Abstract
Purpose
To report a case of postoperative bilateral lower limb hypoesthesia occurring after surgery under general anesthesia in the hyperlordotic position for radical prostatectomy. The possible pathophysiologic mechanisms are discussed.
Clinical features
This 52-yr-old patient was slightly overweight and was on fenofibrate for hypercholesterolemia. He had no history of cardiovascular disease. Arterial blood pressure was overall well maintained except for a very transient hypotension at surgical incision. Blood loss was moderate and did not require transfusion. Soon after recovery, the patient complained of paresthesia in both legs and neurological examination revealed bilateral lower limb hypoesthesia, compatible with an incomplete medullar syndrome at the level of T12-L1. On postoperative day one, a plain magnetic resonance imaging scan demonstrated a hyperintense signal in the spinal cord from T8 to T9 on T2-weighted images consistent with ischemia of the spinal cord whereas the heterogeneous aspect of the spinal cord was due to an unusually high fat content of the epidural space. Neurological signs improved progressively and one week later the patient had recovered normal sensory functions of both lower limbs.
Conclusion
Although arterial ischemia is the most common cause of postoperative spinal cord injury, other mechanisms may be invoked. We raise the possibility that a combination of intraoperative risk factors (hypotension, excessive postural changes) with anatomic predispositions (increased epidural venous pressure or fat content, previous bone disease) can produce arterial and/or venous ischemia of the spinal cord.
Résumé
Objectif
Rapporter un cas d’atteinte neurologique postopératoire bilatérale des membres inférieurs après prostatectomie radicale sous anesthésie générale et en position d’hyperlordose. Les mécanismes physiopathologiques possibles sont discutés.
Eléments cliniques
Un homme de 52 ans, légèrement obèse et traité par un fibrate pour une hypercholestérolémie n’avait aucune histoire cardiovasculaire clinique et ses explorations paracliniques étaient négatives. La pression artérielle a peu baissé au cours de l’intervention à l’exception d’une hypotension transitoire et modérée lors de l’incision. Les pertes sanguines modérées n’ont pas justifié de transfusion. Dès son réveil, le patient s’est plaint de paresthésies des deux membres inférieurs et l’examen clinique montrait une hypoesthésie bilatérale des membres inférieurs avec un niveau supérieur T12- L1. L’imagerie par résonnance magnétique médullaire réalisée le lendemain montrait un hypersignal en mode T2 de T8 à T9. L’aspect hétérogène de la moelle était considéré comme secondaire à une accumulation graisseuse dans l’espace péridural. L’évolution fut complètement favorable en une semaine.
Conclusion
Bien que l’ischémie artérielle soit la cause la plus fréquente des atteintes neurologiques bilatérales des membres inférieurs postopératoires, d’autres mécanismes peuvent être impliqués ou associés. Ce cas soulève la possibilité que des mécanismes peropératoires (hypotension, modifications posturales excessives) puissent s’associer à des facteurs préexistants (augmentation de la pression veineuse épidurale ou anomalies osseuses) pour créer une ischémie artérielle et/ou veineuse de la moelle.
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References
Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia. A closed claims analysis. Anesthesiology 1999; 90: 1062–9.
Amoiridis G, Wohrle JC, Langkafel M, Maiwurm D, Przuntek H. Spinal cord infarction after surgery in a patient in the hyperlordotic position. Anesthesiology 1996; 84: 228–30.
Konstantinidou AS, Balamoutsos NG. Paraplegia in a patient who by chance missed the insertion of an epidural catheter (Letter). Anesth Analg 1996; 82: 1110.
De Souza Neto EP, Andreo R, Kopp C, Long D, Marechal JM, Bouletreau P. Paraplegia after cystectomy and epidural anesthesia (Letter). Anesthesiology 2000; 92: 632–3.
Biglioli P, Spirito R, Roberto M, et al. The anterior spinal artery: the main arterial supply of the human spinal cord — a preliminary anatomic study. J Thorac Cardiovasc Surg 2000; 119: 376–9.
Hirabayashi Y, Saitoh K, Fukuda H, Igarashi T, Shimizu R, Seo N. Magnetic resonance imaging of the extradural space of the thoracic spine. Br J Anaesth 1997; 79: 563–6.
Guegan Y, Fardoun R, Launois B, Pecker J. Spinal cord compression by extradural fat after prolonged corticosteroid therapy. J Neurosurg 1982; 56: 267–9.
Lee M, Lekias J, Gubbay SS, Hurst PE. Spinal cord compression by extradural fat after renal transplantation. Med J Aust 1975; 1: 201–3.
Igarashi T, Hirabayashi Y, Shimizu R, Saitoh K, Fukuda H, Suzuki H. The fiberscopic findings of the epidural space in pregnant women. Anesthesiology 2000; 92: 1631–6.
Hepgul K, Nicoll JA, Coakham HB. Spinal cord compression due to pagetic spinal stenosis with involvement of extradural soft tissues: a case report. Surg Neurol 1991; 35: 143–6.
Urquhart-Hay D, Teague CA. Spinal trombophlebitis after prostatectomy with hypotensive anaesthesia; case report. N Z Med J 1974; 79: 654–6.
Urquhart-Hay D. Paraplegia following epidural analgesia. Anaesthesia 1969; 24: 461–70.
Tetzlaff JE, Dilger JA, Wu C, Smith MP, Bell G. Influence of lumbar spine pathology on the incidence of paresthesia during spinal anesthesia. Reg Anesth Pain Med 1998; 23: 560–3.
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Beloeil, H., Albaladejo, P., Hoen, S. et al. Bilateral lower limb hypoesthesia after radical prostatectomy in the hyperlordotic position under general anesthesia. Can J Anaesth 50, 653–656 (2003). https://doi.org/10.1007/BF03018706
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DOI: https://doi.org/10.1007/BF03018706