Spinal cord infarction following surgery for mesenteric vascular occlusion

We present a case of spinal cord infarction following an operation on a 64-year-old man for mesenteric vascular occlusion under combined general and epidural anesthesia. Several etiological factors, each one able to affect blood flow in the spinal cord and cause infarction, might have been present in our patient, including generalized degenerative atherosclerotic vascular disease, secondary polycythemia resulting from the patient's chronic obstructive pulmonary disease, and intraoperative hypotensive episodes. This case shows that, even with careful technique, hemodynamic monitoring, and early evaluation of neurologic status, patients can experience irreversible spinal cord ischaemia that results in permanent paraplegia.     

Spinal cord infarction and paraplegia after peripheral vascular surgery with spinal anesthesia

Paraplegia after peripheral vascular surgery under spinal anesthesia is rare and may be a result of multiple factors, including hematoma, trauma from the needle, toxic injection, and spinal cord infarction. We report a case of T(10) paraplegia after uncomplicated spinal anesthesia in a patient undergoing emergency thrombectomy and femoral-popliteal bypass.     

Paraplegia after combined general and epidural anesthesia: a case report

Neurological complications after epidural anesthesia performed for abdominal surgery are uncommon, but of important consequence with significant morbidity. Paraplegia is very rare and may be a result of multiple factors. We report a case of elective colectomy under combined general and epidural anesthesia for a carcinoma. An epidural infusion was used for intra-operative and post-operative analgesia. During induction of anesthesia, the patient was asystolic for a few seconds and during the first postoperative day, a hypotensive episode was registered. He then developed a sensory-motor deficit in the legs. A spinal cord infarction at the level of T10 extending to T2 was diagnosed with magnetic resonance imaging. The association of hypotension as a cause of spinal cord infarction is discussed. The factors that may have contributed to paraplegia and preventive neuroprotective strategies are reviewed.     

Spinal cord ischemia following thoracotomy without epidural anesthesia

PURPOSE: Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. CLINICAL FEATURES: A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5-6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5-6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. CONCLUSION: In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.     

Acute flaccid paraplegia: a rare complication of meningococcal meningitis

STUDY DESIGN: A case report of spinal cord dysfunction following meningococcal meningitis. OBJECTIVES: To describe a rare complication of meningococcal meningitis. SETTING: Spinal Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. METHODS: A young healthy male developed meningococcal meningitis followed by acute onset low thoracic flaccid paraplegia with complete motor and sensory loss and sphincter disturbance. He responded well to antibiotics but was not investigated for causes of paraplegia. While at home in a rural area, he developed pressure ulcers, anemia and depression. Magnetic resonance imaging of the whole spine and computed tomography scan of the brain performed after 4 and 10 weeks were normal. RESULTS: The patient had a comprehensive rehabilitation at our institute. Recovery was complicated by ossification in the right thigh, which responded well to radiotherapy. At 1-year follow-up, the motor deficit and neurogenic bladder and bowel persisted and the patient remained wheelchair dependent for mobility. CONCLUSION: Several mechanisms have been proposed to explain spinal cord damage after meningitis. These include spinal cord infarction; autoimmune-mediated inflammatory myelopathy and direct infection of the cord. Most probable cause of spinal cord dysfunction in this case was thoracic myelopathy.     

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.     

Anterior spinal artery syndrome after thoracic surgery

Spinal cord infarction is a rare complication following thoracic surgery. We present a case who developed paraplegia on the first postoperative day of thoracotomy. A 76-year-old man with a history of atherosclerotic cardiovascular disease was operated for bronchial carcinoma. An epidural infusion of ropivacaine and sufentanil was used for postoperative pain. Eight hours after the surgery, he had an episode of hypotension and respiratory depression. One hour later, he described paraplegia and Ischemia of the spinal cord was found on MRI. There was no recovery during the follow-up.     

Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia

Background and Objectives. A case of permanent paraplegia is reported following attempted epidural anesthesia for a total knee replacement in a 62-year-old woman with a history of lumbar laminectomy for a prolapsed intervertebral disc. Methods. Epidural puncture was attempted during general anesthesia and neuromuscular block. Results. After four unsuccessful attempts, an epidural catheter was inserted above the upper end of the laminectomy scar. Several episodes of arterial hypotension occurred intraoperative and postoperative. Operative blood loss was minimal, and no bone glue was used. The patient awoke paraparetic with a sensory level of anesthesia to T5 bilaterally. MRI revealed an air bubble in the cord at T10 and a region of increased T₂-weighted signal in the anterior aspect of the spinal cord between T4 and T5, consistent with infarction. Conclusion. Standards of management are discussed in relation to this case.     

