Acute cauda equina syndrome following orthopedic procedures as a result of epidural anesthesia

Abstract

Background:Cauda equina syndrome (CES) is a rare complication of spinal or epidural anesthesia. It is attributed to direct mechanical injury to the spinal roots of the cauda equina that may result in saddle anesthesia and paraplegia with bowel and bladder dysfunction.Case Description:The first patient underwent a hip replacement and received 5 mL of 1% lidocaine epidural anesthesia. Postoperatively, when the patient developed an acute CES, the lumbar magnetic resonance imaging (MRI) scan demonstrated clumping/posterior displacement of nerve roots of the cauda equina consistent with adhesive arachnoiditis attributed to the patient's previous L4-L5 lumbar decompression/fusion. The second patient underwent spinal anesthesia (injection of 10 mg of isobaric bupivacaine for an epidural block) for a total knee replacement. When the patient developed an acute CES following surgery, the lumbar MRI scan showed an abnormal T2 signal in the conus and lower thoracic spinal cord over 4.3 cm.Conclusions:Acute CES should be considered in patients undergoing spinal or epidural anesthesia for joint replacement surgery. Prompt evaluation with MRI studies may lead to appropriate medical/surgical measures to reverse the deficit.

Spinal arachnoid sleeves and their possible causative role in cauda equina syndrome and transient radicular irritation syndrome

“…In summary, CES (Carron, Behr, & Ori, 2013; Chabbouh et al, 2005; Merino‐Urrutia et al, 2018; Moussa et al, 2006; Ozgen, Baykan, Dogan, Konya, & Pamir, 2004; Shields, Iyer, Zhang, & Shields, 2018; Takasu et al, 2010; Vianna et al, 2001) and transient radicular irritation syndrome (TNS) (Al‐Nasser, Negre, & Hubert, 2002; Evron et al, 2007; Salazar, Bogdanovich, Adalia, Chabás, & Gomar, 2001; Ya‐Deau, Liguori, & Zayas, 2005; Zaric, Christiansen, Pace, & Punjasawadwong, 2005) are rare but still prevalent complications of spinal subarachnoid block, and their exact cause remains unclear. All previously proposed hypotheses have been losing support, and the effects have been described as occurring with most LA agents: lidocaine (Gerancher, 1997; Loo & Irestedt, 1999; Newman et al, 1997; Salmela, Aromaa, & Cozanitis, 1996; Schneider et al, 1993; Tarkkila et al, 1995), tetracaine (Sumi et al, 1996; Vianna et al, 2001), isobaric bupivacaine (Moussa et al, 2006; Tarkkila et al, 1996), hyperbaric bupivacaine (Chabbouh et al, 2005; Keld, Hein, Dalgaard, Krogh, & Rodt, 2000), levobupivacaine (Carron et al, 2013), mepivacaine (Liguori et al, 1998; Salazar et al, 2001; Ya‐Deau et al, 2005), ropivacaine (Al‐Nasser et al, 2002; Ganapathy, Sandhu, Stockall, & Hurley, 2000), and prilocaine (Martínez‐Bourio et al, 1998).…”

Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review

“…Spinal surgery [ 6 , 11 , 22 , [36] , [37] , [38] , [39] , [40] ] and subarachnoid hemorrhages [ 3 ] continue to play a key role in the development of CSAA. In these cases, CSAA often does not occur until years after the event, whereas after epidural blood patches [ 10 , 13 ] or injection of chemical substances [ 11 , 15 , 16 , 35 , 41 ], CSAA manifests earlier. In recent years, spinal epidural and spinal block anesthesias [ 42 ], radicular infiltrations [ 14 ] and intrathecal injections with steroids [ 43 ] have become increasingly causal for CSAA development.…”

“…From 2015 to 2020, seven cases were reported in which patients were treated with corticosteroids. In six patients, treatment was ineffective [ 11 , [13] , [14] , [15] , [16] ]. Clark et al [ 48 ] described one patient who was treated with corticosteroids because he was initially misdiagnosed with neurosarcoidosis.…”

“…CSAA is mainly treated symptomatically with analgesics or physical therapy. To date, corticosteroids have not been extensively investigated, with only a few single case reports describing the effect of corticosteroids [ 11 , [13] , [14] , [15] , [16] ].…”

Transient bladder incontinence following ultrasound guided caudal epidural block

“…2 Cauda equina syndrome is a rare complication following epidural anesthesia due to injury of sacral nerve roots. 5 We report a case of overflow incontinence with perineal sensory loss developed postoperatively who underwent ultrasound guided caudal epidural block for lateral sphincterotomy.…”