1
|
Postpartum acute transverse myelitis complicated by epidural analgesia, a case report. Taiwan J Obstet Gynecol 2022; 61:880-882. [PMID: 36088061 DOI: 10.1016/j.tjog.2022.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Postpartum acute transverse myelitis after epidural anesthesia is uncommon, but this complication is devastating. The relationship between anesthetic procedures and acute transverse myelitis is debatable. CASE REPORT A 34-year-old woman experienced a cesarean section with lumbar epidural anesthesia at a local medical department. According to the patient herself, the process of lumbar puncture was uneven. After she woke up from intravenous anesthesia about 3 h later, she immediately found right lower extremity paralysis, dysesthesia and allodynia. A lumbar spine computed tomography and magnetic resonance imaging study the next day demonstrated subcutaneous emphysema from S1 to T10, an air bubble in the spinal canal between T12 and L1and intramedullary non-gadolinium-enhanced hyper intensity lesion within the cord at the level between T12 and L1 then diagnosed with acute transverse myelitis followed by the several examinations. High-dose IV methylprednisolone (solu-Medrol) pulsed therapy 500 mg Q12H for 4 days following with slowly tapering oral prednisolone was administered and symptoms got improved. CONCLUSION Transverse myelitis may emerge unpredictably following the process of lumbar puncture. If neurologic symptoms are raised after epidural analgesia, we should rule out the most well-known causes of infection, hematoma and use proper diagnostic approaches like CT and MRI as early as possible for diagnosis and management of acute myelitis. Early identification and treatment could minimize the neurologic sequelae.
Collapse
|
2
|
Kitazaki Y, Ueno A, Maeda K, Asano R, Satomi H, Nishio T, Nakamoto Y, Hamano T. A case of longitudinally extensive transverse myelitis with an isolated pontine lesion following epidural and spinal anesthesia for cesarean section. eNeurologicalSci 2020; 21:100264. [PMID: 32885056 PMCID: PMC7452523 DOI: 10.1016/j.ensci.2020.100264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/03/2020] [Accepted: 08/12/2020] [Indexed: 11/25/2022] Open
Abstract
Severe neurologic complications following epidural and spinal anesthesia rarely occur. Transverse myelitis has been reported as a rare complication of epidural or spinal anesthesia. We report a case of longitudinally extensive transverse myelitis and an isolated pontine lesion, which responded to immunotherapy. The patient was a 31-year-old pregnant woman who underwent elective cesarean section under epidural and spinal anesthesia. Though the insertions of the epidural and spinal catheters were smooth, she experienced back pain and transient hearing loss during epidural anesthesia. Postoperatively, she exhibited severe motor weakness in both lower extremities, neuralgia below the level of Th10 dermatome, and urinary retention. Magnetic resonance imaging showed longitudinally extensive transverse myelitis from T6 to T10 with a ring-shaped enhanced lesion and an isolated pontine lesion. These findings on magnetic resonance imaging were suggestive of autoimmune diseases such as neuromyelitis optica. The patient was diagnosed with an immunoreactive disease triggered by epidural or spinal anesthesia and was administered high-dose methylprednisolone, which led to the improvement in clinical symptoms. Clinicians should be aware of the possibility of the development of longitudinally extensive transverse myelitis and isolated pontine lesions after cesarean section under epidural and spinal anesthesia.