Paraplegia following the emergency surgical repair of a nonruptured symptomatic abdominal aortic aneurysm: Report of a case

This report presents an extremely rare case of paraplegia following emergency surgery for a nonruptured symptomatic abdominal aortic aneurysm. A 62-year-old man underwent an emergency surgical repair for a symptomatic nonruptured infrarenal abdominal aortic aneurysm. On postoperative day 2 paraplegia following spinal cord ischemia occurred at the T8 level. The site of the ischemia was situated too high for clamping to have caused this condition, unless the patient had a congenital anomaly in the blood supply to the spinal cord or it had been caused by the previously occluded great radicular artery, which was maintained by the collateral blood supply from the iliac circulation.     

Complete paraplegia as a result of regional anesthesia

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.     

Anesthesia for cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord

PURPOSE: Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case. CLINICAL FEATURES: The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia. CONCLUSIONS: Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.     

Acute aortic thrombosis presenting as painless paraplegia

Two patients with acute aortic thrombosis presented with painless paraplegia secondary to spinal cord infarction. In one case, the initial symptom was unilateral leg weakness, leading to the misdiagnosis of stroke. In the other case, a patient with a large, painful vulvar abscess, experienced spontaneous relief of pain. In the complete absence of pain, both patients slept undisturbed and awoke with complete paraplegia, incontinence, and cadaveric extremities. Aortic reconstruction was advised to obviate thigh or hindquarter amputation, not to restore limb function. One patient died on the second postoperative day; the second remains well but paraplegic two years later.     

Hemodynamic infarction of the spinal cord: involvement of the gray matter plus the border-zone between the central and peripheral arteries

OBJECTIVE: Hemodynamic infarction of the spinal cord that affected an 81-year-old female having a dissecting aortic aneurysm is presented. During the graft replacement operation, systemic hypotension occurred and the patient was subsequently complicated with paraplegia of the lower limbs. The patient died 2 weeks after the surgery due to gastrointestinal bleeding. An autopsy, which did not include the brain, was performed and the spinal cord was sampled. The aim of this report is to describe the pathologic profile of the spinal cord of the patient, and to gain insight into the pathogenesis of the lesion. METHODS: Histochemical and immunohistochemical methods were employed to study the spinal cord ranging from the lower thoracic to sacral segments. RESULTS: The whole central areas of the spinal cord showed coagulation and/or liquefaction necroses, while the white matter on the circumference of the cord remained unaffected, thus exhibiting a 'ring-like' appearance. CONCLUSION: This case is an example of hemodynamic infarction of the spinal cord involving the gray matter that is supplied by the central artery, plus the border-zone that is supplied by both the central and peripheral arteries. The former is probably associated with selective vulnerability of the gray matter to ischemia, while the latter is probably associated with intrinsic vulnerability of the border-zone to systemic hypotension or low blood-flow states.     

Postoperative paraplegia coincident with single shot spinal anaesthesia

Paraplegia is a rare but serious complication of spinal anaesthesia. We report an 83-year-old patient who developed anterior spinal artery syndrome resulting in paraplegia some 24 hours after undergoing spinal anaesthesia for a Moore's hemiarthroplasty. Return of neurologic function was documented prior to the onset of paralysis, with magnetic resonance imaging evidence suggestive of spinal cord infarction.     

Paraplegia caused by painless acute aortic dissection

OBJECTIVES: Painless acute aortic dissection in which paraplegia is the only presenting sign is rare, with limited reported cases. CASE REPORT: The authors report a patient with painless acute aortic dissection who presented with sudden onset paraplegia. Ischemic diseases of the spinal cord were suspected as the cause. MRI revealed extensive acute aortic dissection with an intramural hematoma. The patient was treated conservatively by strictly controlling his blood pressure. The treatment was successful, although the motor function of the lower extremities could not be rescued. Although 3% to 5% of patients with acute aortic dissection present with paraplegia as a result of spinal cord infarction, most of these patients experience severe pain prior to presentation. CONCLUSION: Painless acute aortic dissection in which paraplegia is the only presenting sign is very rare. However, aortic diseases, including acute aortic dissection, should always be considered as a differential diagnosis of patients with sudden onset, painless paraplegia.     

