Radiofrequency ablation is a minimally invasive procedure used to treat chronic back and neck pain. The procedure has been used for decades, yet the procedural guidelines and steps remain inconsistent. The preparation of skin by shaving hair when placing the grounding pad is a necessary step that can avoid harmful implications for the patient. This case report highlights the successful avoidance of a skin burn by thoroughly shaving the skin at the grounding pad site and the need to incorporate this step in universal perioperative guidelines for radiofrequency ablation procedures to optimize patient safety.

Radiofrequency; Spinal; Temperature; Joint pain; Pigmentation

Radiofrequency ablation (RFA) is a common procedure used to treat facet-joint pain [1]. The indications have recently expanded to treat peripheral nerves [2]. Techniques have also evolved to include pulsed and cool RFA [2]. The mechanisms are similar which involve nociceptive pathway disruption via the application of a high-frequency electrical current that destroys peripheral nerve origins along the spinal cord with thermal energy, leading to pain relief [1]. While complications arising from RFA are rare and typically involve local swelling and pain at the needle insertion site, skin burns have been increasingly reported at the grounding pad site [3-7]. A grounding pad is a dispersive electrode that is placed at a separate well-vascularized tissue site, usually the thigh, to complete the electrical circuit through a low-resistance pathway [6,8,9]. Maximal contact between the skin and the grounding pad is important, as a disruption between the skin-pad interface such as with hair increases the voltage across the circuit which can lead to thermal burns at the grounding site [6,8,10]. The procedural guidelines of RFA including electrode size, needle position, and temperature are consistent in the literature [11].

However, no universal guidelines highlight the need to shave hair before placing a grounding pad in preparation for RF ablation procedure [12]. This case report examines a patient who reported feeling burning at the site of the grounding pad placement during RFA procedure which resolved after replacing the pad on an area that was shaved.

The Authors reported a case of a 24-year-old male with cervical spondylosis presenting for a Right Third Occipital Nerve and C3-C4 Medial Branch Radiofrequency Neurotomy with fluoroscopic guidance. Prior to the start of the procedure, universal protocol with a time-out was completed. The patient was positioned prone, a grounding pad was secured to the right thigh, and the skin was prepped in the usual sterile manner.

The fluoroscope was then positioned to provide a caudal and slightly oblique view. Using fluoroscopic guidance, a sterile 20-gauge 100 mm radiofrequency cannula was positioned at the right third occipital nerve, C3 and C4 medial branch nerves. A radiofrequency probe was then inserted into the cannula. With 0.5 volts of 1.0 ms duration, 2 Hz stimulation multifidus muscle twitching was palpated only in the neck to confirm optimal needle placement. To numb the tissues in preparation for thermal ablation, an additional 1 mL of 1% lidocaine was slowly injected. Next, a continuous lesion was applied at 80 degrees Celsius for 90 seconds.

A few minutes after beginning the radiofrequency ablation, the patient reported that his right “leg felt hot”. The procedure was immediately stopped for examination of the grounding pad. The pad was completely adherent to the hairy skin on the right posterior thigh. A decision was made to shave the hair on the posterior left thigh and place the grounding pad here. There was no sign of thermal injury or skin blanched observed on the right posterior thigh once the grounding pad was removed. Once the grounding pad was secure on the left posterior thigh, the ablation resumed. The patient had no further feelings of warmth and the procedure was completed without issues.

Radiofrequency ablation (RFA) was developed in the 1950s as a minimally invasive and relatively safe way to treat lumbar facet joint pain [13]. The treatment modality uses conventional thermal radiofrequency at 60-80 degrees Celsius at the lumbar medial branches for 60-90 seconds [14]. Its use has expanded to treat other spinal areas and peripheral nerves [15]. Adverse effects of RFA include bleeding, infection, nerve damage, procedural discomfort, pigmentation changes, and skin burns [1]. The most common complications of facet interventions include vascular penetration and injury, RFA-related pain or numbness, injury to localized nerve structures, and tissue burns [11]. The risks of complications can be avoided by using sterile technique, fluoroscopic guidance, and procedural checklists with proper skill [1].

Despite these recommendations, skin burns remain a rare complication of RFA procedures due to the high-power energy [16]. There is no clear evidence on how to prepare the skin for the use of the grounding pad. One case report of a woman undergoing a cool-tip RF ablation described a large flaccid bulla at the grounding pad site after firmly placing a grounding pad without shaving the skin [5]. Shaving hair is especially important when patients are sedated during the procedure. Sedation use for RFA, including opioids and benzodiazepines, can increase the risk of a false-positive block and the chance of skin burns and is typically not recommended [11]. However, sedatives are often used for RFA in order to improve patient comfort and reduce anxiety [11]. There may be other ways to mitigate the likelihood of severe burns. In animal models, the use of multiple, large-surface-area foil pads placed on well-prepped skin and oriented on the longest surface can help minimize severe burns [17]. Schutt, et al., discussed how multiple grounding pads can reduce skin temperatures thereby protecting the skin from burns and allowing a higher RF generator power if needed [18].

To avoid skin burns, Cohen et al. also recommend the use of a large grounding pad that is properly positioned along a dry and clean-shaven lower extremity without scars and tattoos [11]. Despite these suggestions to avoid skin burns and well-studied procedural guidelines in place, this is the first report to specifically bring awareness to shaving hair off the skin at the grounding pad site.

This case report presents a patient with a completely adherent grounding pad to skin with hair which resulted in subjective burning of the skin. After the grounding pad was placed entirely on shaven skin, there was no burning sensation. If this patient had been sedated during the procedure, he likely would have acquired at minimum a first-degree burn.

Radiofrequency ablation is a treatment option for intractable nerve pain. The technique involves the use of heat sent through an electrode to target and disrupt nociceptive pathways using fluoroscopic guidance. Although the use of conventional thermal radiofrequency is standardized, there are no universal guidelines for skin preparation at the grounding pad site. Shaving hair is an easy way to reduce the likelihood of skin burns.

This case report highlights the necessity to shave hair when placing the grounding pad and how it should be included as part of the universal protocol during a radiofrequency ablation procedure.

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