Abducens Nerve Palsy after Lumbar Spinal Fusion Surgery with Inadvertent Dural Tearing

Abstract

Abducens nerve palsy associated with spinal surgery is extremely rare. We report an extremely rare case of abducens nerve palsy after lumbar spinal fusion surgery with inadvertent dural tearing, which resolved spontaneously and completely. A 61-year-old previous healthy man presented with chronic lower back pain of 6 weeks duration and 2 weeks history of bilateral leg pain. He was diagnosed as having isthmic spondylolisthesis at L4-5 and L5-S1, and posterior lumbar interbody fusion was conducted on L4-5 and L5-S1. During the operation, inadvertent dural tearing occurred, which was repaired with a watertight dural closure. The patient recovered uneventfully from general anesthesia and his visual analogue pain scores decreased from 9 pre-op to 3 immediately after his operation. However, on day 2 he developed headache and nausea, which were severe when he was upright, but alleviated when supine. This led us to consider the possibility of cerebrospinal fluid leakage, and thus, he was restricted to bed. After an interval of bed rest, the severe headache disappeared, but four days after surgery he experienced diplopia during right gaze, which was caused by right-side palsy of the abducens nerve. Under conservative treatment, the diplopia gradually disappeared and was completely resolved at 5 weeks post-op.

Abducens nerve palsy as a postoperative complication of minimally invasive thoracic spine surgery: a case report

“…Orthopaedic scienceNakagawa et al [10]Spinal tumor ResectionFemale22CervicalNoNot identified3 days PostopConservative1 year2009J. Korean Neur SocietyCho et al [14]Posterior FusionMale61Lumbo-SacralNoNot identified2 days PostopConservative5 weeks2012SpineThomas et al [11]DiscectomyMale53LumbarYesIdentified7 days PostopDural Repair2 weeks2012Eur Spine JournalJoo et al [15]DiscectomyMale48Lumbo-SacralNoIdentified3 days PostopDural Repair1 week2013Eur Spine JournalKhurana et al [9]DiscectomyMale48ThoracicNoIdentified>3 weeks PostopDural Repair + Chest drain3 monthsDiscectomyMale46ThoracicNoIdentified"Few days" PostopConservative5 months…”

Isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy: a rare clinical entity

“…However, outcomes have been poorly studied and no management strategies have been established due to the rarity of cases. Abducens nerve palsy caused by CSF leakage following spinal surgery is such a rare complication that there have been only three cases [2,3,6] reported, two of which were treated by conservative measure for CSF leakage and another by surgical repair (Table 1). They all occurred within 1 week after spine surgery but complete recovery was not successful within 5 weeks after conservative management, whereas it took less than 2 weeks for complete recovery after surgical repair.…”

“…However, considering the long-term period needed for resolution of diplopia, which is generally longer then 4 weeks [2,3], the authors propose that active treatment for dural repair could be a good option of treatment in the light of inducing early recovery. This can be more advantageous because there may be very obvious leakage points that do not require much effort to find due to the existence of a recent surgical site as in this case.…”

“…However, abducens nerve palsy following spinal surgery has been extremely rare in that there have been only three cases [2,3] reported as far we know, two of which were treated by conservative management and another by surgical repair. The authors describe this rare complication of spinal surgery focusing on the advantage of early surgical management.…”

Intravenous mannitol for treatment of abducens nerve paralysis after spinal anesthesia

“…Abducens paralysis (AP) is a well-known but rare complication following spinal anesthesia, recovery from which may take up to 21 months, 3-6 with little evidence suggesting any alternative to 'watchful waiting'. Although the etiology is unknown, literature review shows that symptoms begin almost immediately after the postdural puncture headache (PDPH) develops but these do not respond to standard PDPH treatments, [1][2][3][4][5][6][7][8] suggesting that the pathophysiological mechanisms are different. Cerebrospinal fluid leak contributes to headache after dural puncture.…”