Horner's Syndrome and Trigeminal Nerve Palsy following Epidural Analgesia for Labor

Abstract

Epidural analgesia is a widely used method of pain control in the labor and delivery setting but is not without risks. We present a case of Horner's syndrome and trigeminal nerve palsy as a rare complication of epidural analgesia in an obstetric patient. Although reported in few instances in the anesthesia literature, awareness among providers in obstetrics is critical because this could be the first sign of a high sympathetic blockade resulting in potential maternal-fetal morbidity. Case ReportA healthy 25-year-old woman, gravida 2 para 1, was admitted to the hospital for active labor at 39 weeks gestation. Her past medical history was remarkable only for occasional migraine headaches, and her prenatal course, including labs, had been unremarkable. During an uneventful first stage of labor, epidural anesthesia was requested. A lumbar epidural catheter was placed at the interspace between the third and fourth lumbar vertebrae using a midline approach and a loss of resistance to saline through a 17-gauge Touhy needle. A test dose of 3 mL of 1.5% lidocaine with 5 g of epinephrine per milliliter was administered without appreciable evidence of either intravascular or intrathecal placement of the catheter. A bolus of 10 mL of 0.2% bupivacaine with 2 g of fentanyl per milliliter was administered over 10 minutes, and then an infusion of the same solution was started at 8 mL per hour. Approximately 20 minutes after epidural catheter placement, the patient complained that the left side of her face "felt funny." On evaluation by her family physician, the patient reported decreased sensation to light touch on the left cheek in the distribution of the maxillary branch of the trigeminal nerve and was observed to have miosis and ptosis on the left side. Pinprick demonstrated the level of analgesia at the fourth thoracic segment on the left and at the fifth thoracic segment on the right. The patient's grip strength was found to be normal, and she denied dyspnea. There were no other cranial nerve abnormalities or neurologic deficits appreciated.Simultaneously, the patient's blood pressure dropped from 115/68 mm Hg to a range of 90s/30s mm Hg for several minutes. After receiving 10 mg of ephedrine IV, her blood pressure returned to 110s/50s mm Hg, but her neurologic symptoms persisted. During this period, fetal monitoring was uneventful without decelerations or bradycardia. Due to concerns for these neurologic findings, the epidural infusion was stopped, and labor allowed to progress. About 30 minutes after stopping the infusion, the patient's symptoms of facial numbness, ptosis, and miosis resolved.Within the hour, the patient desired further pain control with epidural anesthesia. Therefore, she was repositioned, and an infusion of the same solution was started at 6 mL per hour without a bolus. This was followed by an uneventful progression of labor and vaginal delivery of a healthy male infant. No further signs or symptoms of Horner's syndrome or trigeminal nerve palsy were evident during the rest of this patient's labor, de...

Horner's syndrome with epidural anaesthesia

“…Facial flushing due to dilation of vessels on the affected side can also occur. It is caused by the disruption of ipsilateral sympathetic fibres supplying the head, including innervation to the levator palpabrae, conjunctiva, pupil and face,3 and can occur along any part of this innervation. Horner's syndrome, mainly unilateral, is most commonly acquired due to underlying pathology; however, it can also be congenital or iatrogenic.…”

“…Due to raised intra-abdominal pressures and epidural venous engorgement, the space surrounding the dura itself has less room and is also thought to be less compliant 3. Blood is diverted from the inferior vena cava through the epidural venous plexuses due to compression of the gravid uterus; hence, further reducing this epidural space 9.…”

Unilateral Horner Syndrome Following Epidural Anaesthesia in a Morbidly Obese Parturient

“…Baş-boyun cerrahisi, travmalar ve internal juguler ven ponksiyonu diğer nedenler arasındadır (3). Epidural anestezi sonrası Horner sendromunun gerçek insidans ve prevalansı ile ilgili net bir bilgi olmamakla beraber, obstetrik nedenlerle yapılan girişimler sonucu daha sık karşılaşılmak-tadır (4,5). Bizim olgumuzda da bu durumu destekler şe-kilde lomber epidural anestezi sonrası ortaya çıkan Horner sendromu görülmüştür.…”

Hypoglossal nerve palsy, trigeminal nerve palsy and Horner’s syndrome in association with epidural block

“…1,2 The only case series reporting inadvertent dural puncture during EBP found one inadvertent dural puncture out of 95 EBPs. 3 We present a case of a woman who suffered an accidental dural puncture during attempted EBP and a novel approach in management.…”

“…Although Horner's syndrome and other cranial nerve palsies have been reported following epidural analgesia and have received wide coverage in the anaesthetic literature, hypoglossal nerve palsy, we believe, has not previously been reported. [1][2][3][4][5][6][7] A 34-year-old (G2 P1) woman with a body mass index of 25 kg/m 2 presented to the delivery suite at 38 weeks of gestation following spontaneous rupture of membranes. During pregnancy she had been fit and well and her past medical history was unremarkable.…”