Horner's Syndrome Secondary to Epidural Anaesthesia Following Posterior Instrumented Scoliosis Correction

Abstract

An 11-year-old girl underwent T4 to L1 posterior instrumented scoliosis correction for adolescent idiopathic scoliosis. Postoperative clinical examination revealed left-sided Horner's syndrome which was preceded by left-sided C8 paraesthesia. The Horner's syndrome resolved after 14 hours following weaning and removal of the epidural catheter. Horner's syndrome following posterior instrumented scoliosis correction associated to epidural use is extremely rare. Surgeons must be aware of the risks of epidural placement and the need for close monitoring of associated complications. Alternative aetiology producing a Horner's syndrome must always be considered because of its devastating long term sequela if missed.

Horner's Syndrome Secondary to Epidural Anesthesia After Scoliosis Correction: A Case Report

“…Hered et al described a case in which the pediatric patient developed persistent Horner’s syndrome that eventually required surgical repair of the ptosis six months after presentation [ 12 ]. We also note a case report by Cowie et al who described complete symptomatic resolution within 14 hours of onset in a pediatric patient after scoliosis correction with the use of epidural analgesia [ 11 ]. As was observed in our reported case, the patient developed symptoms of Horner’s syndrome approximately 41 hours postoperatively with miosis in the right pupil without any other additional signs of paresthesia and hemodynamic or respiratory compromise.…”

“…To our knowledge, there have only been two prior reported cases of Horner’s syndrome occurring after posterior spinal fusion with the use of epidural analgesia [ 11 - 12 ]. Horner’s syndrome related to epidural analgesia usually follows a relatively benign course with complete resolution of symptoms within a few hours.…”

Reversible Horner’s syndrome after cervical spinal cord stimulator implantation in a patient with complex regional pain syndrome

“…Horner’s syndrome can result from the lesion affecting the oculosympathetic pathway 8. The anesthetic or analgesic procedures affecting the oculosympathetic pathway, namely the stellate ganglion blocks, interscalene block, brachial plexus, or thoracic epidural analgesia, could cause transient Horner’s syndrome 7…”

“…Horner’s syndrome is typically diagnosed with a triad of ipsilateral signs – ptosis, meiosis, and anhidrosis. However, anhidrosis could be absent or partial if the postganglionic fibers of the oculosympathetic pathway are disrupted 8…”

“…The second-order neuron (preganglionic fiber) ascends the cervical sympathetic chain to synapse in the superior cervical ganglion. The third-order neuron (postganglionic fiber) emerges from the superior cervical ganglion and travels into the orbit with the trigeminal nerve 8…”