Paraplegia and intracranial hypertension following epidural anesthesia: report of four cases

Kliemann, Frederico A. D.

doi:10.1590/S0004-282X1975000300004

Abstracts

Four patients who received epidural anesthesia presented sustained myelopathy; three of them had complete paraplegia and one a lumbo-sacral myelopathy with urinary retention. All four patients complained of very intense radicular pains immediately after the analgesic effect of Lidocaine was over. Two patients in whom lumbar puncture was done in the first 24 hours presented an aseptic meningitic reaction in CSF. Paraplegia completed in two to ten months in three patients and in two of them severe intracranial hypertension developped at this time. It is proposed that the disease runs a two-stages course, at least in some cases, characterized by an aseptic meningitis, followed, after a silent period of some months, by signs of adhesive spinal and intracranial arachnoiditis. Intracranial hypertension was controlled by ventriculo-peritoneal shunt; in two patients a transitory effect of intrathecal injections of methyl-prednisolone acetate was observed. Two patients recovered almost completely from paraplegia.

Quatro pacientes que receberam anestesia epidural apresentaram mielopatia de longa evolução; em três ocorreu paraplegia completa e um apresentou uma síndrome medular lombo-sacra com retenção urinária. Todos os pacientes se queixaram de intensas dores radiculares imediatamente após a cessação do efeito analgésico da lidocaína. Dois pacientes apresentaram uma reação meningítica asséptica no líquido cefalorraqueano nas primeiras 24 horas. A paraplegia tornou-se completa em 2 a 10 meses após a anestesia; dois pacientes tiveram hipertensão craniana severa. Em alguns casos, senão em todos, esta afecção apresenta uma evolução em duas etapas, caracterizadas por meningite asséptica imediata, seguida, depois de um período silencioso de poucos meses, de sinais de aracnoidite adesiva espinal e intracraniana. A hipertensão intracraniana foi controlada por derivação ventriculo-peritoneal; em 2 pacientes houve melhora transitória pela administração de metil-prednisolona intratecal. Em dois pacientes houve recuperação quase completa da paraplegia.

Paraplegia and intracranial hypertension following epidural anesthesia. Report of four cases

Paraplegia e hipertensão craniana após anestesia epidural. Relato de 4 casos

Frederico A. D. Kliemann

Department or Internal Medicine. Division of Neurology, Faculty of Medicine of Porto Alegre, Federal University of Rio Grande do Sul, and Instituto de Neurocirurgia, Porto Alegre, Brasil

SUMMARY

Four patients who received epidural anesthesia presented sustained myelopathy; three of them had complete paraplegia and one a lumbo-sacral myelopathy with urinary retention. All four patients complained of very intense radicular pains immediately after the analgesic effect of Lidocaine was over. Two patients in whom lumbar puncture was done in the first 24 hours presented an aseptic meningitic reaction in CSF. Paraplegia completed in two to ten months in three patients and in two of them severe intracranial hypertension developped at this time. It is proposed that the disease runs a two-stages course, at least in some cases, characterized by an aseptic meningitis, followed, after a silent period of some months, by signs of adhesive spinal and intracranial arachnoiditis. Intracranial hypertension was controlled by ventriculo-peritoneal shunt; in two patients a transitory effect of intrathecal injections of methyl-prednisolone acetate was observed. Two patients recovered almost completely from paraplegia.

RESUMO

Quatro pacientes que receberam anestesia epidural apresentaram mielopatia de longa evolução; em três ocorreu paraplegia completa e um apresentou uma síndrome medular lombo-sacra com retenção urinária. Todos os pacientes se queixaram de intensas dores radiculares imediatamente após a cessação do efeito analgésico da lidocaína. Dois pacientes apresentaram uma reação meningítica asséptica no líquido cefalorraqueano nas primeiras 24 horas. A paraplegia tornou-se completa em 2 a 10 meses após a anestesia; dois pacientes tiveram hipertensão craniana severa. Em alguns casos, senão em todos, esta afecção apresenta uma evolução em duas etapas, caracterizadas por meningite asséptica imediata, seguida, depois de um período silencioso de poucos meses, de sinais de aracnoidite adesiva espinal e intracraniana. A hipertensão intracraniana foi controlada por derivação ventriculo-peritoneal; em 2 pacientes houve melhora transitória pela administração de metil-prednisolona intratecal. Em dois pacientes houve recuperação quase completa da paraplegia.

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Departamento de Medicina Interna Hospital de Clínicas da U.F.R.G.S. Rita Ramiro Barcelos 90000 Porto Alegre. RS Brasil.

