Recurrent Psychogenic Paresis after Dural Puncture in a Parturient
Abstract Number: S-68
Abstract Type: Case Report/Case Series
This case report describes a 29 year old G4P1 parturient who after undergoing elective cesarean section with general anesthesia, displayed symptoms of lower extremity weakness and sensory deficits. The parturient’s past medical history was significant for asymptomatic Arnold-Chiari Type 1 malformation, migraine disorder and asthma. The patient had initially been given a standard spinal anesthetic, but the spinal anesthetic failed to achieve an adequate surgical level of anesthesia. A general anesthetic was then administered uneventfully. After extubation, the patient exhibited bilateral leg weakness that did not resolve over the next 4-6 hours. An emergent MRI of the spine revealed a normal spine with no evidence of hematoma. The lower extremity paresis persisted and a neurology consult was requested. The neurologist diagnosed the patient with psychogenic paresis, a type of conversion disorder. The patient’s leg weakness spontaneously resolved by postoperative day 5. Interestingly, the patient’s postoperative leg paresis was not her first occurrence of neurological dysfunction after dural puncture. Earlier in her pregnancy at 27 weeks gestation, she had similar lower extremity symptoms after a lumbar puncture was performed to rule out meningitis for severe headache symptoms. Her neurological function spontaneously resolved within a week at that time as well.
Psychogenic paresis is not commonly reported in the medical literature. We found no reports of psychogenic paresis after spinal anesthesia in a parturient or recurrent psychogenic paresis in a patient. Psychogenic paresis, or hysterical paraplegia, is a type of conversion disorder that patients can exhibit after medical procedures. The DSM-IV-TR defines conversion disorder as a “mental disorder whose central feature is the appearance of symptoms affecting the patient's senses or voluntary movements that suggest a neurological or general medical disease or condition”(1). A conversion disorder cannot be explained by a medical condition, substance abuse, or other mental disorder, and is usually a diagnosis of exclusion. The condition is not intentionally produced, as in malingering or factitious disorder (1). Our patient demonstrated a nonanatomic distribution of her neurologic deficit, which is a feature of this disorder (2). Our case report reviews the various risk factors, etiology, neurological signs and symptoms, therapy and future management of a patient with recurrent conversion disorder. We also review the regional anesthetic considerations for patients with Type 1 Arnold Chiari malformation.
(1)American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC; 2000.
(2)Judge, Spielman. Postoperative conversion disorder in a pediatric patient. Pediatric Anesthesia. 20(11):1052-4; 2010.