|Year : 2014 | Volume
| Issue : 4 | Page : 484-486
Neurological complications following spinal anaesthesia in a patient with congenital absence of lumbar vertebra
Shivani Rastogi, Rajlaxmi Bhandari, Virendra Sharma, Tarun Pandey
Department of Anaesthesia and Neurosurgery, Vivekananda Polyclinic and Institute of Medical Sciences, Vivekananda Puri, Lucknow, Uttar Pradesh, India
|Date of Web Publication||17-Aug-2014|
Dr. Shivani Rastogi
C-149, Sector-B, Aliganj, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rastogi S, Bhandari R, Sharma V, Pandey T. Neurological complications following spinal anaesthesia in a patient with congenital absence of lumbar vertebra. Indian J Anaesth 2014;58:484-6
|How to cite this URL:|
Rastogi S, Bhandari R, Sharma V, Pandey T. Neurological complications following spinal anaesthesia in a patient with congenital absence of lumbar vertebra. Indian J Anaesth [serial online] 2014 [cited 2020 Feb 28];58:484-6. Available from: http://www.ijaweb.org/text.asp?2014/58/4/484/139021
| Introduction|| |
Incidence of neurologic complication in central neuraxial blockade (CNB) is reported to be between 1/1000 and 1/1,000,000  higher with spinal than for epidural anaesthesia. Various causes of neurologic complications have been documented in the literature,  as chemical myelitis, injury to the cord, or prexisting neurological lesion, but incidence of paraplegia following regional anaesthesia in a case of congenital deformity is extremely rare. We report a rare case of congenital lumbar agenesis leading to complete paraplegia with bowel and bladder involvement following a spinal anaesthesia for emergency cesarean section. The purpose of our case report is to make anaesthesiologist, surgeon and neurologist aware about the suspected neurological complication in case of delayed recovery from regional block. Early diagnosis and intervention should be ensured for better outcome and recovery.
| Case Report|| |
A 25-year-old, short stature (130 cm), apparently normal female was admitted to neurosurgical Intensive Care Unit with complaints of inability to move both lower limbs and bladder and bowel incontinence immediately following cesarean section under CNB 6 days back at the periphery hospital. The details of perioperative events were not documented. The patient was non-diabetic, normotensive. Patient had a history of surgery for swelling over lower back in infancy which was present since birth. Her antenatal period and pre-operative investigation were normal.
On examination, there was a transverse paramedian scar mark of about six inch over her lumbar area but there was no obvious spinal abnormality externally. Neurological examination revealed complete motor, sensory and autonomic loss of sensation below L 2 level with involvement of bladder and bowel. An urgent X-ray lumbosacral spine and magnetic resonance imaging (MRI) of the spinal cord were done, which revealed congenital absence of L 3-5 lumbar vertebrae with low lying spinal cord at L 2 level, with myelitis and arachnoiditis [Figure 1]. L 2 vertebrae were directly fused to the sacrum without any other deformity at that level. A probable diagnosis of chemical myelitis or direct injury to the cords was suspected. Patient was treated conservatively on rest and high doses of steroid (methyl prednisolone) to which she responded partially after 6 weeks in the form of motor recovery. There was no improvement in bladder and bowel function after 2 years.
| Discussion|| |
Segmental spinal dysgenesis  is a rare congenital abnormality in which a segment of spine and spinal cord fails to develop properly. Segmental vertebral anomalies may involve the thoracolumbar, lumbar or lumbosacral spine. Lumbosacral agenesis is an uncommon malformation with an incidence of 1 of 25,000 lives births.  The incidence of isolated lumbar agenesis is not yet reported. These anomalies of the spine may vary from simple, benign causing no spinal deformity to complex producing severe deformity, which is often incompatible with life. They may be associated with other organ deformities.  Simple malformations of the spine are seldom apparent and are diagnosed as incidental findings as in our patient.
Neurological complications following CNB as anterior spinal artery syndrome, transverse myelitis, chronic arachnoiditis, cauda equina syndrome have been documented. In most of the cases the etiology of paraplegia after CNB are due to direct trauma to the cord, chemical myelitis, intraoperative haemodynamic instability, or pre-existing neurologic lesion. 
Histotoxic properties of local anaesthetics can lead to subarachnoid reactions. These solutions directly irritate nerve roots and damage them due to osmotic effects. Contaminants such as talcum powder of surgical gloves, bits of cotton of the wrapped syringes, incomplete rinsing of the syringes has been reported to cause a chronic arachnoiditis. CSF and MRI findings rule out any incidence of chemical or haemorrhagic myelitis. 
Prolonged hypotension following spinal anaesthesia has been reported in most cases to cause spinal cord ischemia or thrombosis of the anterior spinal artery.  Flaccid paraplegia due to anterior spinal artery thrombosis has been reported.
Pre-existing neurologic lesion may also present with paraplegia following spinal anaesthesia.  Marinacci and Courville reported 482 patients with neurological complaints following spinal anaesthesia in which 478 patients had concurrent unrelated lesions. 
Direct trauma to the spinal cord or nerve root may be due to multiple attempts, faulty technique and severe pain and electric shock like sensation felt by the patient at the time of insertion of the needle. 
In our case, patient had a history of a surgical intervention in the back, but there was no history of any lower limb weakness or back pain. After caesarean section under CNB patient had complete paraplegia and her MRI showed complete absence of L 3-5 . Lumbar vertebra with L 2 fused to S 1 and spinal cord at L 2 level showing myelitis. This low-lying cord favors high probability of direct trauma to the cord during spinal anaesthesia.
| Conclusion|| |
Thorough pre-operative history and examination with proper knowledge of anatomy of spinal and epidural space is of utmost importance before undertaking management of any case for anaesthesia. Use of appropriate anaesthetic agent in proper dose and concentration should also be considered. In the case of paraesthesia during insertion of the needle, probability of needle trauma should be considered. In the case if any neurological complication is suspected prompt neurological intervention should be encouraged as patient is our utmost priority.
| References|| |
|1.||Agarwal A, Kishore K. Complications and controversies of regional anaesthesia: A review. Indian J Anaesth 2009;53:543-53. |
|2.||Kane RE. Neurologic deficits following epidural or spinal anesthesia. Anesth Analg 1981; 60:150-61. |
|3.||Tortori-Donati P, Fondelli MP, Rossi A, Raybaud CA, Cama A, Capra V. Segmental spinal dysgenesis: Neuroradiologic findings with clinical and embryologic correlation. AJNR Am J Neuroradiol 1999;20:445-56. |
|4.||Joshi M, Yadav S. Lumbosacral agenesis. Indian J Radiol Imaging 2005;15:251-4. |
|5.||Guille JT, Benevides R, DeAlba CC, Siriram V, Kumar SJ. Lumbosacral agenesis: A new classification correlating spinal deformity and ambulatory potential. J Bone Joint Surg Am 2002;84-A: 32-8. |
|6.||Rege AS, Navarange S, Ravigopal N, Rohondia O. Complete flaccid paralysis following spinal anaesthesia - A case report. Indian J Anaesth 2002;46:58-60. |
|7.||Marinacci AA, Courville CB. Electromyogram in evaluation of neurological complications of spinal anesthesia. J Am Med Assoc 1958;168:1337-45. |
|8.||Kim SH, Song GS, Son DW, Lee SW. Neurologic complication following spinal epidural anesthesia in a patient with spinal intradural extramedullary tumor. J Korean Neurosurg Soc 2010;48:544-6. |