Neurologic symptoms after epidural anaesthesia. Report of three cases

Association between perioperative neuraxial local anesthetic neurotoxicity and arachnoiditis: a narrative review of published reports

BACKGROUND/IMPORTANCE

Arachnoiditis is a rare but devastating disorder caused by various insults, one of which is purported to be local anesthetic neurotoxicity following neuraxial blockade. However, the relationship between local anesthetics administered into the neuraxis and the development of arachnoiditis has not been clearly elucidated.

OBJECTIVE

We aimed to summarize the existing complex body of literature and characterize both the essential features and strength of any association between neuraxial local anesthetic neurotoxicity and arachnoiditis with a view toward mitigating risk, enhancing prevention, and refining informed consent discussions.

EVIDENCE REVIEW

We reviewed all published reports of arachnoiditis attributed to local anesthetic neurotoxicity following perioperative neuraxial anesthesia. This narrative review was based on a systematic search methodology, which included articles published up until December 2022.

FINDINGS

Thirty-eight articles were included, comprising 130 patients, over one-half of which were published prior to this century and inconsistent with modern practice. Neuraxial techniques included 78 epidurals, 48 spinals, and 5 combined spinal-epidurals, mostly for obstetrics. Reporting of essential procedural data was generally incomplete. Overall, at least 57% of patients experienced complicated needle/catheter insertion, including paresthesia, pain, or multiple attempts, irrespective of technique. The onset of neurological symptoms ranged from immediate to 8 years after neuraxial blockade, while the pathophysiology of arachnoiditis, if described, was heterogeneous.

CONCLUSIONS

The existing literature attributing arachnoiditis to local anesthetic neurotoxicity is largely outdated, incomplete, and/or confounded by other potential causes, and thus insufficient to characterize the features and strength of any association.

[Arachnoiditis following spinal anesthesia-Case report and review of the literature]

A 61-year-old woman underwent a tension-free vaginal tape (TVT) operation due to stress incontinence. After technically difficult spinal anesthesia with two attempts the patient developed symptoms of nerve irritation, complained about neckache and headache and showed signs of agitation. The regimen was shifted to general anesthesia and surgery was performed. Because of postoperatively persistent headache and sensory disturbances an MRI scan of the lumbar spine was performed on the first postoperative day without pathological findings. The patient was able to leave the hospital after 1 week with significant relief of symptoms but 3 weeks later she developed neurocognitive impairment with memory deficits. A second MRI scan of the head now showed signs of disturbance of CSF circulation with hydrocephalus. Treatment was performed with drainage and ventriculoperitoneal shunt. Further evaluation showed a severe, multisegmental arachnoiditis and the patient developed a progressive paraparesis. The patient presented her case for assessment to a commission on medical malpractice 13 months after anesthesia. The commission detected no treatment errors. In connection to the case report a literature review of characteristics and etiologies of chronic adhesive arachnoiditis is given, which is a known but very rare complication of spinal anesthesia or similar procedures.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Adhesive Arachnoiditis following Inadvertent Epidural Injection of 2% Chlorhexidine in 70% Alcohol—Partial Recovery over the Ensuing Eight Years

We report a case of serious neurologic injury due to inadvertent epidural injection of 8 ml of the antiseptic 2% chlorhexidine in 70% alcohol during a procedure aimed to relieve the pain of labour. This resulted in immediate severe back pain, progressive tetraparesis and sphincter dysfunction caused by damage to the spinal cord and nerve roots. Subacute hydrocephalus necessitated drainage, but cranial nerve and cognitive function were spared. Magnetic resonance imaging documented marked abnormality of the spinal cord and surrounding leptomeninges. In the ensuing eight years, there has been clinical and electrophysiological evidence of partial recovery, but neurologic deficit remains severe.

Disseminated Staphylococcus aureus infection following spinal anesthesia: a case report

We here presented a 65-year-old woman with disseminated Staphylococcus aureus infection following spinal anesthesia. The patient underwent spinal anesthesia for great saphenous vein stripping. Twenty days after the procedure, the patient developed hydrocephalus, pulmonary infection, and epidural abscess. Microbiological culture of the pus showed infection by S aureus. Appropriate antibiotic therapy and prompt surgical abscess drainage were associated with good outcome. Hydrocephalus is thought to be associated with arachnoiditis caused by S aureus infection, which provides new insights into the pathophysiology of arachnoiditis. Here we reported a case of disseminated S aureus infection following spinal anesthesia, implicating that appropriate interventions should not be delayed for waiting for the microbiological results.

