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Intrathecal Injection, an Unusual Complication of Translumbar Aortography: Case Report
THE JouRN_\L OF UROLOGY
Vol."88, No. 3 September 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S. A..
INTRATHECAL INJECTION, AN UNUSUAL COMPLICATION OF TRA~SLUMBAR AORTOGRAPHY: CASE REPORT LOUIS W. DOROSHOW, LT. (MC) USNR,* HA YOUNG YOON AND MARTIN A. ROBBINS From the Department of Urology, Sinai Hospital, Baltimore, il[d.
In 1929 dos Santos and his associates1 • 2 added abdominal aortography to the armamentarium of diagnostic aids in renal disease. Since that time, thousands of aortograms have been performed, substantiating the original reports of the procedure as relatively safe and valuable. With more recent attention to surgical relief of hypertension due to renal artery obstruction, aortography has gained more popularity as a useful aid in diagnosis. The technique of renal angiography has changed over the past 33 years with improvements both in method and in the use of safer contrast media. 3- 9 Animal experiments on the direct neurologic effects of diatrizoate solutions revealed that the toxicity of these contrast agents was increased by the anatomic level of injection into the spinal cord. 10 Leadbetter and Markland, 11 reviewing 7,685 cases of renal arteriograms, including 210 of their own, reported no deaths and no significant morbidity. They advocated meticulous technique, non-toxic dyes and injections of less than 20 cc. These authors preferred translumbar aortography because of the simplicity in technique plus the fact that in the prone position the kidneys fall forward, pulling the renal arteries into a straight line. The supine position used in retrograde * Accepted for publication March 13, 1962. Present address: U. S. Naval Hospital, Great Lakes, Illinois 1 dos Santos, R., Lamas, A. C. and Pereira Caldas, J.: Med contemp., 47: 93, 1929. 2 Idem: Paris: Masson, 1931. 3 Killen, D. A., Lance, E. JYI. and Owens, G.: S. Forum, 9: 337, 1958. 4 Killen, D. A. and Foster, J. H.: Ann Surg., 152: 211, 1960. 5 Lance, E. M. and Killen, D. A.: Surgery, 46: 1107, 1959. 6 Killen, D. A., Lance, E. M. and Owens, G.: Surgery, 45: 436, 1959. 7 Foster, J. H. and Killen, D. A.: Surg., Gynec. and Obst., 113: 234, 1961. 8 Killen, D. A. and Owens, G.: Ann Surg., 152: 957, 1960. 9 Steinberg, I., Finby, N. and Evans, J. A.: Am. J. Roentgenol., 82: 758, 1959. 10 Winthrop Laboratories: Personal communication. 11 Leadbetter, G. W., Jr. and Markland, C.: New Engl. J. Med., 266: 10, 1962.
438
femoral cathet8rization causes the renal arteries to curve and bend on themselves, obscuring obstructive lesions in the area of reduplications. McAfee 12 reported an unselected collective series of 13,207 abdominal aortograrns in which the mortality rate was 0.28 per cent and non-fatal complications 0.74 per cent. In this series 12,832 aortograms were obtained by the translumbar technique and in 375 a retrograde femoral catheter was used. In 2 cases, inadvertent puncture of the spinal canal occurred without any significant morbidity or mortality. We believe that the following case report is the third case of accidental entrance into the spinal canal while attempting aortography and is the first reported death from this complication. CASE REPORT
A 31-year-old Negress was admitted to the ward service because of intermittent left flank pain of 1 year's duration. Despite analgesics the pain became more severe during the week prior to admission and was associated with emesis and dysuria. Past history was not remarkable except for cholecystectomy in 1958 which was followed 2 weeks later by common duct exploration because of persistent pain. Physical examination revealed a very obese patient with pain in the left side of the abdomen. Significant findings were limited to the abdomen which showed a right subcostal scar and a left upper quadrant mass, which was tense, slightly movable and tender. Laboratory findings of interest were a white blood cell count of 13,200 with a shift to the left. Urinalysis showed a trace of protein and many bacteria, later shown to be paracolon organisms on culture. Excretory urography and nephrotomography revealed an enlarged, non-functioning left kidney. The right kidney and ureter were normal as were the soft tissue shadows and bone structure. Two attempts to catheterize the left ureter were unsuccessful, meeting obstruction at the intramural segment. Translurnbar aortography was attempted \vith a size 17 spinal needle which was inserted and 12
McAfee, J. G.: Radiology, 68: 825, 1957.
