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Complete paraplegia as a result of regional anesthesia
The Journal of Arthroplasty Vol. 15 No. 8 2000
Case Report
Complete Paraplegia as a Result of Regional Anesthesia C. Christopher Stroud, MD,* David Markel, MD,† and Kenwaldeep Sidhu, MD‡
Abstract: Complications after spinal or epidural anesthesia are rare. We report 2 cases of postoperative, complete paraplegia after regional anesthesia in orthopaedic patients not on anticoagulants. The paralysis was likely the result of spinal cord compression secondary to an epidural hematoma in 1 case and subdural hematoma in 1 case. A review of the literature regarding complications of regional anesthesia is presented. Regional anesthesia should be administered with caution and in selected patients. Key words: regional anesthesia, surgical complications, paralysis.
Case Reports
Complications after spinal or epidural anesthesia for orthopaedic procedures are rare. Adverse sequelae may result from intravascular or high subarachnoid injection. The precise incidence of neurologic dysfunction after spinal or epidural anesthesia is unknown but is not greater than when other modalities of anesthesia are used [1]. Postoperative lower extremity paralysis as a direct result of regional anesthesia has not been reported in the orthopaedic literature. We present 2 cases of postoperative, complete paraplegia after regional anesthesia in orthopaedic patients. The paralysis was likely the result of spinal cord compression secondary to an epidural hematoma in 1 case and a subdural hematoma in 1 case.
Case 1 A 72-year-old woman with osteoarthrosis presented to the hospital for a planned elective right total knee arthroplasty. The patient’s past medical history included hypertension, coronary artery disease, and irritable bowel syndrome. Previous surgeries included a left total knee arthroplasty, a right total hip arthroplasty, an L5-S1 laminectomy and fusion, a cholecystectomy, an appendectomy, and bilateral cataract extraction. The previous 3 orthopaedic procedures were performed under continuous epidural anesthesia without complications. Medications taken before surgery included dipyridamole (Persantine), triamterene-hydrochlorothiazide (Dyazide), nitroglycerin (Nitro-Bid), nifedipine (Procardia), a potassium supplement, and diphenoxylate-atropine (Lomotil). Physical examination was unremarkable except for slight varus alignment and a 30° flexion contracture of the right knee. Severe tricompartmental degenerative changes of the right knee were noted on radiographs. The preoperative laboratory evaluation was unremarkable. The hemoglobin was 10.4 g/dL, the prothrombin time and partial thromboplastin time were 13.3 seconds (range, 11.0 –13.8 seconds) and
From *Union Memorial Hospital, Baltimore, Maryland; †Providence Hospital, Southfield; and ‡St. John’s Hospital, Detroit, Michigan. Submitted December 30, 1999; accepted April 5, 2000. No benefits or funds were received in support of this study. Reprint requests: David Markel, MD, Department of Surgery, Providence Hospital, 16001 W. 9 Mile Rd., Southfield, MI 48075. Copyright © 2000 by Churchill Livingstone威 0883-5403/00/1508-0019$10.00/0 doi:10.1054/arth.2000.8324
1064
Complete Paraplegia as a Result of Anesthesia •
25.3 seconds (range, 21.3–33.0 seconds), and the platelet count was 191,000/L (range, 150,000 – 405,000/L). In the operating room, a midline epidural catheter was easily placed into the L1-2 interspace, using the loss of resistance technique [1]. No blood or cerebrospinal fluid was aspirated from the epidural space. An anesthetic test dose of lidocaine (1.5%) and epinephrine (1:200,000) was injected. No adverse reaction was noted. A cemented right knee arthroplasty was performed uneventfully under continuous bupivacaine (Marcaine) and fentanyl epidural anesthesia. An infusion of meperidine (Demerol) and bupivacaine was maintained for postoperative analgesia. Postoperatively, bilateral lower extremity graduated, thigh-high stockings and sequential compression devices were used for deep venous thrombosis prophylaxis. No oral, parenteral, or subcutaneous anticoagulant was administered. The same-day postoperative examination revealed that the patient was comfortable and able to move both lower extremities. On postoperative day 1, the patient complained of numbness and tingling in both lower extremities from the waist down and an inability to move either lower extremity. Neurologic examination revealed a sensory level at T12 and no voluntary motor function below the waist. The administration of bupivacaine through the epidural catheter was discontinued immediately. On postoperative day 2, the patient’s symptoms continued, and examination findings were unchanged. The epidural catheter was removed intact, and an urgent magnetic resonance imaging (MRI) scan was obtained (Fig. 1). The MRI scan showed findings consistent with an epidural hematoma displacing the thecal sac. The patient was taken to the operating room for urgent decompression of the spinal canal. At the time of surgery, an epidural hematoma extending from T9 to T11 was noted and evacuated. The dura was opened to inspect the spinal cord. No cord pulsations were seen. The postlaminectomy and decompression examination revealed a persistent T12 sensory level and continued motor and sensory paralysis below the waist. A follow-up MRI scan was obtained, which showed findings consistent with spinal cord ischemia at T10 –T12. At 3 years’ follow-up, the patient has had no improvement in neurologic status. The deficit is considered permanent. Case 2 A 79-year-old woman presented to the hospital complaining of increasing right hip pain. The patient had fallen 2 weeks before admission and had
Stroud et al.
