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Paraplegia of Unknown Etiology Following Spinal Anesthesia for Cesarean Section
Abstract Number: T-45
Abstract Type: Case Report/Case Series
INTRODUCTION: Neurologic injury after neuraxial blockade is a rare event with potentially devastating consequences. We present a case of paraplegia following spinal anesthesia for Cesarean section.
CASE: A 45 yo G7P1051 with no significant past medical history presented at 26 1/7 with severe preeclampsia. In addition, this pregnancy was complicated by advanced maternal age and multiple known fetal anomalies. She was delivered by cesarean section for nonreassuring fetal status. Spinal anesthesia with 15mg bupivacaine, 10mcg fentanyl, and 200 mcg hydromorphone was performed without incident. The following day, the patient complained of bilateral mild upper and lower extremity weakness, which was initially thought to be due to magnesium toxicity. However, the weakness progressed after discontinuation of magnesium.
Multiple consultations were obtained including physical medicine, neurology, and psychiatry. Her neurologic exam was inconsistent and progressively worsening. She was found to have significant lower extremity weakness and absent deep tendon reflexes. The differential diagnosis included Guillian-Barre syndrome, spinal cord ischemia or hematoma, multiple sclerosis, cauda equina syndrome, and conversion disorder.
Electrolytes, PTH, vitamin D, and a sensory-motor neuropathy antibody panel were normal. MRIs of the lumbar plexus, cervical, lumbar, thoracic spines, and a head venograph were significant only for mild degenerative changes in the spine. A brain MRI revealed scattered hyperintense white matter foci that were felt to be nonspecific. On postoperative day #6, the patient was transferred to inpatient rehabilitation. An EMG performed six weeks after symptom onset was equivocal. There were findings suggestive of a possible upper motor neuron lesion but the exam was inconclusive for a definitive diagnosis. Deemed medically stable, she was discharged home wheelchair-bound with physical and occupational therapy. She was referred for outpatient follow-up, but remains with an unclear diagnosis and uncertain prognosis.
DISCUSSION: Evaluation of suspected neurologic injury begins with a thorough history and exam to localize the lesion. The deficit may either be transient, require immediate intervention, or require a multidisciplinary approach with appropriately timed neuroconduction studies and imaging(1,2). Patients with pre-existing deficits or predisposing conditions are at increased risk, but unpredictable complications may occur in healthy patients(3). Thorough preoperative assessment, meticulous neuraxial anesthetic technique, and prompt evaluation of any neurologic injury are essential to minimize complications(1). In our patient, the diagnosis was elusive in light of her lack of risk factors, negative or inconclusive imaging, and inconsistent neurologic exam.
1. Wong C. Best Prac & Research Clin Ob & Gyn 2010;24:367-381
2. Sorenson EJ. Reg Anes Pain Med 2008;33:442-448
3. Moen V. et al. Anesthesiology 2004;101:950-959