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Can Direct Spinal Cord Injury Occur Without Paresthesia A Report of Delayed Spinal Cord Injury After

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Can Direct Spinal Cord Injury Occur Without Paresthesia? ... clinical sign of spinal cord ischemia is normally bilateral paresis of the legs ... – PowerPoint PPT presentation

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Title: Can Direct Spinal Cord Injury Occur Without Paresthesia A Report of Delayed Spinal Cord Injury After


1
Can Direct Spinal Cord Injury Occur Without
Paresthesia? A Report of Delayed Spinal Cord
Injury After Epidural Placement in an Awake
PatientAnesth Analg 200510112124
  • Ban C. H. Tsui, MD, MSc, and Kevin Armstrong, MD
  • ?????????????
  • R2 ???

2
Introduction
  • Reports of spinal cord injury occurring while
    performing epidural anesthesia in unconscious or
    awake patients
  • the safety of performing epidural anesthesia in
    awake versus unconscious patients
  • Will the conscious patient always report a
    paresthesia in response to spinal cord or nerve
    root trauma?

3
Case Report
  • An 81-yr-old male (69 kg)
  • Whipple resection for pancreatic cancer
  • physical and neurological examinations were
    unremarkable
  • T8-9 interspace with the patient awake
  • Right paramedian epidura 17-gauge Tuohy needle
  • loss of resistance, but dura puncture

4
Case Report
  • A second single pass attempt was successfully
    made one interspace lower and a soft-tipped
    epidural catheter was threaded easily into the
    epidural space
  • there was no pain or discomfort during the
    procedure. No blood or CSF was returned through
    the catheter
  • 2 5-mL boluses of 0.125 bupivacaine plus 5 µg/mL
    of fentanyl were given and a 12 mL/h infusion of
    the same solution

5
Case Report
  • 80/50 mm Hg at 75 min and 75/45 mm Hg at 150 min
    postinduction. Both episodes responded readily to
    ephedrine (5 and 10 mg respectively)
  • Estimated blood loss was 900 mL, which was
    replaced with 2000 mL of Ringers lactate
    solution and 1000 mL of Pentaspan
  • Surgery lasted approximately 4 h and extubated in
    the operating room. admitted to the intensive
    care unit in stable condition for postoperative
    monitoring

6
Case Report
  • POD 1 obtunded but he moved all four limbs
    spontaneously, so 2 µg/mL of fentanyl instead
  • POD 2 drowsy, 12 mL/h to 9 mL/h.
  • POD 3 more alert, but difficulty when mobilizing
    for any activity, 6mL/h
  • POD 4 infusion was stopped. NE revealed little
    or no movement (0/5) and no sensation to pinprick
    in the right leg. The epidural catheter was
    immediately removed intact

7
Case Report
  • POD 5 Spinal cord edema, a high T2 signal
    intensity on MRI, compatible with direct trauma
    was noted from the mid T9 to the mid T10
    vertebral body

8
Case Report
  • a posterior extradural fluid collection from the
    T8-9 disk level extending inferior to the T11
    vertebral body consistent with a hematoma was
    present

9
Case Report
  • an emergency laminectomy and evacuation of the
    hematoma 7 h after the MRI results
  • Under direct surgical examination, the hematoma
    did not appear to cause significant compression
  • Postlaminectomy, motor and sensory function was
    still profoundly depresse
  • After 8 wk, was able to bear weight on his right
    leg
  • At 12 wk, could ambulate with a walker but with
    impaired proprioception

10
Discussion
  • Spinal cord damage needle or catheter trauma,
    local anesthetic toxicity, epidural hematoma,
    ischemia from an arterial injury, or severe
    hypotension.
  • MRI did not suggest significant compression of
    the spinal cord, a fact confirmed at laminectomy
  • clinical sign of spinal cord ischemia is normally
    bilateral paresis of the legs
  • it is highly unlikely that drug toxicity would
    account for this unilateral right side spinal
    cord edema

11
Discussion
  • This rapid infusion rate would make intrathecal
    catheter placement very unlikely, as there was no
    sign of a total spinal
  • a soft catheter was used further reduces the
    likelihood of direct catheter trauma
  • Edema mainly localized on the right side of the
    spinal cord, and epidural needle placement while
    using a right-sided paramedian approach.
  • So spinal cord needle puncture highly suspected

12
Discussion
13
Discussion
  • whether paresthesia is a reliable sign of spinal
    cord encroachment?
  • Paresthesia associated with spinal cord injury
    can occur at the time of needle placement but it
    also has been reported to develop only at the
    time of injection or secondary to irritation,
    edema, or hematoma
  • pain is more common in extraaxial lesions
    affecting the nerve roots, but no pain receptors
    within the spinal cord itself (or the brain),
    intraaxial lesions may be painless

14
Discussion
  • In addition, pain reported from dural puncture is
    rare in clinical practice
  • A delayed diagnosis as a result of human error,
    lack of vigorous neurological monitoring, and
    uncontrollable environmental conditions
    contributed to the extent of the damage
  • vigorous postoperative neurological monitoring
    should be implemented in all patients receiving
    neuraxial analgesia

15
Discussion
  • Preoperative review of diagnostic imaging of the
    vertebral column may be helpful

16
Summery
  • we should not simply assume paresthesia will
    always occur and be reported if a needle
    encroaches upon the spinal cord
  • there is still no clear evidence that direct
    thoracic epidural placement can be performed
    without risk in either awake or anesthetized
    patients
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