1065
Fig. 1. Axial T1-weighted magnetic resonance image shows an oval-shaped epidural hematoma, displacing the thecal sac posteriorly and to the left.
noted progressive groin and thigh pain. Radiographs revealed a valgus-impacted, right femoral neck fracture. The patient was admitted for surgical stabilization of the hip fracture. The patient’s past medical history was significant only for mild congestive heart failure, which was effectively treated with triamterene-hydrochlorothiazide. Physical examination was remarkable only for irritability of the right hip. The preoperative laboratory evaluation was unremarkable except for a platelet count of 105,000/L (range 150,000 – 405,000/L). The prothrombin time was 13.3 seconds (range, 11.0 –13.9 seconds), the partial thromboplastin time was 36.4 seconds (range, 22.0 –38.4 seconds), and the hemoglobin was 13.8 g/dL. On the day of admission, after medical clearance, the patient was taken to the operating room for percutaneous, cannulated screw fixation of the hip fracture. Spinal anesthesia using bupivacaine was administered through the L3-4 interspace. The midline insertion of the spinal catheter into the subarachnoid space was difficult. Postinjection, a T10 anesthetic sensory level was obtained. The operation was performed without complications. Postoperatively, deep venous thrombosis prophylaxis was provided using bilateral, sequential compression devices and graduated thigh-high stockings. The patient did not receive any oral, parenteral, or subcutaneous anticoagulants. The same-day postoperative examination revealed that the patient was comfortable and able to move both lower extremities. On the 1st postoperative day,
1066 The Journal of Arthroplasty Vol. 15 No. 8 December 2000
Fig. 2. Sagittal T1-weighted magnetic resonance image shows the low-intensity signal of an extensive spinal hematoma. Surgical findings confirmed this to be a subdural hematoma.
the patient was able to move both lower extremities and was believed to be neurologically intact. On the 2nd postoperative day, the patient became confused and was incontinent of urine. Intramuscular narcotics were discontinued, whereupon her mental status improved to baseline. The neurologic examination revealed a T8 sensory level and loss of motor activity bilaterally below the waist. An MRI scan was obtained. Findings consistent with spinal cord compression from a subdural hematoma extending from T8 to L2 were noted (Fig. 2). The patient was taken to the operating room emergently for exploration and decompression of the spinal canal. Operative findings were surprising. An extensive, subdural hematoma extending from T7 to L3 was noted. The spinal cord had an ischemic appearance over these levels. During the decompressive procedure, removal of the hematoma with loss of its concomitant tamponade effect resulted in significant epidural venous bleeding. The blood loss was controlled with digital pressure, and the patient remained hemodynamically stable. At the completion of the procedure, the patient experienced a hypotensive crisis and died despite resuscitative measures.
