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Persistent cauda equina syndrome following uneventful spinal anesthesia with 0.75% hyperbaric bupivacaine in a healthy parturient
Abstract Number: SUN-51
Abstract Type: Case Report/Case Series
Cauda equina syndrome is a rare but serious complication that can occur following intrathecal administration of local anesthetics.[1,2] We present a case of persistent cauda equina syndrome six months following an uncomplicated spinal anesthetic in a parturient with 0.75% hyperbaric bupivacaine.
A 33 year old healthy primiparous lady presented at term gestation for induction of labor. She had no pre-existing history of neurologic disorder. Upon request, labor epidural analgesia was placed uneventfully on first attempt at the level of L2-3. Analgesia was maintained using programmed intermittent epidural boluses with 0.08% bupivacaine and 2 mcg/mL fentanyl solution. Twelve hours later, the obstetrician recommended a cesarean delivery due to failure to progress and non-reassuring fetal heart tracing. An epidural-top-up was not attempted due to evidence of inadequate sensory block and a single-shot-spinal anesthetic was discussed with the patient. No motor block was present prior to the procedure. With the patient in the sitting position, a disposable 2% chlorhexidine swab stick was used for skin sterilization. An appropriate drying period was allowed prior to dural puncture at L3-4 using a 25G Whitacre needle. Clear CSF return was seen on first attempt, and 1.5mL 0.75% hyperbaric bupivacaine, 100 mcg preservative-free morphine and 10 mcg fentanyl was administered. Ten minutes following administration, the patient achieved symmetric T4 block to ice and surgery proceeded uneventfully. Twelve hours postpartum, there was absence of sensation and motor function below the L4 dermatome, with urinary retention requiring bladder catheterization. Lumbar spine MRIs performed at 24 hours, and repeated at 48 hours, showed the conus medullaris terminating normally at L1-2 with no evidence of cord or spinal canal abnormality. A subsequent MRI seven days postpartum, demonstrated enhancement of the conus and cauda equina nerve roots. Investigations with lumbar puncture and nerve conduction studies failed to identify the cause of injury. Pulsed intravenous steroids and immunoglobulins were empirically started for a possible autoimmune etiology. Six months postpartum, the patient continues to have significant sensory and motor deficits, and requires intermittent self-catheterization and assistance in defecation.
Toxic polyradiculopathy due to hyperbaric bupivacaine was the presumptive cause of the injury; however there remains considerable diagnostic uncertainty with this case. Root cause analysis failed to identify an underlying cause of this sentinel event. The lack of an explanation is highly distressing for the patient, her family, and anesthesia providers. Studies into the possible risk factors and mechanism underlying bupivacaine neurotoxicity are desperately needed to help us understand how this devastating complication could be prevented.
1 Kubina P et al. Reg Anesth 1997
2 Chabbouh T et al. Anesth Analg 2005