Focal myelomalacia and syrinx formation after accidental intramedullary lidocaine injection during lumbar anesthesia: A report of 3 cases

Syringomyelia after spinal anaesthesia: A case report

Lumbar spinal or epidural anaesthesia has a lower complication rate compared to general anaesthesia. An occasional patient may develop spinal cord injury during the procedure and develop neurological complications. We report an interesting case of paraparesis due to dorsal spinal cord involvement and syrinx formation following spinal anaesthesia for abdominal surgery.

Are high lumbar punctures safe? A magnetic resonance imaging morphometric study of the conus medullaris

A high lumbar puncture (LP) at L2-L3 or above is often necessary to consider on technical grounds, but complications of conus medullaris (CM) damage during high LP are potentially concerning. We hypothesized that a high LP might be safer than previously thought by accounting for movements of the CM upon patient positional changes. We retrospectively reviewed standard normal supine lumbar spine magnetic resonance imaging of 58 patients and used electronic calipers on axial images at the T12-L1, L1-L2, and L2-L3 disc levels to measure the transverse diameter of the CM relative to the size of the dorsal thecal sac space (DTSS) through which a spinal needle could be inserted. On 142 axial images, the means for CM diameters were 8.2, 6.0, and 2.9 mm at the three levels, respectively. We then used known literature mean CM displacement values in the legs flexed and unflexed lateral decubitus position (LDP) to factor in CM shifts to the dependent side. We found that at all three levels, the likely positional shift of the CM would be too small and insufficient to displace the entire CM out of the DTSS. However, if needle placement could be confined to the midsagittal plane, an LP in the unflexed LDP would theoretically be entirely safe at both L1-L2 and L2-L3, and almost so at L2-L3 in the legs flexed LDP. Thus, high LPs at L1-L2 and L2-L3 are in theory likely safer than considered previously, more so in the legs unflexed than in the flexed LDP. Clin. Anat. 32:618-629, 2019. © 2019 Wiley Periodicals, Inc.

Success with neurotropin in treating pediatric lower extremity pain induced by spinal cord injury after epidural anesthesia

Spinal cord injury (SCI) complicated by epidural anesthesia, though rare, can result in neuropathic pain. However, the treatment for this kind of life-altering injury remains a challenge. A 7-year-old girl was referred with dyskinesia and severe pain in her right lower extremity due to an accidental SCI following lumbar puncture. After treatment with analgesics such as gabapentin, mecobalamin, and dexamethasone/methylprednisolone for 1 week, the myodynamia had improved, but progressive pain persisted. After treatment with neurotropin, a gradual decrease in visual analog scale score from 7 to 0 was observed. We herein first describe that neurotropin produced sustained relief of pain induced by SCI. This case suggests that neurotropin might be a promising drug in treating pediatric neuropathic pain caused by SCI.

Radiological Evaluation of the Line Between the Crista Iliaca (Tuffier's line) in Elderly Patients

OBJECTIVE

Tuffier's line is defined as the line connecting the highest points of both iliac crests, which generally passes through either the body of the fourth lumbar vertebra or the intervertebral space between fourth and fifth vertebrae. In this study, we assessed the radiological correlation of the level of Tuffier's line with changes in age and sex.

METHODS

In this study, antero-posterior pelvic X-rays of 590 patients aged 18 and older were retrospectively analyzed. It is revealed that Tuffier's line crosses the vertebral column at one of three levels, which are the L4 vertebral body, L4-L5 vertebral interspace and L5 vertebral body. Patients' sex, age and vertebral level of the Tuffier's line were recorded. Data was analyzed using the chi-square test.

RESULTS

The assessment of the X-rays of 317 female patients showed that Tuffier's Line passes through the L4 vertebral body in 115 (37.8%), through the L4-L5 intervertebral space in 126 (40%) and through the L5 vertebral body in 76 (22.2%) patients. A Tuffier's line passing through the level of the L5 vertebral body was found to be statistically significant in female patients (p=0.00). No significant relevance was found between male gender and the level of Tuffier's line in 273 male patients. It is found that the height of the vertebral levels that Tuffier's line crosses does not correlate with mean age of the groups (p=0.939).

