///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Unilateral facial nerve palsy with epidural analgesia in labor

Abstract Number: 228
Abstract Type: Case Report/Case Series

Pankaj Jain MD1 ; Susan D Dumas MD2

Idiopathic Bells palsy is more common in pregnant patients but has not been associated with uncomplicated epidural placement.3 We report a case of facial nerve palsy associated with labor epidural analgesia that presented soon after epidural placement and completely resolved after its discontinuation.

CASE REPORT

A 34 year old healthy female G2P1 at 40 weeks was admitted to the labor floor with contractions. History and physical exam were normal. At 5.5 cm of cervical dilation, an epidural was requested. In the sitting position, an epidural catheter was unsuccessfully attempted at L3-4. The catheter was inserted at L2-3, using a 17G Tuohy needle and loss of resistance technique with saline. The catheter threaded easily and was secured with 4.5cm in the space. There was no evidence of dural puncture. Aspiration and test dose were negative for CSF or blood. Vitals signs remained stable. PCEA labor analgesia was established with an ultra low dose bupivicaine infusion. After twenty minutes, sensory exam revealed a T10 block on the left and T8 on the right. While performing a cervical exam, the obstetrician noted that the patient had a right sided Bells palsy. The patient stated that the facial droop started soon after epidural placement. Cervical dilatation was 9 cm and the patient underwent a rapid vaginal delivery with vacuum assist. After delivery, anesthesia was notified of the neurological change. On exam, drooping of the right eyelid, sagging of the right side of the mouth, and increased tearing were noted. Sensory exam revealed a T10 level on the left and C7 on the right. No upper extremity motor block or miosis was noted. The epidural infusion was stopped. The Bells palsy completely regressed three hours after discontinuing the epidural. At no time did the patient complain of a headache.

DISCUSSION

Abducens and trigeminal nerve palsies have been reported with epidural anesthesia in conjunction with inadvertent dural puncture, high sensory block, and epidural blood patch. It has been suggested that changes in subarachnoid and epidural pressures can cause cranial nerve injury or excessive upward extension of the blockade, reaching the cervical sympathetic fibers and the spinal tract nucleus.1,2 In this case, the unilateral Bells palsy was clearly related to epidural placement. A high sensory level was documented on the right side suggesting that there was unilateral cephalad spread of the local anesthetic. However, the exact mechanism remains uncertain.

References

1.Sprung J, Haddox JD, Maitra-DCruze AM. Horners syndrome and trigeminal nerve palsy following epidural anaesthesia for obstetrics. Can J Anaesth 1999 Sep;38(6):767-71.

2.Szokol JW, Falleroni MJ. Lack of efficacy of an epidural blood patch in treating abducens nerve plasy after an unintentional dura puncture. Reg Anesth Pain Med.1999 Sept-Oct;24(5):470-2.

3.Vrabec JT, Isaacson B, Van Hook JW. Bell's palsy and pregnancy.

Otolaryngol Head Neck Surg.2007 Dec;137(6):858-61.

SOAP 2009