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 Table of Contents    
CASE REPORT
Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 375-377  

Cauda equina syndrome after spinal anaesthesia in a patient with asymptomatic tubercular arachnoiditis


Department of Anaesthesia and Intensive Care, Employees' State Insurance Postgraduate Institute of Medical Sciences and Research (ESIC PGIMSR), Basaidarapur, New Delhi, India

Date of Web Publication13-Sep-2011

Correspondence Address:
Divya Sethi
A-2B/118-B, Paschim Vihar, New Delhi - 110 063
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.84864

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A 14-year-old boy underwent emergency debridement surgery of right foot under spinal anaesthesia. Four hours after the surgery, the patient developed symptoms of cauda equina syndrome (CES). Postoperative magnetic resonance imaging of the patient's spine suggested underlying tubercular arachnoiditis. The boy was started on intravenous methylprednisolone and antitubercular therapy. He responded to the therapy and recovered completely in 2 weeks without any residual neurological deficits. We suggest that underlying pathological changes in the subarachnoid space due to tubercular arachnoiditis contributed to maldistribution of the local anaesthetic drug leading to CES.

Keywords: Cauda equina syndrome, spinal anaesthesia, tubercular arachnoiditis


How to cite this article:
Sethi D, Gupta M, Sood S. Cauda equina syndrome after spinal anaesthesia in a patient with asymptomatic tubercular arachnoiditis. Indian J Anaesth 2011;55:375-7

How to cite this URL:
Sethi D, Gupta M, Sood S. Cauda equina syndrome after spinal anaesthesia in a patient with asymptomatic tubercular arachnoiditis. Indian J Anaesth [serial online] 2011 [cited 2019 Dec 15];55:375-7. Available from: http://www.ijaweb.org/text.asp?2011/55/4/375/84864


   Introduction Top


We report a case of cauda equina syndrome (CES) after a spinal anaesthesia in a patient with underlying asymptomatic tubercular arachnoiditis. In this case, this disease pathology may have contributed to maldistribution of intrathecally administered local anaesthetic leading to CES.


   Case Report Top


A boy aged 14 years presented at our hospital with cellulitis of right foot. He had fever with swelling of the right ankle for the past 2 days. The boy had no previous history of any major illness or hospital admission. Preoperative laboratory blood tests yielded normal results. He was posted for emergency debridement of the right foot. After informed consent of the patient's parents, the resident anaesthesiologist elected to give him spinal anaesthesia for the surgery. With the routine monitors attached to the patient in sitting position, lumbar puncture was done in a single attempt with a 25G spinal needle in L3-4 interspace. There was no bloody tap and the cerebrospinal fluid (CSF) drawn was clear and colourless. Thereafter, 50 mg of 5% hyperbaric lignocaine was injected in subarachnoid space after barbotage (dilution to 2% concentration and a total volume of 2.5 ml). Paresthesias or pain at the time of lumbar puncture or injection of the drug was absent. The level of sensory block at the start of surgery was at T10. Intraoperatively, intravenous midazolam 1 mg was given for sedation. The surgery lasting for 45 minutes was completed uneventfully with all the haemodynamic parameters remaining stable. The patient was then shifted to recovery room.

After four hours in the recovery, the patient complained of inability to move his legs. He had also developed paresthesias in medial parts of both thighs and urinary retention. There had been no regression in his sensory block, which had remained at T10. Similarly there had been no recovery of the motor power in the lower limbs and deep tendon reflexes were absent. Fever, headache, vomiting or neck rigidity was absent . As patient's clinical features were suggestive of CES, he was started on intravenous methylprednisolone (500 mg/day) and shifted to intensive care unit (ICU) for further management. A neurologist's opinion was sought who confirmed the finding of CES and advised for an urgent magnetic resonance imaging (MRI) of the spinal cord.

