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Unilateral Horner's Syndrome and Brachial Plexus Palsy with a Labor Epidural
Abstract Number: FCC-153
Abstract Type: Case Report Case Series
A 31-year-old G1P0 at 39w6d with preeclampsia undergoing augmentation of labor requested an epidural. Past medical history included anxiety and migraines with aura. Her CBC and CMP were unremarkable.
The epidural was easily placed using loss of resistance to air and a nylon 20G closed tip catheter was threaded 4.5cm in the epidural space. After negative test dose,10cc of 0.125% bupivacaine was given and a 0.125% bupivacaine with 2mcg/ml fentanyl infusion was started at 6cc/hr. Over the next 30mins, the patient reported right hand paresthesias that progressed to right upper extremity numbness and then, marked weakness. Her sensory level was found to be T10 bilaterally to temperature, without chest wall or left arm numbness, respiratory depression, or hemodynamic compromise. The patient denied headache or vision changes. Neurologic exam was notable for mild right ptosis and injected sclera, right pupil smaller than left, partial paralysis of the right upper extremity (0/5 strength in triceps, finger flexion/extension, interossei, thumb abduction, wrist flexion), decreased sensation to light touch and pinprick on the right upper extremity, and 1+ reflex in the right triceps. The differential included preeclampsia with focal neurologic deficit, migraine with transient weakness, TIA, carotid dissection, and epidural side effect. The epidural infusion was paused for an MRI/MRA of the brain/c-spine, which was unrevealing. Shortly after, the patient experienced resolution of symptoms except for persistent Horner's syndrome. Epidural replacement was discussed with her, and she elected to continue with the original catheter. The catheter was bolused with 7cc of 0.125% bupivacaine and the infusion restarted. Within 30mins, her pain was well controlled with a T11 bilateral sensory level, but the paresis returned to her right fingers and arm. The patient was closely observed during her 8hrs of labor, and the catheter was discontinued after delivery. Within a few hours of removal, her neurologic exam returned to her normal baseline.
Horner’s syndrome is a recognized complication of lumbar epidural anesthesia (1). Multiple possible etiologies have been described, but cephalic spread of the local anesthetic to interrupt the sympathetic chain, in the region of C8 to as low as T4, is surmised. Unilateral Horner’s syndrome accompanied by ipsilateral brachial plexus palsy has been reported exceedingly rare, and the mechanism not well understood. While the symptomatology in this case suggests unilateral cephalic spread of local anesthetic, our assessment of symmetric T10 level is inconsistent with prior case reports, which were associated with truncal levels of T6 or higher (2). Upon our review, this is the first reported instance of Horner’s syndrome and ipsilateral brachial plexus palsy after labor epidural placement with an assessed low (T10) truncal level.
1. Jadon A. Indian J Anaesth. 2014;58(4):464-466.
2. Holzman RS. J Clin Anesth. 2002;14(6):464-466.