Post‐operative paraplegia following spinal cord infarction

Abstract

Thoracic epidural analgesia is a frequently utilised technique. Neurological complications are uncommon, but of grave consequence with significant morbidity. Spinal cord infarction following epidural anaesthesia is rare. We present a case where a hypertensive patient underwent an elective sigmoid colectomy under combined general/epidural anaesthesia for a suspected malignant abdominal mass. An epidural infusion was used for intra-operative and post-operative analgesia. During surgery, the blood pressure was labile and she was hypotensive. Postoperatively, the patient became confused, pyrexial and tachycardic and developed systemic inflammatory response syndrome requiring intensive care management. She developed a flaccid paralysis at L3 level with areflexia, analgesia and impaired sensation. A spinal cord infarct in the region of the conus extending into the thoracic cord was diagnosed. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia and the post-operative period may be misjudged or underestimated when they appear after a delay, if neurological signs are masked by lack of patient cooperation and drowsiness or if the epidural anaesthesia is prolonged by long-acting drugs. New neurological deficits should be evaluated promptly to document the evolving neurological status and further testing or intervention should be arranged if appropriate. The association with epidural anaesthesia as a cause of paraplegia is reviewed. The aetiological factors that may have contributed to this tragic neurological complication are discussed.

Perioperative spinal cord infarction in nonaortic surgery: report of three cases and review of the literature

“…Such typical presentations are, however, rare [1], as seen in our cases and in two other reports [18,19]. In some reports, it is unclear whether SCI develops intraoperatively or postoperatively, especially if persistent postoperative mental status changes preclude an effective neurologic examination [20].…”

“…In Case 1, the aortic disease was asymptomatic at the time of surgery, but led to a complete aortic occlusion two months later. Another published case [20] implicated undiagnosed Wegener's vasculitis.…”

Spinal cord infarction and paraplegia after peripheral vascular surgery with spinal anesthesia

“…Diagnosis of paraplegia was delayed because of altered mental status. 18 Decreased BP during the onset of spinal anesthesia in the present patient was treated intraoperatively with ephedrine, phenylephrine, and IV fluids so as to maintain SBP Ͼ110 mm Hg. Hypercoagulability was prevented with heparin and aspirin therapy.…”

“…They postulated that the reason for infarction was prolonged hypotension (SBP 85 mmHg for 25 min) in combination with a hypercoagulable state. Weinberg et al 18 reported a 61-year-old hypertensive female who suffered spinal cord infarction after sigmoid colectomy during combined general-regional anesthesia (thoracic epidural). In their patient, blood loss was 1260 mL, and there were two brief intraoperative hypotensive episodes (78/38 mmHg) of less than 5 minutes each.…”

Clinical Evaluation of Patients with Spinal Cord Infarction in Mashhad, Iran

“…Hypoperfusion was the mechanism of SCI in one of our cases (number 8 in Table 1) who underwent cardiac surgery. SCI is a well-known complication of epidural anesthesia in other case reports [11, 12], and we had one patient (number 1 in Table 1) with this complication. Neurosurgery especially in sitting position had been reported by Morandi as a cause of SCI [13] however none of our SCI developed after neurosurgery.…”