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LETTER TO THE EDITOR

Drop Foot After Pediatric Urological Surgery Under General and Epidural Anesthesia

Nesrin A. Yigit, MD, Bars Bagbanc, MD, and Hulya Celebi, MD

Faculty of Medicine; Gazi University; Ankara, Turkey; nesriny88{at}hotmail.com

To the Editor:

We used a combination of epidural and general anesthesia for a 9-yr-old boy who underwent a 4-h ureteroneosistostomy in the supine position. Epidural bupivacaine was administered for 2 days for postoperative analgesia. Upon removing the epidural catheter we observed bilateral ankle weakness, toe dorsiflexion, and foot eversion, without sensorial loss. Electromyographic studies showed focal demyelination of the peroneal nerve bilaterally at the level of the fibular head with minimal axonal damage.

Common peroneal nerve compression is a well-documented cause of postoperative drop foot (1). Several cases of common peroneal nerve injury resulting from epidural analgesia have been reported in the literature (2–4). Although the etiology of the injury in this child was likely direct pressure on the common peroneal nerve, the bilateral symmetry and lack of sensory deficit are surprising, as both sensory and motor function deficits are expected (5,6). We speculate that the common peroneal nerve injuries in our patient were due to mild pressure on the peroneal nerve that was sustained over many hours because of the anesthetic and motor blocking effects of the epidural bupivacaine infusion.

Birmingham et al. (7) demonstrated that patient-controlled epidural analgesia provides satisfactory analgesia with a small incidence of adverse side effects in children. However Chalkiadis (8) concluded that IV opioid infusion may be safer in children than epidural infusion. Our efforts to provide a completely pain-free recovery using continuous epidural bupivacaine supports Chalkiadis’s view that perhaps IV opioids are preferable, even though they provide relatively inferior pain relief.

REFERENCES

1. Britt BA, Gordon RA. Peripheral nerve injuries associated with anaesthesia. Can Anaesth Soc J 1964;11:514–36.[Medline]
2. Horlocker TT, Cabanela ME, Wedel DJ. Does postoperative epidural analgesia increase the risk of peroneal nerve palsy after total knee arthroplasty? Anesth Analg 1994;79:495–500.[Abstract/Free Full Text]
3. Hubbert CH. Peroneal palsy after epidural analgesia. Anesth Analg 1993;77:405–6.[Web of Science][Medline]
4. Cohen DE, Van Duker B, Siegel S, Keon TP. Common peroneal nerve palsy associated with epidural analgesia. Anesth Analg 1993;76:429–31.[Web of Science][Medline]
5. Britt BA, Gordon RA. Peripheral nerve injuries associated with anaesthesia. Can Anaesth Soc J 1964;11:514–36.[Medline]
6. Parks BJ. Postoperative peripheral neuropathies. Surgery 1973;74:348–57.[Web of Science][Medline]
7. Birmingham PK, Wheeler M, Suresh S, et al. Patient-controlled epidural analgesia in children: can they do it? Anesth Analg 2003;96:686–91.[Abstract/Free Full Text]
8. Chalkiadis G. Paediatr Anaesth 2003;13: 91–3.

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