Acknowledgments The author wishes to express his tanks to Dr. Felizberto Ferreira for his support and encouragement and to the anesthesiologists whose kind and precise informations were of great value.

1. AUTIO, E.; SUOLANEN, J.; NORRBACK, S. & SLÄTIS, P. Adhesive arachnoiditis after lumbar myelography with meglumine iothalamate (Conray). Acta Radiologica Diagnosis 12:17, 1972.
2. BONICA, J. J.; BACKUP, P. H.; ANDERSON, C. E.; HADFIELD, D.; CREPPS, W. F. & MONK, B. F. Peridural block: analysis of 3.637 cases and a review. Anesthesiology 18:723, 1957.
3. BRAHAM, M. C. & SAIA, A. Neurological complications of epidural anesthesia. British Med. J., Sept. 13:657, 1958.
4. CATTERBERG, J. & INSAUSTI, T. Paraplegias consecutivas a anestesia peridural (Estudo clínico y experimental). Rev. Asociación Médica Argentina 78:1, 1984.
5. DAVIES, A.; SOLOMON, B. & LEVENE, A. Paraplegia following epidural anesthesia. British Med. J. 2:654, 1958.
6. DAVIS, F. M.: LLLEWELLIN, R. C. & KIRGIS, H. D. Water soluble contrast myelography using meglumine iothalamate (Conray) with methyl-prednisole acetate (Depo-Medrol). Radiology 90:7905, 1968.
7. DRIPPS, R. D. & VANDAM, L. D. -- Long-term follow-up of patients who received 10.098 spinal anesthetics. J.A.M.A. 156:1486, 1954.
8. DROGUET, M. P. & DJINDJIAN, R. A props d'un malade atteint d'arachnoidite spinale, opéré et considérablement amélioré. Rev. Neurol. (Paris) 102:295, 1960.
9. GREENFIELD, J. G.; RICKARDS, A. G. & MANNING, G. B. The pathology of paraplegia occurring as a delayed sequela of spinal anesthesia, with special reference to the vascular changes. J. Path. Bact. 119:107, 1955.
10. HELLMANN, K. Epidural anaesthesia in Obstetrics: a second look at 26.127 cases. Can. Anaesth. Soc. J. 12:398, 1965.
11. HOWLAND, W. J. & CURRY, J. L. Experimental studies of Pantopaque arachnoiditis. Radiology 87:253, 1966.
12. JOSEPH, S. I. & DENSON, J. S. Spinal anesthesia, arachnoiditis and paraplegia. J.A.M.A. 168:1330, 1958
13. KENNEDY, F.; SOMBERG, H. M. & GOLDBERG, B. R. Arachnoiditis and paralysis following spinal anesthesia. J.A.M.A. 129:664, 1945.
14. LEHRER, G. M.; MAKER, H. S. & WEISSBARTH, S. Brain uptake of Cortisol and cortisone from the CSF and systemic sites. Neurology (Minneapolis) 23: 63, 1973.
15. LÖFSTRÖM, B. Clinical evaluation of local anesthetics. In BONICA, J. J. Regional Anesthesia. F. A. Davis Co., Philadelphia, 1969, pág. 20-43.
16. LUNDY, J. S.; ESSEX, H. E. & KERNOHAN, J. W. Experiments with anesthetics: lesions produced in spinal cord of dogs by dose of procaine hydrochloride sufficient to cause permanent and fatal paralysis. J.A.M.A. 101:1546, 1933.
17. MCDONALD, A. D. & WATKINS. K. H. An experimental investigation into the cause of paralysis following spinal anaesthesia. British J. Surg. 25:897, 1938.
18. MEYER, A. Intoxications. In BLACKWOOD, W.; MAcMENEMEY, H. W.; MEYER, A.; NORMAN, R. M. & RUSSELL, D. S. Greenfields Neuropathology. 2nd ed. Edward Arnold Publishers, London, 1963, pág. 249-251.
19. MOORE, D. C. & BRIDENBAUGH, L. D. Spinal (subarachnoid) block: a review of 11.574 cases. J.A.M.A. 195:907, 1966.
20. NELSON, D.; VATES Jr., T. & THOMAS Jr., R. Complications from intrathecal steroid therapy in patients with multiple sclerosis. Acta Neurol. Scand. 49:176, 1973.
21. NICHOLSON, M. J. & EVERSOLE, V. H. Neurologic complications of spinal anesthesia. J.A.M.A. 132:679, 1964.
22. PADDISON, R. M. & ALPERS, B. J. Role of intra-thecal detergents in pathogenesis of adhesive arachnoiditis. Arch. Neurol. Psychiat. (Chicago) 71: 87, 1954.
23. PHILLIPS, O. C.; EBNER, H.; NELSON, A. T. & BLACK, M. H. Neurologic complications following spinal anesthesia with Lidocaine: a prospective review of 10.440 cases. Anesthesiology 30:284, 1969.
24. RITCHIE, J. M.; COHEN, P. J. & DRIPPS, R. D. Local Anesthetics. In GOODMAN, L. S. & GILMAN, A. The Pharmacological Basis of Therapeutics. 4th Ed. The MacMillan Co., New York, 1970, pág. 371-401.
25. SCHWARTZ, G. A. & BEVILACQUA, J. E. Paraplegia following spinal anesthesia. Arch. Neurol. (Chicago) 10:308, 1964.
26. SHANTHA, T. R. & EVANS, J. A. The relationship of epidural anesthesia to neural membranes and arachnoid viii. Anesthesiology 37:543, 1972.
27. TSUKAGOSHI, H.; MORI, H.; ENOMOTO, A.; NAKAO, K. & FUKUSHIMA, N. Sensory polyradiculoneuropathy following spinal anesthesia. Neurology (Minneapolis) 20:266, 1970.
28. URQUHART-HAY, D. Paraplegia following epidural analgesia. Anesthesia 24:461, 1969.
29. WEISS, R. M.; SWEENEY, L. & DREYFUSS, M. Circunscribed adhesive spinal arachnoiditis. J. Neurosurg. 10:435, 1962.
30. WINKELMAN, N. W. Neurologic symptoms following accidental intraspinal detergent injection. Neurology (Minneapolis) 2:284, 1952.
31. WISE, B. L. & SMITH, M. Spinal arachnoiditis ossificans. Arch. Neurol. (Chicago) 13:391, 1965.
32. YASKIN, H. A. & ALPERS, B. J. Neuropsychiatry complications following spinal anesthesia. Ann. Int. Med. 23:184, 1945.

