Article

Cord damage in the awake epidural.

Anesthesia & Analgesia (Impact Factor: 3.3). 07/2005; 100(6):1859. DOI: 10.1213/01.ANE.0000151479.10798.C2
Source: PubMed
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    ABSTRACT: Seven cases are described in which neurological damage followed spinal or combined spinal-epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2-3 interspace. In all cases, there was free flow of cerebrospinal fluid before spinal injection. There was one patchy block but, in the rest, anaesthesia was successful. Unilateral sensory loss at the levels of L4-S1 (and sometimes pain) persisted in all patients; there was foot drop in six and urinary symptoms in three. Magnetic resonance imaging showed a spinal cord of normal length with a syrinx in the conus (n = 6) on the same side as both the persisting clinical deficit and the symptoms that had occurred at insertion of the needle. The tip of the conus usually lies at L1-2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.
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    ABSTRACT: We report a case of permanent paraplegia in an 81-yr-old patient who had thoracic epidural catheterization performed under general anesthesia for abdominal surgery. The epidural needle was introduced at the T9-10 interspace, and 3 passes were made to locate the epidural space with the loss-of-resistance-to-air technique. During the postoperative epidural pump infusion, the patient was unaware of the progressive motor and sensory impairment. Sensory loss below T11 and paraplegia with no movement of either lower extremity were identified 8 h after surgery. Magnetic resonance imaging demonstrated an intramedullary split-like lesion extending from T4 to T12 and an intramedullary air bubble at T9. Spinal cord injury caused by an intracord catheterization with subsequent local anesthetic injection was diagnosed. Little improvement was noted after large-dose IV methylprednisolone for initial treatment and subsequent rehabilitation for 6 mo. The possible causes of the delayed detection of the neurologic deficits and the timing of performing epidural anesthesia are discussed.
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