The MRI imaging of lumbosacral region of spinal cord revealed arachnoiditis with dural ectasia, myelitis with intradural granulomas, clumping of cauda equina nerve roots and fluid collection close to the right posterior paraspinal muscle [Figure 1]. As the MRI findings were indicative of tubercular arachnoiditis, antitubercular drugs (isoniazid, pyrizinamide, ethambutol, rifampicin and pyridoxine) were started while continuing intravenous methylprednisolone (500 mg/day). A serum sample for polymerase chain reaction (PCR) test for tuberculosis was sent which was later reported positive.
Figure 1: Sagittal T2-weighted MR image of dorsolumbar spine shows CSF loculation (asterix) and clumped cauda equine nerve roots (arrow)

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In the ICU, on postoperative day 2 the patient showed gradual recovery of sensations in lower limb. Return of motor power was seen on postoperative day 6 and recovery of bladder functions on day 8. A repeat MRI scan done during second week showed significant reduction in size and number of intradural granulomas and resolution of arachnoiditis with normal cauda equina nerve roots. There was mild reduction in the paraspinal collection but dural ectasia still persisted. The dosage of steroid was gradually tapered. On postoperative day 15, the patient was transferred to the ward with complete recovery of motor power of lower limbs and bladder functions, and with no residual sensory deficits. He was discharged from hospital a week later with advice to continue antitubercular treatment and to follow-up in neurology clinic.


   Discussion Top


We describe a case of CES that occurred when a patient with previously undiagnosed tubercular arachnoiditis underwent an uneventful surgery for debridement of right foot under spinal anaesthesia with hyperbaric lignocaine. With the postoperative MRI suggesting the diagnoses of tubercular arachnoiditis, later confirmed by a PCR test for tuberculosis, the patient was put on high-dose steroid therapy and antitubercular drugs, to which he responded very well, gaining complete neurological recovery in 2 weeks. In our review of the literature, we did not find any previous reports of diagnosed or undiagnosed tubercular arachnoiditis complicating spinal anaesthesia.

Although tubercular arachnoiditis is the most common type of infectious arachnoiditis in India, increasing incidence of the disease is being seen in the developed nations in conjunction with acquired immunodeficiency syndrome (AIDS). [1] Frequent involvement of nerve root and spinal cord in the subarachnoid space differentiates tubercular arachnoiditis from arachnoiditis due to other causes like intrathecal administration of contrast agents, antibiotics, local anaesthetics; traumatic punctures or 'bloody taps' occurring after a neuraxial block; trauma; surgery; disc disease; etc. Hence the disease process is sometimes termed 'tubercular radiculomyelitis'.

Tubercular arachnoiditis may occur as a primary lesion, or as secondary to tubercular meningitis or vertebral tuberculosis. Most patients present with backache (86%) and fever (67%), and smaller numbers with radicular pain, paraesthesias, subacute paraparesis, bladder and bowel disturbances, and vertebral kyphosis. In some cases, however, the disease may be entirely asymptomatic, as in our patient. [2],[3] In early stages of this disease, inflammation leads to the clumping of cauda equine nerve roots and granulomas formation. The later stages are marked by irregular CSF loculations and blockage of CSF flow due to formation of arachnoid bands. Unchecked, the disease may progress to vascular involvement causing cord infarction and cavitation. MRI is the primary modality used for screening patients with suspected spinal tuberculosis. [4] Early diagnosis and institution of antitubercular therapy is important to ensure good recovery.

It has been seen that in patients receiving central neuraxial block, undetected underlying spinal pathologies such as spinal canal stenosis [5],[6] spinal metastatic lesion [7],[8] and subarachnoid cyst [9] can cause CES due to the local anaesthetic drug being maldistributed in the compromised subarachnoid space. The maldistribution in turn causes high concentrations of the local anaesthetic drug in CSF leading to structural and functional changes in the neural tissue. The same mechanism is responsible for CES from use of spinal microcatheter [10] or with repeat spinal injections in the event of failed or patchy blocks. [11]

Although CES has been reported with several local anaesthetics, it is frequently associated with lignocaine. Yet lignocaine remains a useful drug for the procedure in short ambulatory surgery due to its fast onset, intense sensory and motor blocks, and rapid recovery, [12] with dosage below 60 mg considered safe for subarachnoid block. [13] Other identified causes of CES after spinal anaesthesia include direct needle trauma, spinal cord ischaemia, abscess and spinal haematomas. Cases of CES complicating spinal block have been typically seen in the immediate postoperative period, but these may occur later as well, as documented in two cases reports where CES due to subdural haematoma [14] and epidural haematoma [15] was seen 96 hours and 3 months respectively, after uneventful spinal anaesthesia.

In the present case, we presume that the underlying disease pathology of tubercular arachnoiditis may have caused neurotoxicity of lignocaine by restricting the spread of the drug in the subarachnoid space, eventually resulting in CES, even though a safe dosage (50 mg lignocaine) was used. Besides, the use of small bore spinal needle, the hyperbaric drug, or the sitting position could have been additional contributory factors in the CES. However, direct damage to the spinal cord by dural puncture did not seem a likely factor as there was no neurological pain or dysethesia at the time of needle insertion.