UNUSUAL COMPLICATION OF TRANSLUMBAR AORTOGRAPHY
clear watery fluid withdrawn. In the belief that the needle was in a hydronephrotic sac, 7 cc of 50 per cent hypaque was injected in an effort to obtain an antegrade pyelogram. When the film was seen a myelogram had been obtained (fig. 1). The needle was withdrawn and reinserted, this time into the abdominal aorta. Subsequent aortography with a total of 30 cc of 50 per cent hypaque injected revealed no vascular supply to the left kidney. The patient's condition remained stable throughout these procedures while under anesthesia. Approximately 45 minutes following the inadvertent myelogram, the patient began to have myoclonic contractions of the lower limbs 6 to 10 seconds apart with severe pain in the lumbar region. Over the next hour the symptoms and signs persisted despite intravenous sedation with the contractions ascending to involve both upper limbs with subsequent apnea. She was intubated and placed on the Bird respirator. A lumbar puncture was attempted to relieve the intrathecal pressure. However, contractions recurred and it became impossible to complete the procedure. The patient died several minutes later, approximately 2 hours following the accidental myelogram. Postmortem examination revealed tuberculosis of the left kidney with extensive caseous necrosis.
439
Fibrous pleural adhesions in the right lower lobe and a calcified tracheobronchial lymph node were noted. The brain and spinal cord were negative. The site of aortogram injection was negative. Postmortem films of the spine disclosed no contrast medium and no bony abnormalities. Cause of death was attributed to shock following introduction of hypaque into the subarachnoid space. DISCUSSION
This case presented the problem of a left renal mass. An excretory urogram revealed a nonfunctioning left kidney which was enlarged and tender. Two unsuccessful attempts to catheterize the left ureter were made in addition to nephrotomography. In an effort to arrive at a diagnosis translumbar aortography resulted in the accident. Several important factors contributed to the outcome of this case. The patient was markedly obese, making landmarks difficult to recognize. The possibility that the needle might be within the spinal cord was not considered when clear fluid was obtained following removal of the trocar. Because of the mistaken assumption that the needle was draining urine from a hydronephrotic kidney, hypaque was injected directly in an effort to obtain an antegrade pyelogram. Finally, when the accident was recognized, further attempt to perform aortography should have been deferred. In retrospect, certain steps could have been taken to prevent the fatal outcome. Since hypaque is hyperbaric and rapidly absorbed, the patient should have been immediately placed in a sitting position. Our neurosurgical consultant advised that immediate spina} puncture should have been performed and the spinal fluid drawn off. This may have limited the diffusibility of the injected medium in a cephalad direction. Translumbar aortography is a relatively safe procedure and the information obtained is usually worth the small risk involved. However, we should like to reiterate that the safety factor increases with the degree of attention to technique. Moreover, those performing the test should be aware of the pitfalls and their management. SUMMARY
Fm. 1
An unusual complication of translumbar aortography has been cited. The probable mechanisms leading to the death of the patient and possible countermeasures are stated.
Vol."88, No. 3 September 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S. A..
INTRATHECAL INJECTION, AN UNUSUAL COMPLICATION OF TRA~SLUMBAR AORTOGRAPHY: CASE REPORT LOUIS W. DOROSHOW, LT. (MC) USNR,* HA YOUNG YOON AND MARTIN A. ROBBINS From the Department of Urology, Sinai Hospital, Baltimore, il[d.
In 1929 dos Santos and his associates1 • 2 added abdominal aortography to the armamentarium of diagnostic aids in renal disease. Since that time, thousands of aortograms have been performed, substantiating the original reports of the procedure as relatively safe and valuable. With more recent attention to surgical relief of hypertension due to renal artery obstruction, aortography has gained more popularity as a useful aid in diagnosis. The technique of renal angiography has changed over the past 33 years with improvements both in method and in the use of safer contrast media. 3- 9 Animal experiments on the direct neurologic effects of diatrizoate solutions revealed that the toxicity of these contrast agents was increased by the anatomic level of injection into the spinal cord. 10 Leadbetter and Markland, 11 reviewing 7,685 cases of renal arteriograms, including 210 of their own, reported no deaths and no significant morbidity. They advocated meticulous technique, non-toxic dyes and injections of less than 20 cc. These authors preferred translumbar aortography because of the simplicity in technique plus the fact that in the prone position the kidneys fall forward, pulling the renal arteries into a straight line. The supine position used in retrograde * Accepted for publication March 13, 1962. Present address: U. S. Naval Hospital, Great Lakes, Illinois 1 dos Santos, R., Lamas, A. C. and Pereira Caldas, J.: Med contemp., 47: 93, 1929. 2 Idem: Paris: Masson, 1931. 3 Killen, D. A., Lance, E. JYI. and Owens, G.: S. Forum, 9: 337, 1958. 4 Killen, D. A. and Foster, J. H.: Ann Surg., 152: 211, 1960. 5 Lance, E. M. and Killen, D. A.: Surgery, 46: 1107, 1959. 6 Killen, D. A., Lance, E. M. and Owens, G.: Surgery, 45: 436, 1959. 7 Foster, J. H. and Killen, D. A.: Surg., Gynec. and Obst., 113: 234, 1961. 8 Killen, D. A. and Owens, G.: Ann Surg., 152: 957, 1960. 9 Steinberg, I., Finby, N. and Evans, J. A.: Am. J. Roentgenol., 82: 758, 1959. 10 Winthrop Laboratories: Personal communication. 11 Leadbetter, G. W., Jr. and Markland, C.: New Engl. J. Med., 266: 10, 1962.