Symptomatic spinal cord kinking due to focal adhesive arachnoiditis, with ossification of the ligamentum flavum: a case report

STUDY DESIGN

A case report.

OBJECTIVE

To describe a rare case of symptomatic spinal cord kinking due to focal adhesive arachnoiditis, with ossification of the ligamentum flavum (OLF).

SUMMARY OF BACKGROUND DATA

Spinal cord kinking without spinal surgery is rare, and symptomatic spinal cord kinking due to focal adhesive arachnoiditis, with OLF is even rarer.

METHODS

A 66-year-old female presented with numbness of the lower extremities and subsequently experienced gait disturbance due to motor weakness. Magnetic resonance imaging of the thoracic spine showed anterior displacement and kinking of the spinal cord from T11 to T12. Laminectomy and OLF resection were performed. The arachnoid membrane at the affected part was markedly thick and seemed cloudy. Adhesiolysis for arachnoid adhesion and release of spinal kinking were performed.

RESULTS

She could walk with a cane 6 months postoperatively. One year postoperatively, thoracic computed tomography-myelography showed that the cord was repositioned in the dural sac, and that release of the spinal cord kink was maintained.

CONCLUSION

Symptomatic spinal cord kinking due to focal adhesive arachnoiditis, with OLF is a rare clinical condition. It was difficult to diagnose the precise pathology of the spinal cord before surgery. Microsurgical arachnoidolysis resolved the spinal cord kinking, and no recurrence was noted within the follow-up period.

LEVEL OF EVIDENCE

N/A.

Adhesive arachnoiditis with extensive syringomyelia and giant arachnoid cyst after spinal and epidural anesthesia: a case report

STUDY DESIGN

A case report of a patient with adhesive arachnoiditis after combined spinal and epidural anesthesia.

OBJECTIVE

To report an extremely rare case of paraplegia due to adhesive arachnoiditis with extensive syringomyelia (ES) and a giant anterior arachnoid spinal cyst (AASC) after spinal and epidural anesthesia for obstetric surgery.

SUMMARY OF BACKGROUND DATA

Progressive inflammation of the arachnoid mater due to trauma, infection, or hydrocortisone was reported as early as the 1970s. However, coexistence of ES and a giant AASC after spinal and epidural anesthesia is extremely rare.

METHODS

A 29-year-old woman suffered from sudden anuresis 5 months after spinal and epidural anesthesia for a cesarean section and subsequently experienced paraplegia and numbness below the chest. Magnetic resonance imaging showed an AASC compressing the spinal cord at T1-T6 and an adhesive lesion at T7. Posterior laminectomy at T6-T7 and adhesiolysis for arachnoid adhesion at T7 were performed. Although there was slight recovery of locomotive function postoperatively, it gradually worsened until 3 years after surgery. Magnetic resonance imaging at that time demonstrated a giant AASC and ES at the lower-thoracic cord. The cord compressed by the AASC became thinner sagittally. Secondary surgery involving posterior laminectomy at T5-T6 and insertion of a cyst-peritoneal shunt into the AASC was performed.

RESULTS

The patient could walk without a cane 3 years after the shunt operation, although numbness and motor weakness of the lower extremities remained. Magnetic resonance imaging 3 years after the shunt operation showed a reduction of the AASC and decompression of the cord despite no improvement in ES.

CONCLUSION

This is the first report of a patient with a giant AASC and ES caused by spinal and epidural anesthesia. Although the optimal surgical treatment for these conditions remains unclear, shunting of the cyst effectively prevented the progression of symptoms.

Anaesthetic considerations for patients with a pre-existing neurological deficit: are neuraxial techniques safe?

Pre-existing neurological and muscular disease may be a specific concern for anaesthetists as they need to consider the effect of anaesthesia upon the disease, vice versa, and the interaction of anaesthesia with the medication taken by the patient. Despite a lack of controlled studies, many anaesthetists, being afraid of a claim, will prefer general rather than regional anaesthesia in these patients. Nevertheless regional anaesthesia certainly merits its place because it offers undeniable advantages. A good pre-operative examination is very important while patients should also be informed about peri-operative implications of anaesthesia, surgery and stress. Paraesthesias, epinephrine and high concentrations of local anaesthetics should be avoided in the majority of the diseases. Some diseases may benefit from epidural anaesthesia while for others a spinal technique may be the technique of preference. Special attention should be paid to patients with spinal stenosis despite recent reassuring reports with respect to safety of regional anaesthetic techniques. Anaesthetists should not automatically take all responsibility in case of progressive or new deficit after the procedure.

