Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy

Abstract

CAN J ANESTH 54: 1 www.cja-jca.org Januar y, 2007Purpose: We describe a complication of epiduroscopy with encephalopathy and rhabdomyolysis associated with the contrast medium iotrolan. Clinical features:A 76-yr-old man with failed back surgery syndrome underwent epiduroscopy. Sufficient lysis could not be achieved in the epidural space above the level of L 4 due to dense adhesions and scar tissue. After epidural injections of iotrolan and mepivacaine, he developed motor weakness and hypoesthesia in both legs, which lasted for three hours. He also became confused, agitated, disoriented, and developed neck stiffness and tremors involving the head and legs. Computed tomography revealed diffuse contrast enhancement within the intracranial cerebrospinal fluid (CSF) spaces, indicating an intraoperative dural tear. Marked increases in serum creatinine phosphokinase and myoglobin indicated subsequent acute rhabdomyolysis. Crystalloid infusion and semi-recumbent positioning facilitated iotrolan absorption from the CSF, and the patient recovered uneventfully. Conclusions:Dural tear during epiduroscopy may allow access of contrast media into the CSF. Neurotoxicity secondary to iotrolan within the CSF was a likely contributing factor to the encephalopathy and subsequent rhabdomyolysis. This is an instructive example of the importance of diagnosing inadvertent dural tear during epiduroscopy under iotrolan, for avoidance of adverse events such as encephalopathy and rhabdomyolysis. Eléments cliniques : Un homme de 76 ans présentant des séquelles d'un échec d'une chirurgie aux rachis a subi une épidur-oscopie. Une lyse suffisante n'a pas pu être obtenue dans l'espace péridural au-dessus de L 4 à cause d'adhésions denses et de tissus cicatriciels. Suite à des injections péridurales d'iotrolan et de mépivacaïne, il a développé une parésie ainsi qu'une hypoesthésie au niveau des membres inférieurs qui durèrent trois heures. Il est également devenu confus, agité, désorienté, et a développé une raideur du cou et des tremblements de la tête et des jambes. La tomodensitométrie a révélé un rehaussement diffus du produit de contraste dans les espaces intracrâniens du liquide céphalo-rachidien (LCR), indiquant

Results of Lumbar Endoscopic Adhesiolysis Using a Radiofrequency Catheter in Patients with Postoperative Fibrosis and Persistent or Recurrent Symptoms After Discectomy

“…The only postoperative adverse effect in the present series was 1 case of a transient radicular sensory disturbance, with a full recovery within 48 hours, thus confirming spinal endoscopic adhesiolysis as a safe procedure when performed according to strict criteria and using a meticulous technique. This result is in line with a recent systematic review on the topic, where the authors conclude that the procedure is generally well tolerated, with infrequent, minimal, and transient complications, although rare but significant adverse events have been described, including visual impairment, neurogenic bladder, encephalopathy, meningitis, seizures, radiculopathy, and intradural cyst formation …”

Epiduroscopy: Complications and troubleshooting

“…Severe but extremely rare complications associated with dural puncture or tear during epiduroscopy such as encephalopathy and rhabdomyolysis induced by intradural contrast media 12 and intradural lumbosacral cyst 15 have been reported. Teaching in both the cases is that any patient with symptoms suggestive of dural puncture must be accurately maintained under observation.…”

Epiduroscopy (Epidural Endoscopy)

“…Another clinically relevant complication described by Mizuno et al [46] in which encephalopathy and rhabdomyolysis was induced by the administration of the contrast agent iotrolan during epiduroscopy.…”