Can Direct Spinal Cord Injury Occur Without Paresthesia? A Report of Delayed Spinal Cord Injury After Epidural Placement in an Awake Patient

Accidental Spinal Cord Injury Following an Attempted Thoracic Epidural for acute Pancreatitis Pain Management

We report a case of spinal cord injury following an attempted epidural in a conscious woman for pain management in acute pancreatitis. The epidural needle was inserted at the T11–T12 interspace. On the second attempt, dural puncture occurred. The patient did not complain of pain or discomfort during the procedure. Thirty-two hours after the attempted epidural, the patient was found to have motor deficit on her right lower limb. Magnetic resonance imaging showed a spinal haematoma with direct spinal cord injury. Post-laminectomy neurological recovery was slow but progressive. The possible causes for spinal cord injury and spinal haematoma without pain or paraesthesia during the procedure are discussed.

Intestinal transplantation: The anesthesia perspective

Intestinal transplantation is a complex and challenging surgery. It is very effective for treating intestinal failure, especially for those patients who cannot tolerate parenteral nutrition nor have extensive abdominal disease. Chronic parental nutrition can induce intestinal failure associated liver disease (IFALD). According to United Network for Organ Sharing (UNOS) data, children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list when compared with all candidates for solid organ transplantation. Intestinal transplant grafts can be isolated or combined with the liver/duodenum/pancreas. Organ Procurement and Transplantation Network (OPTN) has defined intestinal donor criteria. Living donor intestinal transplant (LDIT) has the advantages of optimal timing, short ischemia time and good human leukocyte antigen matching contributing to lower postoperative complications in the recipient. Thoracic epidurals provide excellent analgesia for the donors, as well as recipients. Recipient management can be challenging. Thrombosis and obstruction of venous access maybe common due to prolonged parenteral nutrition and/or hypercoaguability. Thromboelastography (TEG) is helpful for managing intraoperative product therapy or thrombosis. Large fluid shifts and electrolyte disturbances may occur due to massive blood loss, dehydration, third spacing etc. Intestinal grafts are susceptible to warm and cold ischemia and ischemia-reperfusion injury (IRI). Post-reperfusion syndrome is common. Cardiac or pulmonary clots can be monitored with transesophageal echocardiography (TEE) and treated with recombinant tissue plasminogen activator. Vasopressors maybe used to ensure stable hemodynamics. Post-intestinal transplant patients may need anesthesia for procedures such as biopsies for surveillance of rejection, bronchoscopy, endoscopy, postoperative hemorrhage, anastomotic leaks, thrombosis of grafts etc. Asepsis, drug interactions between anesthetic and immunosuppressive agents and venous access are some of the anesthetic considerations for this group.

Arteriovenous fistula and pseudoaneurysm of the anterior spinal artery caused by an epidural needle in a 5-year-old patient

Authors present the case of a 5-year-old patient with a spinal arteriovenous fistula (AVF) and pseudoaneurysm of the anterior spinal artery (ASA) caused by a traumatic epidural needle stick injury. A discussion and relevant review of the literature follow. The boy had a remote history of a liver transplant and required neuraxial blockade for an unrelated abdominal surgical procedure. Initial insertion of the epidural needle at the T9-10 interspace yielded blood. A second attempt at T10-11 was successful. Delayed left leg weakness developed on postoperative Day 8, with an MR image showing a track injury through the cord and a ventral subarachnoid hematoma. Laminectomies from T-9 to T-11were performed emergently to decompress the spinal cord. The dura mater was opened, the ventral hematoma was evacuated, and brisk venous bleeding was controlled with cauterization. Postoperative spinal angiography demonstrated an AVF and pseudoaneurysm of the ASA. Repeat angiography at postoperative Week 4 demonstrated complete resolution of the AVF and pseudoaneurysm, probably due to intraoperative cauterization of the draining vein. The patient underwent a short course of rehabilitation and had no clinical or electrophysiological evidence of spinal cord damage at the 20-month follow-up. One should be cognizant of the possibility of a cord injury in a patient with new-onset neurological deficits following an interventional spine procedure. Neuroimaging is essential for prompt diagnosis and treatment.