Collapse
Key Words
- AQP4, anti-aquaporin-4
- Autoimmune diseases
- CSF, cerebrospinal fluid
- DWI, Diffusion-weighted imaging
- Epidural anesthesia
- Immunotherapy
- LETM, Longitudinally extensive transverse myelitis
- Longitudinally extensive transverse myelitis
- MMT, manual muscle tests
- MRI, Magnetic resonance imaging
- MS, Multiple sclerosis
- NBD, Neuro-Behcet's disease
- NMO, neuromyelitis optica
- PCEA, Patient-controlled epidural analgesia
- POD, Postoperative day
- PSL, prednisolone
- Pontine lesion
- STIR, Short TI-inversion recovery
- Spinal anesthesia
- TM, Transverse myelitis
Collapse
Affiliation(s)
- Yuki Kitazaki
- Department of Neurology, Fukui-ken Saiseikai Hospital, Fukui, Japan.,Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Asako Ueno
- Department of Neurology, Fukui-ken Saiseikai Hospital, Fukui, Japan.,Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kenichiro Maeda
- Department of Neurology, Fukui-ken Saiseikai Hospital, Fukui, Japan.,Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Rei Asano
- Department of Neurology, Fukui-ken Saiseikai Hospital, Fukui, Japan.,Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroyuki Satomi
- Department of Obstetrics and Gynecology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Taro Nishio
- Department of Anesthesiology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Fukui, Japan.,Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| |
Collapse
|
3
|
El-Tahan MR. Role of Thoracic Epidural Analgesia for Thoracic Surgery and Its Perioperative Effects. J Cardiothorac Vasc Anesth 2017; 31:1417-1426. [DOI: 10.1053/j.jvca.2016.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Indexed: 11/11/2022]
|
4
|
Shimada T, Yufune S, Tanaka M, Akai R, Satoh Y, Kazama T. Acute transverse myelitis arising after combined general and thoracic epidural anesthesia. JA Clin Rep 2015; 1:4. [PMID: 29497636 PMCID: PMC5818689 DOI: 10.1186/s40981-015-0006-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/14/2015] [Indexed: 12/03/2022] Open
Abstract
Acute transverse myelitis after surgery is a rare condition, but this complication is devastating. The relationship between anesthetic procedures and acute transverse myelitis is controversial. A 46-year-old woman was scheduled a colostomy closure, and general anesthesia with thoracic epidural anesthesia was performed. Epidural catheter was inserted at the T10–11 interspace, and insertion was smooth, and no blood or cerebrospinal fluid leakage was seen. However, 28 h after the surgery, the patient complained motor, sensory, and autonomic dysfunction. Two days after onset, a magnetic resonance imaging study demonstrated intramedullary hyperintensity, particularly in the gray matter, extending from T5–T9 and then diagnosed with acute transverse myelitis followed by the several examinations. High-dose IV methylprednisolone treatment was initiated and neurologic function restored 2 months after onset. Transverse myelitis may unpredictably occur following surgery. We are not able to determine the pathogenic relationship between anesthesia and myelitis with certainty, but proper diagnostic approach to myelitis may improve the prognosis.
Collapse
Affiliation(s)
- Tetsuya Shimada
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Shinya Yufune
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Motoshi Tanaka
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Ryosuke Akai
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Yasushi Satoh
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| | - Tomiei Kazama
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513 Japan
| |
Collapse
|
5
|
Hung MH, Chan KC, Liu YJ, Hsu HH, Chen KC, Cheng YJ, Chen JS. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases. Medicine (Baltimore) 2015; 94:e727. [PMID: 25837768 PMCID: PMC4554018 DOI: 10.1097/md.0000000000000727] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intubated general anesthesia with single-lung ventilation has been considered mandatory for thoracoscopic lobectomy for nonsmall cell lung cancer. Few reports of thoracoscopic lobectomy without tracheal intubation are published, using either thoracic epidural anesthesia (TEA) or intercostal blockade. The comparisons of perioperative outcomes of nonintubated thoracoscopic lobectomy using epidural anesthesia and intercostal blockade are not reported previously. From September 2009 to August 2014, a total of 238 patients with lung cancer who underwent nonintubated thoracoscopic lobectomy were recruited from our prospectively maintained database of all patients undergoing nonintubated thoracoscopic surgery using TEA or intercostal blockade. A multiple regression analysis, adjusting for preoperative variables, was performed to compare the perioperative outcomes of the 2 anesthesia methods. Overall, 130 patients underwent nonintubated thoracoscopic lobectomy using epidural anesthesia whereas 108 had intercostal blockade. The 2 groups were similar in demographic data, except for sex, preoperative lung function, physical status classification, and history of smoking. After adjustment for the preoperative variables, nonintubated thoracoscopic lobectomy using intercostal blockade was associated with shorter durations of anesthetic induction and surgery (P < 0.001). Furthermore, hemodynamics were more stable with less use of vasoactive drugs (odds ratio: 0.53; 95% confidence interval [CI], 0.27 to 1.04; P = 0.064) and less blood loss (mean difference: -55.2 mL; 95% CI, -93 to -17.3; P = 0.004). Postoperatively, the 2 groups had comparable incidences of complications. Patients in the intercostal blockade group had a shorter average duration of chest tube drainage (P = 0.064) but a similar average length of hospital stay (P = 0.569). Conversion to tracheal intubation was required in 13 patients (5.5%), and no in-hospital mortality occurred in either group. Nonintubated thoracoscopic lobectomy using either epidural anesthesia or intercostal blockade is feasible and safe. Intercostal blockade is a simpler alternative to epidural anesthesia for nonintubated thoracoscopic lobectomy in selected patients with lung cancer.
