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Foot drop following cesarean section under spinal anesthesia
Abstract Number: S2C-1
Abstract Type: Case Report/Case Series
Introduction: Neurological complications with permanent deficit following neuraxial anesthesia in obstetrics are extremely rare (0.2-1.2:100,000) compared to neurological deficits associated with pregnancy and labor (1:1000).(1) It can be difficult to immediately identify the etiology of a neurological complication that occurs in the early postpartum period, therefore neuraxial anesthesia is often suspected as the primary cause.
Case report: A healthy 33-year-old woman (G2P1) at 39 weeks gestation underwent a repeat elective cesarean section. Spinal anesthesia was successfully performed in the sitting position at the L3-L4 interspace (using a 25G Whitacre needle), with no evidence of paresthesia. Approximately 6 hours later the patient reported paresthesia in the lateral aspect of her left lower leg, and when she attempted ambulation 4 hours later left foot drop was observed. Neurological examination revealed significant weakness of plantar flexion of the left foot (1/5), an absent plantar reflex, and reduced sensation to light touch and pinprick in the left L5-S1 dermatomes. Electromyography confirmed severe left peroneal nerve injury and mild left tibial nerve injury. Spinal MRI (performed three weeks later) was normal other than incidental findings of degeneration and mild spinal stenosis (T10-L5). Pelvic MRI revealed a 4-fold increase in the size of the left sciatic nerve because of edema and hemorrhage within the nerve sheath (Figure 1). The most likely explanation was injury to the sciatic nerve from needle penetration during intramuscular injection of methergine that was administered in the left gluteal region immediately postoperatively. Due to sensorimotor block from the spinal anesthesia at the time of the injection the patient would not have been aware of any pain from the intraneural injection. Clinical examination at 6- and 12-months showed minimal improvement in recovery of the peroneal nerve, however there was complete recovery of the tibial nerve.
Conclusion: Intramuscular injection in the gluteal region should be administered with caution or omitted in patients with sensorimotor blockade. Direct injury of the sciatic nerve from needle penetration has a poor prognosis. Neurological examination and imaging are essential to confirm the diagnosis.
1) Maronge L, Bogod D. Complications in obstetric anaesthesia. Anaesthesia 2018;73(1):61–66