Intradural Herniation of a Thoracic Disc Causing Paraplegia Coincident with Epidural Anesthesia

[Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report]

A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Paraplegia caused by giant intradural herniation of a lumbar disk after combined spinal-epidural anesthesia in total hip arthroplasty

Total paraplegia after epidural or spinal anesthesia is extremely rare. We herein report a case of total paraplegia caused by a giant intradural herniation of a lumbar disk at the L3-L4 level after total hip arthroplasty for coxarthrosis. The patient had no preoperative neurologic abnormalities. Intraoperative anesthetic management involved combined spinal-epidural anesthesia at the L3-L4 level with continuous intravenous propofol administration. Postoperatively, the patient complained of numbness and total paraplegia of the lower extremities. Magnetic resonance imaging showed a giant herniation of a lumbar disk compressing the spinal cord at the L3-L4 level. The intradural herniation was surgically treated, and the patient's symptoms completely resolved.

Management of massive calcified transdural thoracic disk herniation

Thoracic disk herniation is a not uncommon pathology faced by the spinal surgeon. The management of massive intradural thoracic disk herniation with ventral cord compression is problematic both in terms of obtaining adequate decompression and ensuring no subsequent leakage of cerebrospinal fluid. A 54-year-old woman presented with a 10 year history of back pain and left leg pain. Over the past 6 months she experienced a progressive spastic paraparesis in both legs with recent urinary incontinence. A left anterolateral thoracotomy for excision of T8/9 thoracic disk protrusion was affected. A transdural decompression was performed with resection of the calcified dura and performance of a Gore-Tex duraplasty and pleuroplasty. A free muscle graft was placed in the intervening space and the chest drains were placed on non-suction. A spinal drain was maintained for 5 days. She made an excellent neurological recovery. Avoidance of cerebrospinal leakage is paramount when performing transthoracic approaches as negative intrapleural pressure can lead to persistence of leakage. This report documents a safe and reliable way to deal with massive intradural thoracic disk rupture with avoidance of subsequent spinal fluid leak.

Postoperative paraplegia as a result of undiagnosed primitive neuroectodermal tumor, not epidural analgesia

Postoperative paraplegia is a rare complication after epidural analgesia and often occurs with spinal hematoma or cord injury. We present the case of a 16-year-old girl who suffered from a tumor mass in the neck and abdomen who underwent gynecologic operation. Preoperatively, liver metastasis was found by computed tomography. Pathologic findings revealed that the abdominal mass was an ovarian dermoid cyst. After the operation, the patient complained of paraplegia while receiving epidural analgesia for postoperative pain control. A peripheral primitive neuroectodermal tumor in the thoracic and lumbar spines with spinal cord compression was later detected using magnetic resonance imaging. Learning from this case, we suggest that when a patient is preoperatively diagnosed with tumor metastasis, back pain and soreness, spinal cord compression from tumor metastasis should be excluded before epidural analgesia is implemented.

Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients

BACKGROUND

Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population.

METHODS

During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0-10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest.

RESULTS

Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements.

CONCLUSION

In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.