[Neurologic complications of central neuraxial blocks]

Central neuraxial blocks, which are associated with a low incidence of complications, are safe. When complications do occur, however, the resulting morbidity and mortality is considerable. The reported incidence of complications in all series is under 4 per 10000 patients, but given the absence of formal registries and notification procedures, which have legal implications, the real rate of occurrence of these rare events is uncertain. We searched the literature through PubMed and the Cochrane Plus Library for a 5-year period, using the search terms epidural anesthesia AND safety, spinal anesthesia AND safety, complications AND epidural anesthesia, complications AND spinal anesthesia, neurologic complications AND epidural anesthesia, and neurologic complications AND spinal anesthesia. Neuraxial injury after a central blockade may be the result of anatomical and/or physiological lesions affecting the spinal cord, spinal nerves, nerve roots, or blood supply. The pathophysiology of neuraxial injury may be related to mechanical, ischemic, or neurotoxic damage or any combination. When a complication occurs, factors related to the technique will have interacted with pre-existing patient-related conditions. Various scientific societies have published guidelines for managing the complications of regional anesthesia. Recently published clinical practice guidelines recommend ultrasound imaging as a useful tool in performing a central neuraxial block.

Safety of amide local anesthetics: new trends

IMPORTANCE OF THE FIELD

Local anesthetics have become one of the most common drugs used in daily practice worldwide. Neurologic and cardiovascular events are the most frequent adverse reactions related to local anesthetics use. Recently, new trends have been developed on this topic.

AREAS COVERED IN THIS REVIEW

We performed an overview of the data available so far on local anesthetics adverse reactions. Relevant literature was identified using PubMed search of articles published up to November 2009, including experimental studies, case reports or clinical studies when available. Search terms included: 'local anaesthetics', 'adverse drug reaction', 'pharmacovigilance' and 'complication'.

WHAT THE READER WILL GAIN

Neurologic, cardiovascular and allergic reactions remain the most frequent adverse drug reactions related to local anesthetics in the literature. Studies based on pharmacovigilance systems have highlighted the frequency of adverse reactions little known until now, such as failure of block. Lipid emulsions are included into algorithm for cardiac resuscitation. Recent studies have demonstrated the myotoxicity and chondrotoxic effects of long-acting local anesthetics.

TAKE HOME MESSAGE

Physicians must keep in mind all these adverse reactions to better prevent their occurrence and give the most appropriate treatment.

Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23-year survey in a district general hospital

Post dural puncture headache can be a debilitating complication of epidural and subarachnoid anaesthesia for a new mother. In a survey of 18,337 epidurals and 5021 subarachnoid blocks performed for obstetric procedures over a 23-year period in a district general hospital maternity unit, there were 167 recognised accidental dural punctures after epidurals (0.91%), with 147 patients (88%) developing post dural puncture headache. In addition there were 52 post dural puncture headaches after subarachnoid blocks (1.04%). Successful management of accidental dural puncture and post dural puncture headache requires adherence to clear policies and protocols, with close follow-up of patients by an experienced obstetric anaesthetist.

Cauda Equina Syndrome and Profound Hearing Loss After Spinal Anesthesia with Isobaric Bupivacaine

A 33-yr-old man undergoing anorectal surgery developed cauda equina syndrome and bilateral profound hearing loss after single-injection spinal anesthesia with isobaric bupivacaine. There was no pain on needle placement. Neurologic assessment found impaired sensation to pinprick in the perineal region, lower extremity paralysis, and bowel and bladder incontinence. In addition, he developed a bilateral profound hearing loss involving the low frequencies, with the left side more affected than the right side. Although hearing impairment can occur with cerebrospinal fluid leakage, the etiology of cauda equina syndrome is uncertain. The simultaneous occurrence of these events has not been previously reported.