Discussion This is the first report in the orthopaedic literature of postoperative, complete paraplegia associ-
ated with the administration of regional spinal anesthesia in patients who were not taking oral or parenteral anticoagulants. Regional spinal anesthesia commonly is administered to patients undergoing orthopaedic surgical procedures. Absolute contraindications to regional spinal anesthesia include localized infection at the puncture site, anatomic abnormalities precluding proper catheter placement, severe or uncorrected hypovolemia, raised intracranial pressure, or uncorrected coagulation deficits. Relative contraindications include generalized infection, neurologic disorders, and minidose heparin therapy [2]. Complications of regional spinal anesthesia include intravascular injection of an anesthetic agent into the epidural veins, which may produce systemic toxicity; inadvertent introduction of an anesthetic agent into the subarachnoid space, which may cause central nervous system dysfunction; and high level of spinal anesthesia producing respiratory and nervous system dysfunction, resulting in transient or permanent neurologic injury, back pain, and postspinal headache [3]. The incidence of complications resulting from regional anesthesia is estimated to be 1:10,000 to 1:11,000 [4]. The incidence of serious neurologic injury, including paralysis, is unknown. Dawkins [5] reported transient paralysis in 0.1% and complete paralysis in 0.02% in ⬎32,000 surgical cases in which regional anesthesia was used. Previous reports of paraplegia associated with epidural anesthesia have implicated preoperative, intraoperative, or postoperative anticoagulation as a cause of an epidural hematoma and subsequent spinal cord ischemia [3,6 –9]. Thrombosis of the anterior spinal artery, arachnoiditis, spinal stenosis, and trauma to the cord have been described as factors in the cause of postoperative paralysis after regional anesthesia [10 –13]. In a literature review of procedures performed under epidural anesthesia, Kane [7] noted only 3 patients in ⬎50,000 who developed permanent paralysis. Each patient had received anticoagulation. No direct cause of the paralysis was noted. Possible causes included spinal cord ischemia or infarction secondary to hypotension or arterial spasm [14,15], the surgical procedure itself, chemical contamination of the local anesthetic solution leading to arachnoiditis, and an epidural or subdural hematoma. There is no evidence to suggest that hypotension, chemical irritants, or trauma played a role in our cases of permanent paralysis. In a report by Janis [12], an epidural hematoma was responsible for paraplegia in 4 of 36 patients studied, all of whom were receiving anticoagulant therapy. Other reports of epidural hematoma after
Complete Paraplegia as a Result of Anesthesia •
regional anesthesia have dealt with patients receiving anticoagulants preoperatively, intraoperatively, or postoperatively [5,11,16]. Regional spinal anesthesia generally has been avoided in patients receiving antiplatelet or anticoagulant therapy because of the risk of excessive bleeding; however, there are no data to support this practice [1]. Odoom and Sih [13] used continuous epidural anesthesia without complications in 1,000 patients who had received preoperative anticoagulants. Brown [1] stated that “the acceptable magnitude of preoperative anticoagulation and the risk-benefit ratio of performing epidural anesthesia must remain undetermined at the time.” The benefits of spinal or epidural anesthesia must be weighed against the possible risks of general anesthesia. Although controversial, there appears to be a lower morbidity and mortality in the immediate postoperative period in patients undergoing surgical procedures when regional anesthesia is used [17,18]. In case 1, an epidural hematoma developed after total knee arthroplasty in a patient who had had an epidural catheter placed for intraoperative anesthesia and postoperative analgesia. Complete bilateral, lower extremity paraplegia occurred. This patient had been on long-standing dipyridamole therapy but had a normal coagulation profile preoperatively. The epidural catheter had been inserted with ease, and no adverse reaction occurred until postoperative day 1. No anticoagulant agents were administered postoperatively. The role that antiplatelet therapy played in the cause of the paralysis is unknown. Dipyridamole may have contributed to the development of the epidural hematoma, however. In case 2, a subdural hematoma developed in a patient who had surgical stabilization of a femoral neck fracture under spinal anesthesia. The hematoma resulted in complete paraplegia, which was noted on postoperative day 2. No anticoagulants were administered postoperatively. The patient died as a result of treatment of the hematoma. In this case, the administration of the spinal anesthetic was difficult, and the patient had a relative preoperative thrombocytopenia (platelet count, 105,000/ L; normal range, 150,000 – 450,000/L). Despite the low incidence of complications related to the use of regional spinal anesthesia, these cases and the literature review illustrate the serious morbidity and mortality that may occur. It is important to identify contraindications to the procedure and patients who may be at risk. Epidural or spinal anesthesia should be administered cautiously, if at all, to patients with abnormal coagula-
Stroud et al.
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tion profiles, patients with prolonged bleeding times, or patients taking medications known to interfere with platelet function or the coagulation scheme.
