Stefano Ricci
Case reportA 43-year old woman had previously undergone bilateral surgical stripping of the great saphenous vein and the right small saphenous vein and subsequent sclerottherapy. She later presented with reticular visible asymptomatic varicose veins on the dorsolateral side of the right upper leg up to shortly below her knee. A phlebectomy was performed by local anesthesia (non-tumescent) with approximately 15 cm3 lidocaine 1%. Immediately after phlebectomy, the patient noticed weakness of the right foot, right foot drop, without neurological pain. The drop foot disappeared spontaneously after several hours without therapy.
The sciatic nerve runs behind the femur from the buttock to the lower thigh where it divides into the common peroneal nerve (CPN) and tibial nerve. The CPN then descends along the lateral side of the popliteal fossa to the head of the fibula. It winds round the head of the fibula and divides into the superficial peroneal nerve and the deep peroneal nerve.
The deep peroneal nerve is responsible for dorsiflexion of the foot. Injury to this branch produces weakness or paralysis of the muscles responsible for these actions. In this case, the anesthesia infiltrated around the fibula head caused temporary blockage of the CPN. When operating in the field of the lateral knee, the area around the fibula head should be avoided or managed with extreme caution.
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Muller’s phlebectomy is easy, safe, and effective. As for all the handicrafts, craftsmen must care for details. As an example, many can make a pizza, but only a few people can make a good pizza. Robert Muller (unfortunately not cited in references) described many of these details and many others were later reported by his pupils. But it is ourdestiny that, in the field of medicine, the pearls are lost over time because of a kind of bibliographic laziness. This is the case of the anesthesia used for this patient: a concentration of 1% lidocaine is very high, given that a dilution to 0.4 (or lower) has been shown to be completely adequate. At this concentration, the nerve is more easily involved in infiltration. Furthermore, injections should remain superficial (subcutaneous) and not perforate the fascial sheet covering the nerve structures. Finally, surgeons should always be aware of the potential dangers in particular areas (head of fibula, foot, anterior aspect of tibia, distal SSV) when performing Muller’s phlebectomy. This case report has the merit of reminding us of some of those forgotten details. Final remark: Muller is a French Swiss and the u is simple; another sign of its bibliographic oblivion.
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