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Paraplegia after epidural anaesthesia
  1. Andrés Labiano-Fontcuberta1,
  2. Julián Benito-León1,2,3,
  3. Juan Francisco Gonzalo-Martínez1
  1. 1Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
  2. 2Department of Medicine, Complutense University, Madrid, Spain
  3. 3Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
  1. Correspondence to Dr Julián Benito-León, Avda. de la Constitución 73, portal 3, 7° Izquierda, Coslada, Madrid E-28821, Spain; jbenitol{at}meditex.es

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A 59-year-old woman presented with 6-week history of recurrent haematuria. Her medical history was unremarkable apart from a 22-pack-year smoking history and hypothyroidism. There was no history of alcohol or drug abuse. Physical examination was normal. An intravenous pyelogram showed a pedunculated tumour in the bladder mucosa, for which she underwent a transurethral resection under spinal anaesthesia. The preoperative clinical and laboratory assessments, including a chest x-ray, were normal, apart from haematuria. Her intraoperative electrocardiogram was normal, her oxygen saturation was >98%, and there were no respiratory symptoms. The biopsy revealed a low-grade papillary urothelial carcinoma.

The patient recovered uneventfully from the spinal anaesthetic. However, the next morning, approximately 12 h after the operation, she developed mild leg numbness and could not move her legs. An urgent neurology opinion was requested.

She was alert but apathetic. There was marked but painless weakness of both legs with absent deep tendon reflexes and equivocal plantar responses. Pain and temperature sensation were mildly reduced in both legs but vibration and joint position sense were normal. She could urinate and defecate normally.

Question 1

What is the differential diagnosis and what would be the most appropriate initial investigation?

Comment

The patient developed flaccid paraparesis following spinal anaesthesia for resection of a bladder tumour. When evaluating a patient with acute bilateral leg weakness in this setting one should consider the conditions listed in box 1.

Box 1

Causes of acute paraparesis

  • Myelopathy

  •   Vascular

  •     Ischaemic: spinal cord infarction

  •     Haemorrhagic

  •     Epidural haematoma (spontaneous or secondary to lumbar puncture)

  •     Haematomyelia (eg, secondary to arteriovenous malformation)

Traumatic: Direct needle injury to the cord

Neoplastic: Extradural metastases

Infective: Epidural abscess

Inflammatory

  • Nerve Roots

  •   Cauda equina syndrome

  •    Axonal damage secondary to local anaesthetics

  •    Epidural extension from lumbosacral metastases

Acute inflammatory demyelinating polyradiculoneuropathy

  • Cerebral Lesions

  •   Parasagittal lesion

  • Functional (psychogenic) paraparesis

Her clinical presentation …

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