References 1. Brown DL: Spinal, epidural, and caudal anesthesia. p 1506. In Miller RD (ed): Anesthesia, 4th ed. Churchill Livingstone, New York, 1994 2. Adriani J, Naragi M: Paraplegia associated with epidural anesthesia. South Med J 79:1350, 1986 3. Braham J, Saia A: Neurologic complications of epidural anesthesia. BMJ 2:657, 1958 4. Stephanov S, de Preux J: Lumbar epidural hematoma following epidural anesthesia. Surg Neurol 18:351, 1982 5. Dawkins CJM: An analysis of the complications of extradural and caudal block. Anesthesia 24:554, 1969 6. Hachisuka K, Ogata H, Kohshi K: Post-operative paraplegia with spinal myoclonus possibly caused by epidural anesthesia: case report. Int Med Soc Paraplegia 29:130, 1991 7. Kane RE: Neurologic deficits following epidural or spinal anesthesia. Anesth Analg 60:150, 1981 8. Onishchuk JL, Carlsson C: Epidural hematoma associated with epidural anesthesia: complications of anticoagulant therapy. Anesthesiology 77:1221, 1992 9. Auccarello M, Scanarini M, D’Avella K, et al: Spontaneous spinal extradural hematoma during anticoagulant therapy. Surg Neurol 14:411, 1980 10. Chaudhari LS, Kop BR, Dhruva AJ: Paraplegia and epidural analgesia. Anesthesia 33:722, 1978 11. Helperin SW, Cohen DD: Hematoma following epidural anesthesia: report of a case. Anesthesiology 35:641, 1971 12. Janis KM: Epidural hematoma following postoperative epidural analgesia: a case report. Anesth Analg 51:689, 1972 13. Odoom JA, Sih IL: Epidural analgesia and anticoagulant therapy: Experience with one thousand cases of continuous epidurals. Anesthesia 38:254, 1983 14. Davies A, Solomon B, Levene A: Paraplegia following epidural anesthesia. BMJ 2:654, 1958 15. Harik SI, Raichle ME, Reis DJ: Spontaneously remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med 284:1355, 1971 16. Gingrich TF: Spinal epidural hematoma following continuous epidural anesthesia. Anesthesiology 29: 162, 1968 17. Covino BG, Lambert DH: Epidural and spinal anesthesia. p 816. In Barash BF, Cullen BF, Stoelting RK (eds): Clinical anesthesia, 2nd ed. JB Lippincott, Philadelphia, 1992 18. Usibiaga JE: Neurological complications following epidural anesthesia. Int Anesthesiol Clin 13:100, 1975
Case Report
Complete Paraplegia as a Result of Regional Anesthesia C. Christopher Stroud, MD,* David Markel, MD,† and Kenwaldeep Sidhu, MD‡
Abstract: Complications after spinal or epidural anesthesia are rare. We report 2 cases of postoperative, complete paraplegia after regional anesthesia in orthopaedic patients not on anticoagulants. The paralysis was likely the result of spinal cord compression secondary to an epidural hematoma in 1 case and subdural hematoma in 1 case. A review of the literature regarding complications of regional anesthesia is presented. Regional anesthesia should be administered with caution and in selected patients. Key words: regional anesthesia, surgical complications, paralysis.
Case Reports
Complications after spinal or epidural anesthesia for orthopaedic procedures are rare. Adverse sequelae may result from intravascular or high subarachnoid injection. The precise incidence of neurologic dysfunction after spinal or epidural anesthesia is unknown but is not greater than when other modalities of anesthesia are used [1]. Postoperative lower extremity paralysis as a direct result of regional anesthesia has not been reported in the orthopaedic literature. We present 2 cases of postoperative, complete paraplegia after regional anesthesia in orthopaedic patients. The paralysis was likely the result of spinal cord compression secondary to an epidural hematoma in 1 case and a subdural hematoma in 1 case.