Publication Dates

Publication in this collection
05 Apr 2013
Date of issue
Sept 1975

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. AUTIO, E.; SUOLANEN, J.; NORRBACK, S. & SLÄTIS, P. Adhesive arachnoiditis after lumbar myelography with meglumine iothalamate (Conray). Acta Radiologica Diagnosis 12:17, 1972.

[2] 2. BONICA, J. J.; BACKUP, P. H.; ANDERSON, C. E.; HADFIELD, D.; CREPPS, W. F. & MONK, B. F. Peridural block: analysis of 3.637 cases and a review. Anesthesiology 18:723, 1957.

[3] 3. BRAHAM, M. C. & SAIA, A. Neurological complications of epidural anesthesia. British Med. J., Sept. 13:657, 1958.

[4] 4. CATTERBERG, J. & INSAUSTI, T. Paraplegias consecutivas a anestesia peridural (Estudo clínico y experimental). Rev. Asociación Médica Argentina 78:1, 1984.

[5] 5. DAVIES, A.; SOLOMON, B. & LEVENE, A. Paraplegia following epidural anesthesia. British Med. J. 2:654, 1958.

[6] 6. DAVIS, F. M.: LLLEWELLIN, R. C. & KIRGIS, H. D. Water soluble contrast myelography using meglumine iothalamate (Conray) with methyl-prednisole acetate (Depo-Medrol). Radiology 90:7905, 1968.

[7] 7. DRIPPS, R. D. & VANDAM, L. D. -- Long-term follow-up of patients who received 10.098 spinal anesthetics. J.A.M.A. 156:1486, 1954.

[8] 8. DROGUET, M. P. & DJINDJIAN, R. A props d'un malade atteint d'arachnoidite spinale, opéré et considérablement amélioré. Rev. Neurol. (Paris) 102:295, 1960.

[9] 9. GREENFIELD, J. G.; RICKARDS, A. G. & MANNING, G. B. The pathology of paraplegia occurring as a delayed sequela of spinal anesthesia, with special reference to the vascular changes. J. Path. Bact. 119:107, 1955.

[10] 10. HELLMANN, K. Epidural anaesthesia in Obstetrics: a second look at 26.127 cases. Can. Anaesth. Soc. J. 12:398, 1965.

[11] 11. HOWLAND, W. J. & CURRY, J. L. Experimental studies of Pantopaque arachnoiditis. Radiology 87:253, 1966.