438
femoral cathet8rization causes the renal arteries to curve and bend on themselves, obscuring obstructive lesions in the area of reduplications. McAfee 12 reported an unselected collective series of 13,207 abdominal aortograrns in which the mortality rate was 0.28 per cent and non-fatal complications 0.74 per cent. In this series 12,832 aortograms were obtained by the translumbar technique and in 375 a retrograde femoral catheter was used. In 2 cases, inadvertent puncture of the spinal canal occurred without any significant morbidity or mortality. We believe that the following case report is the third case of accidental entrance into the spinal canal while attempting aortography and is the first reported death from this complication. CASE REPORT
A 31-year-old Negress was admitted to the ward service because of intermittent left flank pain of 1 year's duration. Despite analgesics the pain became more severe during the week prior to admission and was associated with emesis and dysuria. Past history was not remarkable except for cholecystectomy in 1958 which was followed 2 weeks later by common duct exploration because of persistent pain. Physical examination revealed a very obese patient with pain in the left side of the abdomen. Significant findings were limited to the abdomen which showed a right subcostal scar and a left upper quadrant mass, which was tense, slightly movable and tender. Laboratory findings of interest were a white blood cell count of 13,200 with a shift to the left. Urinalysis showed a trace of protein and many bacteria, later shown to be paracolon organisms on culture. Excretory urography and nephrotomography revealed an enlarged, non-functioning left kidney. The right kidney and ureter were normal as were the soft tissue shadows and bone structure. Two attempts to catheterize the left ureter were unsuccessful, meeting obstruction at the intramural segment. Translurnbar aortography was attempted \vith a size 17 spinal needle which was inserted and 12
McAfee, J. G.: Radiology, 68: 825, 1957.
UNUSUAL COMPLICATION OF TRANSLUMBAR AORTOGRAPHY
clear watery fluid withdrawn. In the belief that the needle was in a hydronephrotic sac, 7 cc of 50 per cent hypaque was injected in an effort to obtain an antegrade pyelogram. When the film was seen a myelogram had been obtained (fig. 1). The needle was withdrawn and reinserted, this time into the abdominal aorta. Subsequent aortography with a total of 30 cc of 50 per cent hypaque injected revealed no vascular supply to the left kidney. The patient's condition remained stable throughout these procedures while under anesthesia. Approximately 45 minutes following the inadvertent myelogram, the patient began to have myoclonic contractions of the lower limbs 6 to 10 seconds apart with severe pain in the lumbar region. Over the next hour the symptoms and signs persisted despite intravenous sedation with the contractions ascending to involve both upper limbs with subsequent apnea. She was intubated and placed on the Bird respirator. A lumbar puncture was attempted to relieve the intrathecal pressure. However, contractions recurred and it became impossible to complete the procedure. The patient died several minutes later, approximately 2 hours following the accidental myelogram. Postmortem examination revealed tuberculosis of the left kidney with extensive caseous necrosis.
439
Fibrous pleural adhesions in the right lower lobe and a calcified tracheobronchial lymph node were noted. The brain and spinal cord were negative. The site of aortogram injection was negative. Postmortem films of the spine disclosed no contrast medium and no bony abnormalities. Cause of death was attributed to shock following introduction of hypaque into the subarachnoid space. DISCUSSION
This case presented the problem of a left renal mass. An excretory urogram revealed a nonfunctioning left kidney which was enlarged and tender. Two unsuccessful attempts to catheterize the left ureter were made in addition to nephrotomography. In an effort to arrive at a diagnosis translumbar aortography resulted in the accident. Several important factors contributed to the outcome of this case. The patient was markedly obese, making landmarks difficult to recognize. The possibility that the needle might be within the spinal cord was not considered when clear fluid was obtained following removal of the trocar. Because of the mistaken assumption that the needle was draining urine from a hydronephrotic kidney, hypaque was injected directly in an effort to obtain an antegrade pyelogram. Finally, when the accident was recognized, further attempt to perform aortography should have been deferred. In retrospect, certain steps could have been taken to prevent the fatal outcome. Since hypaque is hyperbaric and rapidly absorbed, the patient should have been immediately placed in a sitting position. Our neurosurgical consultant advised that immediate spina} puncture should have been performed and the spinal fluid drawn off. This may have limited the diffusibility of the injected medium in a cephalad direction. Translumbar aortography is a relatively safe procedure and the information obtained is usually worth the small risk involved. However, we should like to reiterate that the safety factor increases with the degree of attention to technique. Moreover, those performing the test should be aware of the pitfalls and their management. SUMMARY
Fm. 1
An unusual complication of translumbar aortography has been cited. The probable mechanisms leading to the death of the patient and possible countermeasures are stated.