The patient was a 66-year-old male with a history of renal cell carcinoma with metastasis to the L2, L3, and L4 vertebral bodies scheduled for a radical nephrectomy and adrenalectomy. Prior to surgery the patient had undergone 10 radiation treatments for the vertebral metastasis. Patient medications included colace, prednisone, ibuprofen (taken 4 days prior to procedure), sunitinib, hydrocodone, benazepril, nexium, rosuvastatin, allopurinol, and azor. Physical exam prior to surgery was normal with no focal findings. Laboratory values were within normal limits with a platelet count of 286. General anesthesia was planned with a pre-operative thoracic epidural for postoperative analgesia. The epidural was placed at the T9-T10 level without complication. Adequate pain control was present post operatively and the epidural was discontinued on post-operative day 3. At that time the patient was noted to have numbness over the bilateral lower extremities and decreased strength. Heparin 5000 units subcutaneous had been given 12 hours prior to discontinuation of the epidural. The patient was afebrile, hemoglobin was 7, white blood cell count was 9.7, and platelets were 166 at time of epidural removal. Subcutaneous heparin was restarted 6 hours after catheter removal. The anesthesia acute pain service was contacted by the primary service 25 hours after discontinuation of the epidural catheter regarding complaints of persistent bilateral lower extremity weakness and sensory loss. An magnetic resonance image (MRI) revealed a focus posterior to the spinal cord at the T10/T11 interspace likely representing a hematoma. A high intensity T2 signal within the central spinal cord at T10/T11 was also observed; likely a vascular infarct. The patient was immediately scheduled for a T9-T10 laminectomy and evacuation of the epidural hematoma. No significant abnormalities were noted in coagulation studies prior to surgery. The patient was discharged on post-operative day 20 with no neurologic deficits. An epidural hematoma is rare with an estimated occurrence of <1 in 150,000 [1]. Issues related to anticoagulation therapy are involved in 25%-30% of cases. The utilization of three times daily dosed (TID) heparin could have played a role in the development of this complication in the present case. Other contributing factors may have been chemotherapy and radiation therapy. These treatments B. A. Abdelfattah et al. 164 are quite damaging to bone marrow and may cause severe marrow suppression thereby suppressing the function and number of platelets. Cancer cells are also capable of producing local cell signals which can initiate new blood vessel growth and proliferation [2]. This can also lead to blood vessels that are defective and leaky at the level of the endothelium. Increasing the number of fragile blood vessels may easily predispose this patient to laceration and shearing of blood vessels during epidural placement.

The double crush syndrome is described as an increased risk of distal nerve injury after a more proximal injury. This was a case series of two patients who developed Complex Regional Pain Syndrome under circumstances when a double crush phenomenon could have occurred. Both initially had spinal stenosis and subsequent spinal surgery. Both later had crush injuries to a unilateral lower extremity, which progressed to CRPS. There is no documented correlation between double crush syndrome and CRPS; however, these cases raise awareness about a heightened propensity for CRPS in such patients, which will lead to earlier, accurate diagnosis and treatment.

No abstract

Lumbar synovial cysts are benign fluid collections thought to form in a background of facet joint degeneration, allowing for fluid to leak from the joint capsule and form cysts in the synovium. Although often asymptomatic, patients with symptomatic synovial cysts will present with low back pain and possibly an associated radiculopathy. Clinicians can consider conservative management, epidural steroid injection, surgical intervention, or facet joint block with aspiration and rupture. This case describes a 59-year-old male facilities manager with intermittent low back pain for one year with worsening right-sided radicular symptoms secondary to a lumbar facet joint synovial cyst in the context of severe facet arthropathy and microinstability. The patient's low back pain and radicular symptoms were refractory to conservative treatment. Imaging demonstrated a lumbar synovial cyst and subsequent management included transforaminal epidural steroid injection and facet joint block with cyst aspiration and rupture. The patient's radicular pain resolved but axial lumbar pain returned after 3 weeks of relief. Follow-up imaging demonstrated decreased cyst size with fluid accumulation and joint space widening. Although the cyst was successfully decompressed with resolution of radicular pain, the underlying facet arthropathy remains contributing to persistent axial low back pain and potential for continued degenerative changes including cyst recurrence.

Objective: To understand an unusual complication of a low risk procedure. Design: This article chronicles the side effect of a Ganglion Impar Block. Setting: Loyola University Medical Center Outpatient Chronic Pain Clinic. Patients: One. Results: Our patient had tachycardia after a Ganglion Impar Block. Conclusions: An unusual complication of a ganglion impar block can be increased heart rate.