[12] 12. JOSEPH, S. I. & DENSON, J. S. Spinal anesthesia, arachnoiditis and paraplegia. J.A.M.A. 168:1330, 1958

[13] 13. KENNEDY, F.; SOMBERG, H. M. & GOLDBERG, B. R. Arachnoiditis and paralysis following spinal anesthesia. J.A.M.A. 129:664, 1945.

[14] 14. LEHRER, G. M.; MAKER, H. S. & WEISSBARTH, S. Brain uptake of Cortisol and cortisone from the CSF and systemic sites. Neurology (Minneapolis) 23: 63, 1973.

[15] 15. LÖFSTRÖM, B. Clinical evaluation of local anesthetics. In BONICA, J. J. Regional Anesthesia. F. A. Davis Co., Philadelphia, 1969, pág. 20-43.

[16] 16. LUNDY, J. S.; ESSEX, H. E. & KERNOHAN, J. W. Experiments with anesthetics: lesions produced in spinal cord of dogs by dose of procaine hydrochloride sufficient to cause permanent and fatal paralysis. J.A.M.A. 101:1546, 1933.

[17] 17. MCDONALD, A. D. & WATKINS. K. H. An experimental investigation into the cause of paralysis following spinal anaesthesia. British J. Surg. 25:897, 1938.

[18] 18. MEYER, A. Intoxications. In BLACKWOOD, W.; MAcMENEMEY, H. W.; MEYER, A.; NORMAN, R. M. & RUSSELL, D. S. Greenfields Neuropathology. 2nd ed. Edward Arnold Publishers, London, 1963, pág. 249-251.

[19] 19. MOORE, D. C. & BRIDENBAUGH, L. D. Spinal (subarachnoid) block: a review of 11.574 cases. J.A.M.A. 195:907, 1966.

[20] 20. NELSON, D.; VATES Jr., T. & THOMAS Jr., R. Complications from intrathecal steroid therapy in patients with multiple sclerosis. Acta Neurol. Scand. 49:176, 1973.

[21] 21. NICHOLSON, M. J. & EVERSOLE, V. H. Neurologic complications of spinal anesthesia. J.A.M.A. 132:679, 1964.

[22] 22. PADDISON, R. M. & ALPERS, B. J. Role of intra-thecal detergents in pathogenesis of adhesive arachnoiditis. Arch. Neurol. Psychiat. (Chicago) 71: 87, 1954.

[23] 23. PHILLIPS, O. C.; EBNER, H.; NELSON, A. T. & BLACK, M. H. Neurologic complications following spinal anesthesia with Lidocaine: a prospective review of 10.440 cases. Anesthesiology 30:284, 1969.

[24] 24. RITCHIE, J. M.; COHEN, P. J. & DRIPPS, R. D. Local Anesthetics. In GOODMAN, L. S. & GILMAN, A. The Pharmacological Basis of Therapeutics. 4th Ed. The MacMillan Co., New York, 1970, pág. 371-401.

[25] 25. SCHWARTZ, G. A. & BEVILACQUA, J. E. Paraplegia following spinal anesthesia. Arch. Neurol. (Chicago) 10:308, 1964.

[26] 26. SHANTHA, T. R. & EVANS, J. A. The relationship of epidural anesthesia to neural membranes and arachnoid viii. Anesthesiology 37:543, 1972.

[27] 27. TSUKAGOSHI, H.; MORI, H.; ENOMOTO, A.; NAKAO, K. & FUKUSHIMA, N. Sensory polyradiculoneuropathy following spinal anesthesia. Neurology (Minneapolis) 20:266, 1970.

[28] 28. URQUHART-HAY, D. Paraplegia following epidural analgesia. Anesthesia 24:461, 1969.

[29] 29. WEISS, R. M.; SWEENEY, L. & DREYFUSS, M. Circunscribed adhesive spinal arachnoiditis. J. Neurosurg. 10:435, 1962.

[30] 30. WINKELMAN, N. W. Neurologic symptoms following accidental intraspinal detergent injection. Neurology (Minneapolis) 2:284, 1952.

[31] 31. WISE, B. L. & SMITH, M. Spinal arachnoiditis ossificans. Arch. Neurol. (Chicago) 13:391, 1965.

[32] 32. YASKIN, H. A. & ALPERS, B. J. Neuropsychiatry complications following spinal anesthesia. Ann. Int. Med. 23:184, 1945.

Brasil

Brasil

Paraplegia and intracranial hypertension following epidural anesthesia: report of four cases

Paraplegia e hipertensão craniana após anestesia epidural: relato de 4 casos

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