Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review

Abstract

SummaryA 27-year-old woman developed severe adhesive arachnoiditis after an obstetric spinal anaesthetic with bupivacaine and fentanyl, complicated by back pain and headache. No other precipitating cause could be identified. She presented one week postpartum with communicating hydrocephalus and syringomyelia and underwent ventriculoperitoneal shunting and foramen magnum decompression. Two months later, she developed rapid, progressive paraplegia and sphincter dysfunction. Attempted treatments included exploratory laminectomy, external drainage of the syrinx and intravenous steroids, but these were unsuccessful and the patient remains significantly disabled 21 months later. We discuss the pathophysiology of adhesive arachnoiditis following central neuraxial anaesthesia and possible causative factors, including contamination of the injectate, intrathecal blood and local anaesthetic neurotoxicity, with reference to other published cases. In the absence of more conclusive data, practitioners of central neuraxial anaesthesia can only continue to ensure meticulous, aseptic, atraumatic technique and avoid all potential sources of contamination. It seems appropriate to discuss with patients the possibility of delayed, permanent neurological deficit while taking informed consent. Case reportA 27-year-old woman with no significant medical history and in her first pregnancy underwent spinal anaesthesia for caesarean section for fetal compromise at another hospital at 42 weeks' gestation, after going into spontaneous labour. With the patient sitting, the skin over the L4-5 interspace was cleaned once by a consultant anaesthetist using a SOLU-I.V.Ò MAXI swabstick (Solumed, Laval, Canada) impregnated with 2% chlorhexidine gluconate and 70% isopropyl alcohol. There was no delay between opening the swabstick packaging and its use on the patient's skin. It is not clear whether the swabstick and its packaging were disposed of immediately. The prepared area was allowed to air-dry for 3 min before a 24-G needle (Becton, Dickinson & Company, Franklin Lakes, NJ, USA) was placed at L4-5 on the first attempt by a consultant anaesthetist wearing a sterile surgical gown and gloves, mask and hat, using an aseptic technique. After aspiration of free-flowing, clear cerebrospinal fluid (CSF), 2.5 ml bupivacaine 0.5% with 12.5 lg fentanyl was administered over approximately 15 s. A few seconds after the end of the injection, the patient complained of severe, burning pain in the lower back radiating into the legs bilaterally, worse on the right than the left. The pain began to recede as the block took effect and this was formally assessed 10 min after the

The sting in the tail: antiseptics and the neuraxis revisited

“…Killeen et al. describe what appears to have been a straightforward spinal injection of bupivacaine and fentanyl for elective caesarean section, following which the patient immediately complained of leg pain and headache [4]. Once again, hydrocephalus developed over the following 11 days, necessitating shunt surgery, followed by foramen magnum decompression and C1 laminectomy when the problem recurred.…”

Case Report of Two Level Thoracic Disc Herniation with Syringomyelia

“…Anestezi sırasında kullanılan kateter kontaminasyonu, intratekal kan geçişi ve lokal anestezik nörotoksisitesi gibi çeşitli faktörle-rin yol açtığı adezif araknoidit sonucu nadir olarak parapleji/parezi gelişebilen vakalar da mevcuttur. 8 Yakınmalarının spinal anestezi sonrası başladığını belirten hastamızda siringomiyeli gelişimi, geçir-diği spinal girişime bağlanabilir.…”

“…Bu iki klinik durumunun birlikteliği tesadüfi mi, yoksa sebep-sonuç ilişkisine mi dayalı konusu açık değildir. [7][8][9][10] Sonuç olarak, siringomiyeli ve torakal disk hernileri asemptomatik hastalarda görülebilmekte veya atipik yakınmalar ile ortaya çıkabilmektedir. Atipik semptomlar (gastrointestinal, kardiyopulmoner, genitoüriner sistemler ile ilgili) tanının yanlış konmasına ve hastalığın ilerleyerek kötüleş-mesine neden olabilmektedir.…”

Arachnoiditis: are we accusing the wrong agent(s)?

“…Dr Bogod's editorial [1], detailing yet another case of chronic adhesive arachnoiditis following neuraxial anaesthesia [2], makes disturbing reading for those who regularly practise spinal anaesthesia. The unfortunate case of arachnoiditis, described in the editorial, following the accidental epidural administration of chlorhexidine gluconate to a woman in labour, was a catastrophic medical error that serves to emphasise the neurotoxicity of chlorhexidine.…”