Case 1 A 72-year-old woman with osteoarthrosis presented to the hospital for a planned elective right total knee arthroplasty. The patient’s past medical history included hypertension, coronary artery disease, and irritable bowel syndrome. Previous surgeries included a left total knee arthroplasty, a right total hip arthroplasty, an L5-S1 laminectomy and fusion, a cholecystectomy, an appendectomy, and bilateral cataract extraction. The previous 3 orthopaedic procedures were performed under continuous epidural anesthesia without complications. Medications taken before surgery included dipyridamole (Persantine), triamterene-hydrochlorothiazide (Dyazide), nitroglycerin (Nitro-Bid), nifedipine (Procardia), a potassium supplement, and diphenoxylate-atropine (Lomotil). Physical examination was unremarkable except for slight varus alignment and a 30° flexion contracture of the right knee. Severe tricompartmental degenerative changes of the right knee were noted on radiographs. The preoperative laboratory evaluation was unremarkable. The hemoglobin was 10.4 g/dL, the prothrombin time and partial thromboplastin time were 13.3 seconds (range, 11.0 –13.8 seconds) and
From *Union Memorial Hospital, Baltimore, Maryland; †Providence Hospital, Southfield; and ‡St. John’s Hospital, Detroit, Michigan. Submitted December 30, 1999; accepted April 5, 2000. No benefits or funds were received in support of this study. Reprint requests: David Markel, MD, Department of Surgery, Providence Hospital, 16001 W. 9 Mile Rd., Southfield, MI 48075. Copyright © 2000 by Churchill Livingstone威 0883-5403/00/1508-0019$10.00/0 doi:10.1054/arth.2000.8324
1064
Complete Paraplegia as a Result of Anesthesia •
25.3 seconds (range, 21.3–33.0 seconds), and the platelet count was 191,000/L (range, 150,000 – 405,000/L). In the operating room, a midline epidural catheter was easily placed into the L1-2 interspace, using the loss of resistance technique [1]. No blood or cerebrospinal fluid was aspirated from the epidural space. An anesthetic test dose of lidocaine (1.5%) and epinephrine (1:200,000) was injected. No adverse reaction was noted. A cemented right knee arthroplasty was performed uneventfully under continuous bupivacaine (Marcaine) and fentanyl epidural anesthesia. An infusion of meperidine (Demerol) and bupivacaine was maintained for postoperative analgesia. Postoperatively, bilateral lower extremity graduated, thigh-high stockings and sequential compression devices were used for deep venous thrombosis prophylaxis. No oral, parenteral, or subcutaneous anticoagulant was administered. The same-day postoperative examination revealed that the patient was comfortable and able to move both lower extremities. On postoperative day 1, the patient complained of numbness and tingling in both lower extremities from the waist down and an inability to move either lower extremity. Neurologic examination revealed a sensory level at T12 and no voluntary motor function below the waist. The administration of bupivacaine through the epidural catheter was discontinued immediately. On postoperative day 2, the patient’s symptoms continued, and examination findings were unchanged. The epidural catheter was removed intact, and an urgent magnetic resonance imaging (MRI) scan was obtained (Fig. 1). The MRI scan showed findings consistent with an epidural hematoma displacing the thecal sac. The patient was taken to the operating room for urgent decompression of the spinal canal. At the time of surgery, an epidural hematoma extending from T9 to T11 was noted and evacuated. The dura was opened to inspect the spinal cord. No cord pulsations were seen. The postlaminectomy and decompression examination revealed a persistent T12 sensory level and continued motor and sensory paralysis below the waist. A follow-up MRI scan was obtained, which showed findings consistent with spinal cord ischemia at T10 –T12. At 3 years’ follow-up, the patient has had no improvement in neurologic status. The deficit is considered permanent. Case 2 A 79-year-old woman presented to the hospital complaining of increasing right hip pain. The patient had fallen 2 weeks before admission and had
Stroud et al.
1065
Fig. 1. Axial T1-weighted magnetic resonance image shows an oval-shaped epidural hematoma, displacing the thecal sac posteriorly and to the left.
noted progressive groin and thigh pain. Radiographs revealed a valgus-impacted, right femoral neck fracture. The patient was admitted for surgical stabilization of the hip fracture. The patient’s past medical history was significant only for mild congestive heart failure, which was effectively treated with triamterene-hydrochlorothiazide. Physical examination was remarkable only for irritability of the right hip. The preoperative laboratory evaluation was unremarkable except for a platelet count of 105,000/L (range 150,000 – 405,000/L). The prothrombin time was 13.3 seconds (range, 11.0 –13.9 seconds), the partial thromboplastin time was 36.4 seconds (range, 22.0 –38.4 seconds), and the hemoglobin was 13.8 g/dL. On the day of admission, after medical clearance, the patient was taken to the operating room for percutaneous, cannulated screw fixation of the hip fracture. Spinal anesthesia using bupivacaine was administered through the L3-4 interspace. The midline insertion of the spinal catheter into the subarachnoid space was difficult. Postinjection, a T10 anesthetic sensory level was obtained. The operation was performed without complications. Postoperatively, deep venous thrombosis prophylaxis was provided using bilateral, sequential compression devices and graduated thigh-high stockings. The patient did not receive any oral, parenteral, or subcutaneous anticoagulants. The same-day postoperative examination revealed that the patient was comfortable and able to move both lower extremities. On the 1st postoperative day,
1066 The Journal of Arthroplasty Vol. 15 No. 8 December 2000
Fig. 2. Sagittal T1-weighted magnetic resonance image shows the low-intensity signal of an extensive spinal hematoma. Surgical findings confirmed this to be a subdural hematoma.