Collapse
Affiliation(s)
- Ming-Hui Hung
- From the Department of Anesthesiology (MHH, KCC, YJL, YJC); Graduate Institute of Clinical Medicine (MHH, KCC); Division of Thoracic Surgery (HHH, KCC, JSC), Department of Surgery; and Department of Traumatology (JSC), National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | | | | | | | | | | | | |
Collapse
|
6
|
Hung MH, Cheng YJ, Chan KC, Han SC, Chen KC, Hsu HH, Chen JS. Nonintubated uniportal thoracoscopic surgery for peripheral lung nodules. Ann Thorac Surg 2014; 98:1998-2003. [PMID: 25443006 DOI: 10.1016/j.athoracsur.2014.07.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/16/2014] [Accepted: 07/21/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Uniportal video-assisted thoracoscopic surgery (VATS) has recently been introduced for various thoracic diseases. However, management of peripheral lung nodules by uniportal VATS without tracheal intubation has rarely been attempted. We evaluated the feasibility and safety of nonintubated uniportal VATS for peripheral lung nodules. METHODS From January to March 2014, 32 patients with indeterminate peripheral lung nodules underwent uniportal VATS without tracheal intubation using a combination of intercostal nerve block, intrathoracic vagal block, and target-controlled sedation. Computed tomography-guided dye localization was sometimes used to identify small or ground-glass opacity lesions. RESULTS A definite diagnosis was obtained in all 32 patients. A wedge resection was performed in 31 patients and a lobectomy in 1. Conversion to nonintubated multiport VATS was required in 4 patients (13%), in 3 because of primary lung cancer requiring further resection for adequacy of margins and in 1 because of difficulty in identifying a small nodule. Conversion to intubated 1-lung ventilation was required in 1 patient (3%) because of vigorous mediastinal movement. Operative complications developed in 2 patients who had air leaks for more than 3 days postoperatively. The median durations of postoperative chest tube drainage and hospital stay were 1 and 3 days, respectively. Postoperative neuralgia that required occasional use of analgesics occurred in only 1 patient (3%), and 97% of patients were very satisfied or satisfied with the resulting scars at 1 month. CONCLUSIONS Nonintubated uniportal VATS is technically feasible and safe for selected patients and is a less invasive alternative in managing indeterminate peripheral lung nodules.
Collapse
Affiliation(s)
- Ming-Hui Hung
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Su-Chuan Han
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ke-Cheng Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Traumatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
7
|
Hung MH, Hsu HH, Cheng YJ, Chen JS. Nonintubated thoracoscopic surgery: state of the art and future directions. J Thorac Dis 2014; 6:2-9. [PMID: 24455169 DOI: 10.3978/j.issn.2072-1439.2014.01.16] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 01/13/2014] [Indexed: 12/19/2022]
Abstract
Video-assisted thoracoscopic surgery (VATS) has become a common and globally accepted surgical approach for a variety of thoracic diseases. Conventionally, it is performed under tracheal intubation with double lumen tube or bronchial blocker to achieve single lung ventilation. Recently, VATS without tracheal intubation were reported to be feasible and safe in a series of VATS procedures, including management of pneumothorax, wedge resection of pulmonary tumors, excision of mediastinal tumors, lung volume reduction surgery, segmentectomy, and lobectomy. Patients undergoing nonintubated VATS are anesthetized using regional anesthesia in a spontaneously single lung breathing status after iatrogenic open pneumothorax. Conscious sedation is usually necessary for longer and intensively manipulating procedures and intraoperative cough reflex can be effectively inhibited with intrathoracic vagal blockade on the surgical side. The early outcomes of nonintubated VATS include a faster postoperative recovery and less complication rate comparing with its counterpart of intubated general anesthesia, by which may translate into a fast track VATS program. The future directions of nonintubated VATS should focus on its long-term outcomes, especially on oncological perspectives of survival in lung cancer patients. For now, it is still early to conclude the benefits of this technique, however, an educating and training program may be needed to enable both thoracic surgeons and anesthesiologists providing an alternative surgical option in their caring patients.
Collapse
Affiliation(s)
- Ming-Hui Hung
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan ; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan ; Division of Experimental Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|