In conclusion, this case highlights that like any undetected pre-existing spinal pathology, asymptomatic tubercular arachnoiditis can contribute to CES even after carefully administered spinal anaesthesia. Therefore, after surgery under spinal anaesthesia, careful monitoring for recovery of sensory and motor functions is important for early detection of a neurological complication such as CES. In a case where CES is suspected (1) the patient should be investigated thoroughly and an MRI done to identify and suitably address any underlying contributory spinal pathology; and (2) appropriate treatment should be immediately instituted for the same.

 
   References Top

1.Eroles Vega G, Castro Vilanova MD, Mendivil Ferrer M, Arach Gómez Rodrigo J, Lacambra Calvet C, Ruiz-Capillas JJ, et al. Arachnoiditis and intraspinal lesion. Complications of tuberculous meningitis in 2 patients with human immunodeficiency virus infection. Rev Clin Esp 2001;201:575-8.  Back to cited text no. 1
    
2.Hernández-Albújar S, Arribas JR, Royo A, González-García JJ, Peña JM, Vázquez JJ. Tuberculous radiculomyelitis complicating tuberculous meningitis: Case report and review. Clin Infect Dis 2000;30:915-21.  Back to cited text no. 2
    
3.Moghtaderi A, Alavi-Naini R, Rahimi-Movaghar V. Tuberculous myelopathy: Current aspects of neurologic sequels in the southeast of Iran. Acta Neurol Scand 2006;113:267-72.  Back to cited text no. 3
    
4.Sharma A, Goyal M, Mishra NK, Gupta V, Gaikwad SB. MR imaging of tubercular spinal arachnoiditis. AJR Am J Roentgenol 1997;168:807-12.  Back to cited text no. 4
    
5.Kubina P, Gupta A, Oscarsson A, Axelsson K, Bengtsson M. Two cases of cauda equina syndrome following spinal-epidural anesthesia. Reg Anesth1997;22:447-50.  Back to cited text no. 5
    
6.Stambough JL, Stambough JB, Evans S. Acute cauda equina syndrome after total knee arthroplasty as a result of epidural anesthesia and spinal stenosis. J Arthroplasty 2000;15:375-9.  Back to cited text no. 6
    
7.Leidinger W, Meierhofer JN, Ullrich V. Unusual complication after combined spinal/epidural anaesthesia. Anaesthesist 2003;52:703-6.  Back to cited text no. 7
    
8.Kim HT, Gim TJ, Lee JH. Transient cauda equina syndrome related to a sacral schwannoma with cauda equine compression after a lumbar epidural block -A case report-. Korean J Anesthesiol 2010;59:S222-5.  Back to cited text no. 8
    
9.de Sèze MP, Sztark F, Janvier G, Joseph PA. Severe and long-lasting complications of the nerve root and spinal cord after central neuraxial blockade. Anesth Analg 2007;104:975-9.  Back to cited text no. 9
    
10.Lambert DH, Hurley RJ. Cauda equina syndrome and continuous spinal anesthesia. Anesth Analg 1991;72:817-9.  Back to cited text no. 10
    
11.Drasner K, Rigler ML. Repeat injection after a "failed spinal": At times, a potentially unsafe practice. Anesthesiology 1991;75:713-4.  Back to cited text no. 11
    
12.Korhonen AM. Use of spinal anaesthesia in day surgery. Curr Opin Anaesthesiol 2006;19:612-6.  Back to cited text no. 12
    
13.Loo CC, Irestedt L. Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine: A review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997. Acta Anaesthesiol Scand 1999;43:371-9.  Back to cited text no. 13
    
14.Moussallem CD, El-Yahchouchi CA, Charbel AC, Nohra G. Late spinal subdural haematoma after spinal anaesthesia for total hip replacement. J Bone Joint Surg Br 2009;91:1531-2.  Back to cited text no. 14
    
15.Wildförster U, Schregel W, Harders A. Delayed lumbar epidural hematoma. Discussion of the risk factors: Hypertension, anticoagulation and spinal anesthesia. Anasthesiol Intensivmed Notfallmed Schmerzther 1998;33:517-20.  Back to cited text no. 15
    


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