Subarachnoid hematoma and spinal anesthesia

Two cases of spinal subarachnoid haematoma occurring after spinal anaesthesia are reported. In the first case, lumbar puncture was attempted three times in a 81-year-old man; spinal anaesthesia trial was than abandoned, and the patient given a general anaesthetic. He was given prophylactic calcium heparinate soon after surgery. On the fourth day, the patient became paraparetic. Radioculography revealed a blockage between T10 and L3. Laminectomy was performed to remove the haematoma, but the patient recovered motor activity only very partially. The second case was a 67-year-old man, in whom spinal anaesthesia was easily carried out. He was also given prophylactic calcium heparinate soon after surgery. On the fourth postoperative day, pulmonary embolism was suspected. Heparin treatment was then started. Twelve hours later, lumbar and bilateral buttock pain occurred, which later spread to the neck. On the eighth day, the patient had neck stiffness and two seizures. Emergency laminectomy was carried out, which revealed a subarachnoid haematoma spreading to a level higher than T6 and below L1, with no flow of cerebrospinal fluid, and a non pulsatile spinal cord. Surgery was stopped. The patient died on the following day. Both these cases are similar to those previously reported and point out the role played by anticoagulants. Because early diagnosis of spinal cord compression is difficult, the prognosis is poor, especially in case of paraplegia.     

Post-thoracotomy paraplegia coincident with epidural anaesthesia

We report a case of paraplegia in the immediate postoperative period following right bilobectomy for carcinoma of the lung. An epidural catheter had been inserted following induction of anaesthesia and an infusion of bupivacaine 0.15% was used for postoperative pain relief. Magnetic resonance imaging failed to reveal any spinal or epidural haematoma or spinal cord ischaemia. The patient developed respiratory failure on the third postoperative day and required assisted ventilation. He was weaned from the ventilator on day 15. Two days later he sustained a cardiac arrest and died. Post-mortem examination demonstrated spinal cord infarction and severely stenosed spinal arteries. The thoracotomy position and/or intra-operative hypotension might have compromised the blood flow to the spinal cord and although suspected as a possible cause, the use of epidural analgesia was not implicated.     

Paraplegia following intraaortic balloon assistance.

In a patient receiving intraaortic balloon counterpulsation following myocardial revascularization, paraplegia developed two days post-operatively. Postmortem examination demonstrated a dissecting hematoma of the thoracic aorta and spinal cord infarction. The neurological deficit is thought to be due to embarrassment of spinal cord blood supply, and mechanisms of injury are discussed.     

Primary amyloidoma of the thoracic spine presenting with acute paraplegia

BACKGROUND

Primary solitary amyloidoma of the spine is a rare disease characterized by localized deposition of amyloid. To the best of our knowledge, there have been only 14 cases previously reported in the literature. Patients with focal spinal amyloidoma usually have relatively long symptomatic periods preoperatively, ranging from 3 weeks to 6 years (mean: 12 months). Only two reported patients had acute paraplegia. We add a third case of a thoracic spine amyloidoma presenting with acute paraplegia.

CASE DESCRIPTION

A 65-year-old man presented with a three-day history of progressive paraplegia and urinary retention. He was found to have severe cord compression at T2 on magnetic resonance imaging. He underwent emergent decompressive laminectomy with instrumentation for spinal stabilization. Histopathology revealed abundant amyloid deposits. A systemic work-up was negative for amyloidosis. The patient showed marked neurological improvement with residual mild spastic gait after 1 year.

CONCLUSIONS

Primary spinal amyloidoma with acute paraplegia is rare. One-stage surgery combining prompt decompression and stabilization of the spinal column is mandatory in cases of spinal amyloidoma with acute myelopathy, because primary solitary amyloidoma carries a good prognosis.     

Cerebrospinal fluid drainage to treat delayed paraplegia after stent grafting of the descending thoracic aorta

Delayed onset of paraplegia secondary to spinal cord ischemia is a rare but serious complication that can appear after endovascular repair of an aneurysm in the descending thoracic aorta, although this complication is significantly less frequent after stent grafting than after conventional surgical repair. We report the case of a man who developed paraplegia 36 hours after insertion of 4 stents in the descending thoracic aorta. The paraplegia reversed after a spinal catheter was placed to monitor cerebrospinal fluid pressure and to provide drainage.