Anesth Analg 2007;104:201-203
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000250362.34569.20
REGIONAL ANESTHESIA
Lower Extremity Paralysis After Thoracotomy or Thoracic Epidural: Image First, Ask Questions Later
John Butterworth, MD*, and
Annette Douglas-Akinwande, MD
From the Departments of *Anesthesia and Radiology, Indiana University School of Medicine, Indianapolis, Indiana.
Address correspondence and reprint requests to J. Butterworth, MD, Department of Anesthesia, 1120 South Dr., FH 204, Indianapolis, IN. Address e-mail to jfbutter{at}iupui.edu.
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Abstract
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BACKGROUND: When an epidural catheter is present, new motor deficits will often be attributed to a local anesthetic effect, potentially delaying imaging studies, or to an epidural hematoma, ignoring other mechanisms of spinal cord injury.
METHODS: A 69-yr-old female patient undergoing thoracotomy received a preoperative thoracic epidural for postoperative analgesia.
RESULTS: Intraoperatively, there was bleeding near the costovertebral junction. Hemorrhage was controlled with cellulose gauze and bone wax. Paralysis developed postoperatively and was initially misdiagnosed as a local anesthetic effect when, in fact, it was caused by an extradural deposit of cellulose gauze and bone wax.
CONCLUSIONS: We emphasize the need for prompt, definitive imaging when new lower extremity weakness develops after thoracotomy or thoracic epidural analgesia.
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Introduction
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Lower extremity paralysis is rarely seen after either thoracotomy or thoracic epidural analgesia (1,2). It is difficult to exclude conditions that warrant surgical intervention using clinical examination. Therefore, we emphasize the importance of quickly obtaining high-quality diagnostic images whenever new lower extremity weakness appears in these circumstances.
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CASE REPORT
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A 69-yr-old 70-kg woman presented for thoracotomy and resection of a right upper lobe lung mass. Her medical history was remarkable for hypertension, hypothyroidism, and a 35-yr history of cigarette smoking. She received terazosin 2 mg and thyroxine 0.25 mg daily. Her physical examination was not remarkable.
At 15:40 on the day of surgery, an epidural catheter was inserted between the 6th and 7th thoracic vertebrae 4 cm beyond the tip of the 18-gauge Tuohy needle. Epidural puncture had been first attempted between the 5th and 6th thoracic vertebrae, with venous blood return from the epidural needle. The patient was awake throughout the epidural procedure, and no blood or paresthesia was noted during the successful needle/catheter insertion. No medications were given through the catheter intraoperatively.
General anesthesia was induced at 16:15. During the thoracotomy, brisk bleeding from a rib fracture near the costovertebral junction was controlled with cautery, bone wax, and cellulose gauze. Upon awakening at 20:50, the patient moved her arms and legs and complained of pain. An infusion of bupivacaine 0.1% and fentanyl 5 µg/mL was initiated at 5 mL/h through the epidural catheter.
At 23:20, another anesthesiologist evaluated the patient for painless lower extremity weakness. A T6 sensory level was documented. Cerebrospinal fluid could not be aspirated through the epidural catheter. Intrathecal injection was considered more likely than epidural hematoma; so the infusion was discontinued and the patient's neurological examination was repeated at 30-min intervals. At 00:35, the sensory block began to recede, and at 01:40, the patient could move both of her legs.
At 03:50, there was worsening motor weakness and new back pain. Being immediately available, a nonhelical computed tomographic (CT) scan of the thoracic spine was obtained and a neurosurgeon and magnetic resonance (MR) imaging technician were summoned. The CT scan was not diagnostic for an acute epidural hematoma (Fig. 1), which is typically hyperdense (3). At 05:50, MR imaging began. At 06:25, the MR image (Fig. 2) demonstrated a dorsal epidural mass compressing the spinal cord at the level of the 5th thoracic vertebra. At 07:36, methylprednisolone was given, and the patient underwent laminectomy. The neurosurgeon found bloody cellulose gauze and bone wax within the right-sided intervertebral foramen and the right side of the spinal canal. Dense paraplegia from the T6 level extending caudad was noted when the patient awakened. Multiple postoperative consultation notes indicated that this patient had had a complication of epidural analgesia. There was no improvement after 6 yr.