CONCLUSION

It should be considered that Tuffier's line can cross at vertebral levels other than anticipated. The level of Tuffier's line should be precisely determined with supplementary radiological methods, such as AP pelvic X-ray in addition to physical examination, to reduce the complications in association with regional anaeshesia and to achieve sensorial block levels sufficient to sustain a comfortable surgery, particularly in female patients who carry higher cardiac and respiratory risks.

Spinal arteriovenous fistula with progressive paraplegia after spinal anaesthesia

A case of an iatrogenic spinal arteriovenous fistula with progressive paraplegia in a young woman is reported. The fistula was eventually created after repetitive lumbar punctures performed in the process of spinal anaesthesia. Her symptoms were progressed to paraplegia over a period of 2 years. The digital subtraction angiography demonstrated a single-hole fistula, involving the anterior spinal artery and vein. The lesion was occluded by embolization with immediate improvement. The potential mechanism is discussed.

Evaluating the reliability of anatomic landmarks in safe lumbar puncture using magnetic resonance imaging: does sex matter?

Aim. To determine the level of the conus medullaris-Tuffier's line, and conus medullaris-Tuffier's line distance using imaging and evaluate their relation to age and gender. Methods. We performed a cross-sectional study of 189 adult participants, who underwent MR imaging of lumbosacral spine. Each vertebra was divided into 3 equal segments (upper, middle, and lower), and intervertebral disc space was also assumed as one segment. All segments from T12 upper segment to L5S1 intervertebral disc were numbered consecutively. The position of conus medullaris and Tuffier's line was determined by the vertebral segment or intervertebral disc space at the same level. The patients were stratified into high/low conus medullaris position (cutpoint: L1 middle segment) and short/long conus-Tuffier's distance (cutpoint: 14 segments). Results. Women with low conus were significantly more than men, in patients older than 50 years old (72.7% in females versus 55.3% in males; P < .05), whereas there was not such a sexual dimorphism in patients younger than 50 years old. Similarly, short conus-Tuffier's distance was more frequent among women than men in patients older than 50 years old (59.7% in females versus 39.5% in males; P < .05), whereas there was not any gender difference in patients younger than 50 years old. Conus-Tuffier's distance was negatively correlated with age (r = −0.32, P < .001) in all studied population. Conclusion. Anatomical landmarks vary according to age and gender, with a lower end of conus medullaris in women, so clinicians should use more caution on the identification of the appropriate site for lumbar puncture, particularly in elderly women.

Cervical epidural injection complicated by syrinx formation: a case report

STUDY DESIGN

Case report and review of literature.

OBJECTIVE

Review the common side-effects of interlaminar cervical epidural injection (CEI) and to report a novel complication of this procedure. SUMMARY OF BACKGROUND AND DATA: CEIs are commonly used to treat chronic radicular neck pain. Several minor and major complications have been reported in literature. We report a rare complication of syrinx formation resulting from a CEI.

METHODS

A 52-year-old woman presented from an outside hospital after undergoing a CEI. Under fluoroscopic guidance, an epidural needle was inserted at C7-T1 level. Radiologic contrast showed appropriate epidural spread. Shortly after waking up from the procedure, the patient complained of inability to move her right arm and leg, numbness of her right hemibody below the neck, and urinary retention.

RESULTS

Magnetic resonance imaging of the spine revealed a syrinx extending from the C1 to T4 levels. There was no evidence of epidural collection or blood.

CONCLUSION

Interlaminar CEI is thought to be a relatively safe procedure. Spinal cord injury is a documented complication of spinal anesthesia at any level of the spinal cord, even with fluoroscopic guidance, but most complications are thought to be minor and transient in nature. Syrinx formation with focal myelomalacia following spinal anesthesia has been reported in the lumbar area Pradhan et al, J Neurol Sci 2006;251:70-2, but we know of no existing reports involving the cervical region. We report this rare complication in this case report.