the patient was able to move both lower extremities and was believed to be neurologically intact. On the 2nd postoperative day, the patient became confused and was incontinent of urine. Intramuscular narcotics were discontinued, whereupon her mental status improved to baseline. The neurologic examination revealed a T8 sensory level and loss of motor activity bilaterally below the waist. An MRI scan was obtained. Findings consistent with spinal cord compression from a subdural hematoma extending from T8 to L2 were noted (Fig. 2). The patient was taken to the operating room emergently for exploration and decompression of the spinal canal. Operative findings were surprising. An extensive, subdural hematoma extending from T7 to L3 was noted. The spinal cord had an ischemic appearance over these levels. During the decompressive procedure, removal of the hematoma with loss of its concomitant tamponade effect resulted in significant epidural venous bleeding. The blood loss was controlled with digital pressure, and the patient remained hemodynamically stable. At the completion of the procedure, the patient experienced a hypotensive crisis and died despite resuscitative measures.
Discussion This is the first report in the orthopaedic literature of postoperative, complete paraplegia associ-
ated with the administration of regional spinal anesthesia in patients who were not taking oral or parenteral anticoagulants. Regional spinal anesthesia commonly is administered to patients undergoing orthopaedic surgical procedures. Absolute contraindications to regional spinal anesthesia include localized infection at the puncture site, anatomic abnormalities precluding proper catheter placement, severe or uncorrected hypovolemia, raised intracranial pressure, or uncorrected coagulation deficits. Relative contraindications include generalized infection, neurologic disorders, and minidose heparin therapy [2]. Complications of regional spinal anesthesia include intravascular injection of an anesthetic agent into the epidural veins, which may produce systemic toxicity; inadvertent introduction of an anesthetic agent into the subarachnoid space, which may cause central nervous system dysfunction; and high level of spinal anesthesia producing respiratory and nervous system dysfunction, resulting in transient or permanent neurologic injury, back pain, and postspinal headache [3]. The incidence of complications resulting from regional anesthesia is estimated to be 1:10,000 to 1:11,000 [4]. The incidence of serious neurologic injury, including paralysis, is unknown. Dawkins [5] reported transient paralysis in 0.1% and complete paralysis in 0.02% in ⬎32,000 surgical cases in which regional anesthesia was used. Previous reports of paraplegia associated with epidural anesthesia have implicated preoperative, intraoperative, or postoperative anticoagulation as a cause of an epidural hematoma and subsequent spinal cord ischemia [3,6 –9]. Thrombosis of the anterior spinal artery, arachnoiditis, spinal stenosis, and trauma to the cord have been described as factors in the cause of postoperative paralysis after regional anesthesia [10 –13]. In a literature review of procedures performed under epidural anesthesia, Kane [7] noted only 3 patients in ⬎50,000 who developed permanent paralysis. Each patient had received anticoagulation. No direct cause of the paralysis was noted. Possible causes included spinal cord ischemia or infarction secondary to hypotension or arterial spasm [14,15], the surgical procedure itself, chemical contamination of the local anesthetic solution leading to arachnoiditis, and an epidural or subdural hematoma. There is no evidence to suggest that hypotension, chemical irritants, or trauma played a role in our cases of permanent paralysis. In a report by Janis [12], an epidural hematoma was responsible for paraplegia in 4 of 36 patients studied, all of whom were receiving anticoagulant therapy. Other reports of epidural hematoma after
Complete Paraplegia as a Result of Anesthesia •