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Figure 1. Nonhelical axial computed tomography (CT) image of the thoracic spine at T5 level shows ventral and left lateral displacement of he spinal cord (arrow head) in the spinal canal. There is an abnormal amount of dorsal hypodensity (arrow) which is a combination of hemostatic products and blood. The other diagnostic consideration from this image is epidural lipomatosis (an abnormal amount of epidural fat), but the clinical presentation does not support this diagnosis. On CT acute epidural hematoma without hemostatic products typically appears hyperdense. Further imaging with magnetic resonance is therefore warranted (3,4).
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Figure 2. Magnetic resonance imaging of the blood-saturated cellulose gauze and bone wax in the thoracic spine. A. Sagittal T2-weighted image of the thoracic spine demonstrates a markedly hypointense bilobed dorsal epidural mass at T5 level (arrow). B. Axial T1-weighted image at T5 demonstrates mixed signal right, dorsal epidural mass (arrow) which compresses and displaces the spinal cord ventrally and to the left (arrow head) of the spinal canal. C. Axial T1-weighted image demonstrates severe cord compression (arrows). The mixed signal arising from the blood-saturated cellulose gauze and bone wax is present both in the spinal canal (solid arrow heads) and in the right neural foramen (open arrow head). There is an artifact in the lower left corner of the image that could not be removed.
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DISCUSSION
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Bleeding at the costovertebral junction during thoracotomy procedures may be difficult to control. Surgeons may use bone wax, cellulose gauze, or cautery to achieve hemostasis. Cellulose gauze absorbs blood, expands, and provides a nidus for coagulation. Spinal cord injury from cellulose surgical gauze during thoracotomy has been described in surgical case reports (2,5–10), but only once in the anesthesia and pain management literature (11). The product labeling for both bone wax and cellulose gauze state that they are not to be used near the spine because of the fear of accidental placement or migration into the spinal canal. A memorandum in 2002 indicates that the United States Food and Drug Administration was aware of five cases in which the use of cellulose gauze near the spine led to paralysis (12).
In general, epidural compression caused by hemostatic products will appear within 24 h postoperatively, whereas "conventional" epidural hematomas may occur as late as several days postoperatively after removal of an epidural catheter. The rare occurrence of motor block from local anesthetic would be expected early after initiation of epidural dosing, and would be more likely with larger doses of local anesthetic. It will often be impossible to distinguish among these possibilities based on their clinical presentation.
MR imaging has greater resolution than that of CT and is the imaging modality of choice for the evaluation of cord compression (13) or the detection of spinal hemorrhage (3,14). In this case, the abnormal displacement and compression of the spinal cord by hypodensity due to the presence of surgically proven bone wax (4), and bloody cellulose gauze was identified retrospectively on the original CT.
Despite Food and Drug Administration intervention, most physicians may not be aware of epidural compression from cellulose gauze or bone wax used during thoracotomy procedures. This may delay diagnostic imaging in the patient with an indwelling neuraxial catheter. When new signs of leg paralysis appear after thoracotomy and/or thoracic epidural analgesia, we recommend immediate MR imaging to enable the earliest possible diagnosis of potentially reversible causes of neural deficits.
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Footnotes
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Accepted for publication October 3, 2006.
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REFERENCES
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- Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia a meta-analysis. JAMA 2003;290:2455–63.[Abstract/Free Full Text]
- Attar S, Hankins JR, Turney SZ, et al. Paraplegia after thoracotomy: report of five cases and review of the literature. Ann Thorac Surg 1995;59:1410–15.[Abstract/Free Full Text]
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Abstract
Introduction
