ValleyLabs Surgistat using a bipolar electrosurgical forceps.Even on relatively high power settings, the patient expe-rienced no discomfort. Presumably, this was becausewith a bilateral application with the Valley Labs device,this results in low heat electrocoagulation. Finally, thepatient turned off his pulse generator during a thirdprocedure on his chin, using his hand held control mag-net. He became extremely tremulous and somewhat up-set, making the surgical procedure difficult. With hisstimulator turned off, the Valley Lab device was used inthe monopolar mode with the dispersive plate on theleft lower leg. The patient experienced no pain whenthe electrosurgical device was used to control bleeding.However, he required several attempts to reactivate hispulse generator, since he had trouble steadying themagnet on his chest.

During a third surgical session, when bleeding wascontrolled on the left cheek, the Valley Labs Surgistatwas used in the monopolar mode with the dispersiveplate on the left trapezius area, so that it was closer tothe electrical output yet away from the device. The pa-tient experienced no discomfort with this arrangement.

Discussion

The medical literature contains many references thatdiscuss the use of electrosurgery in patients with im-plantable cardiac devices.

7–18

However, little if any in-formation is available on how to manage electrosurgeryin patients with the recently developed tremor controlsystem implanted in the central nervous system such asthe Medtronics Activa.

Thousands of deep brain stimulators have been im-planted around the world since they became available.Since they have been found safe and effective and re-

leased for use in the United States, it seems likely thatdermatologic surgeons will encounter these patientswith increasing frequency in the near future.

19,4,3

The manufacturer of the deep brain stimulator tremorcontrol system warms that electrosurgery may adverselyeffect the device in its product information packet.

3

Inpersonal communication, their technical departmentadvised placing a dispersive plate as far away from thegenerator and lead as possible (Pierce M, Therapy De-velopment Manager, personal communication, Novem-ber 1997). This maneuver was not effective in our pa-tient although perhaps it may be effective in otherpatients.

Our trial and error experience with 1 patient sug-gests that the following approaches may be more help-ful when using electrocoagulation in a patient im-planted with a deep brain stimulator.

1. Have the patient turn the device off with the mag-net supplied for that purpose. This may not bepractical if the tremor is so severe that it interfereswith surgery as in our patient.

2. Use a bipolar electrosurgical device (electrocoagu-lation) to reduce the potential for interference.

3. Use a monopolar device with the dispersive plate(electrodessication) positioned so that the pulsegenerator or lead wire are not located between theplate and the surgical site.

4. Use a handheld ophthalmic cautery for electroco-agulation since this does not generate an electricalfield but this is more useful for small lesions.

We would like to conclude this discussion with a ca-veat, and that is that all types of electrosurgery are notalike. Electrodesiccation, electrofulgeration, electrot-omy or electrocutting with their unique current char-acteristics may have different effects on a deep brainstimulator. It may be unwise to extrapolate these sug-gestions to the use of other types of high frequency elec-trosurgery. For example, electrotomy that is used to cuttissue uses a higher current, and it is known to be themost hazardous type of electrosurgery to use in patientswith implanted cardiac devices.

20,21,22

Dermatologic surgeons should be aware that electri-cal devices are now being implanted in the CNS to treatmovement disorders. The use of electrosurgery in thesepatients can create pain and discomfort. Adjustments intechnique can be made to eliminate this problem.

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3. Medtronic. Product Information-Questions and Answers Essential

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