Obstetric epidurals and chronic adhesive arachnoiditis

It has been suggested that obstetric epidurals lead to chronic adhesive arachnoiditis (CAA). CAA is a nebulous disease entity with much confusion over its symptomatology. This review outlines the pathological, clinical, and radiological features of the disease. The proposed diagnostic criteria for CAA are: back pain that increases on exertion, with or without leg pain; neurological abnormality on examination; and characteristic MRI findings. Using these criteria, there is evidence to show that epidural or subarachnoid placement of some contrast media, preservatives and possibly vasoconstrictors, may lead to CAA. No evidence was found that the preservative-free, low concentration bupivacaine with opioid mixtures or plain bupivacaine currently used in labour lead to CAA.

Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient insurance claims [see comment]

BACKGROUND

The Patient Injury Act has been in effect in Finland since 1 May 1987. This legislation is a no-fault compensation scheme and implies that if a patient during the course of medical treatment suffers any injury as a result of that treatment he or she may file a claim to the Patient Insurance Association (PIA). From 1 May 1987 to 31 December 1993, 23,500 claims for compensation were made.

METHODS

All claims made to PIA involving spinal and epidural anaesthesias during the above period were collected and reviewed and a data base was prepared. The total number of anaesthetics given during this period was estimated by sending questionnaires to every hospital in the country.

RESULTS

Eighty-six claims were associated with spinal and/or epidural anaesthesia. Respectively, the total the number of spinal and epidural anaesthesias administered was 550,000 and 170,000. There were 25 serious complications associated with spinal anaesthesia: cardiac arrests (2), paraplegia (5), permanent cauda equina syndrome (1), peroneal nerve paresis (6), neurological deficits (7), and bacterial infections (4). The 9 serious complications which were associated with epidural anaesthesia were: paraparesis (1), permanent cauda equina syndrome (1), peroneal nerve paresis (1), neurological deficit (1), bacterial infections (2), acute toxic reactions related to the anaesthetic solution (2), and overdose of epidural opioid (1).

CONCLUSIONS

According to this material the incidence of serious complications was 0.45:10,000 following spinal and 0.52:10,000 following epidural anaesthesia. Atraumatic technique, careful patient selection and early diagnosis and treatment of complications are essential in avoiding permanent injury.

Spinal anaesthesia for Caesarean section in a patient with a cervical arteriovenous malformation

PURPOSE

Arteriovenous malformations (AVM) of the spinal cord are rare. We report the successful management of a patient with a cervical spinal cord AVM undergoing Caesarean section delivery, using a spinal anaesthetic.

CLINICAL FEATURES

Based on previous radiological investigations, the patient was known to have an AVM at the third cervical level of her spinal cord. After application of monitors and intravenous administration of 1 L normal saline, a 25 g Whitacre needle was inserted into the subarachnoid space at the L3-4 interspace. Spinal anaesthesia was established with a solution consisting of hyperbaric spinal bupivacaine 12 mg, fentanyl 12.5 micrograms and epidural morphine 0.25 mg. There was no neurological deficit during hospital stay or after discharge.

CONCLUSION

The safe outcome of spinal anaesthesia for our patient is encouraging. The presence of spinal cord AVM at the cervical region is not an absolute contraindication to spinal anaesthesia.

Major neurological sequelae of lumbar epidural anesthesia. Report of three cases

We here report the major permanent neurological complications that developed in three patients after epidural anesthesia. MR clearly showed that paraplegia, which arose one and nine days after anesthesia, was due to epi-subdural haematoma in the first case and epidural abscess in the second. The sudden left lower limb palsy in the third patient was caused by a paracentral ischemic lesion all along the conus-epiconus following a probable trauma of the cord during the insertion of the needle. Despite the fact that this was reported to have been performed at L1-L2, an erroneous introduction into the upper interspace must be postulated since the spinal cord of this patient terminated at mid-L1. Our report is useful insofar as it may remind anesthesiologists and neurologists to pay attention to the unusual complications of spinal anesthesia that may require urgent intervention.