regional anesthesia have dealt with patients receiving anticoagulants preoperatively, intraoperatively, or postoperatively [5,11,16]. Regional spinal anesthesia generally has been avoided in patients receiving antiplatelet or anticoagulant therapy because of the risk of excessive bleeding; however, there are no data to support this practice [1]. Odoom and Sih [13] used continuous epidural anesthesia without complications in 1,000 patients who had received preoperative anticoagulants. Brown [1] stated that “the acceptable magnitude of preoperative anticoagulation and the risk-benefit ratio of performing epidural anesthesia must remain undetermined at the time.” The benefits of spinal or epidural anesthesia must be weighed against the possible risks of general anesthesia. Although controversial, there appears to be a lower morbidity and mortality in the immediate postoperative period in patients undergoing surgical procedures when regional anesthesia is used [17,18]. In case 1, an epidural hematoma developed after total knee arthroplasty in a patient who had had an epidural catheter placed for intraoperative anesthesia and postoperative analgesia. Complete bilateral, lower extremity paraplegia occurred. This patient had been on long-standing dipyridamole therapy but had a normal coagulation profile preoperatively. The epidural catheter had been inserted with ease, and no adverse reaction occurred until postoperative day 1. No anticoagulant agents were administered postoperatively. The role that antiplatelet therapy played in the cause of the paralysis is unknown. Dipyridamole may have contributed to the development of the epidural hematoma, however. In case 2, a subdural hematoma developed in a patient who had surgical stabilization of a femoral neck fracture under spinal anesthesia. The hematoma resulted in complete paraplegia, which was noted on postoperative day 2. No anticoagulants were administered postoperatively. The patient died as a result of treatment of the hematoma. In this case, the administration of the spinal anesthetic was difficult, and the patient had a relative preoperative thrombocytopenia (platelet count, 105,000/ L; normal range, 150,000 – 450,000/L). Despite the low incidence of complications related to the use of regional spinal anesthesia, these cases and the literature review illustrate the serious morbidity and mortality that may occur. It is important to identify contraindications to the procedure and patients who may be at risk. Epidural or spinal anesthesia should be administered cautiously, if at all, to patients with abnormal coagula-
Stroud et al.
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tion profiles, patients with prolonged bleeding times, or patients taking medications known to interfere with platelet function or the coagulation scheme.
References 1. Brown DL: Spinal, epidural, and caudal anesthesia. p 1506. In Miller RD (ed): Anesthesia, 4th ed. Churchill Livingstone, New York, 1994 2. Adriani J, Naragi M: Paraplegia associated with epidural anesthesia. South Med J 79:1350, 1986 3. Braham J, Saia A: Neurologic complications of epidural anesthesia. BMJ 2:657, 1958 4. Stephanov S, de Preux J: Lumbar epidural hematoma following epidural anesthesia. Surg Neurol 18:351, 1982 5. Dawkins CJM: An analysis of the complications of extradural and caudal block. Anesthesia 24:554, 1969 6. Hachisuka K, Ogata H, Kohshi K: Post-operative paraplegia with spinal myoclonus possibly caused by epidural anesthesia: case report. Int Med Soc Paraplegia 29:130, 1991 7. Kane RE: Neurologic deficits following epidural or spinal anesthesia. Anesth Analg 60:150, 1981 8. Onishchuk JL, Carlsson C: Epidural hematoma associated with epidural anesthesia: complications of anticoagulant therapy. Anesthesiology 77:1221, 1992 9. Auccarello M, Scanarini M, D’Avella K, et al: Spontaneous spinal extradural hematoma during anticoagulant therapy. Surg Neurol 14:411, 1980 10. Chaudhari LS, Kop BR, Dhruva AJ: Paraplegia and epidural analgesia. Anesthesia 33:722, 1978 11. Helperin SW, Cohen DD: Hematoma following epidural anesthesia: report of a case. Anesthesiology 35:641, 1971 12. Janis KM: Epidural hematoma following postoperative epidural analgesia: a case report. Anesth Analg 51:689, 1972 13. Odoom JA, Sih IL: Epidural analgesia and anticoagulant therapy: Experience with one thousand cases of continuous epidurals. Anesthesia 38:254, 1983 14. Davies A, Solomon B, Levene A: Paraplegia following epidural anesthesia. BMJ 2:654, 1958 15. Harik SI, Raichle ME, Reis DJ: Spontaneously remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med 284:1355, 1971 16. Gingrich TF: Spinal epidural hematoma following continuous epidural anesthesia. Anesthesiology 29: 162, 1968 17. Covino BG, Lambert DH: Epidural and spinal anesthesia. p 816. In Barash BF, Cullen BF, Stoelting RK (eds): Clinical anesthesia, 2nd ed. JB Lippincott, Philadelphia, 1992 18. Usibiaga JE: Neurological complications following epidural anesthesia. Int Anesthesiol Clin 13:100, 1975