1 Perth, Western Australia 2 Newcastle-upon-Tyne, UK
EditorThe case report by Dr Roberts and colleagues1 is interesting and I write to support their concerns. I recently anaesthetized a hypertensive, 78-year-old patient for a partial hepatectomy. The patient received an awake epidural at the midthoracic level. A bean bag was placed under her back to produce hyperlordosis, as is the surgeons usual practice. Surgery lasted 7 h and there was neither significant hypotension nor anaemia in the perioperative period. When the epidural infusion was stopped on the third postoperative day, the patient complained of leg weakness associated with sensory loss. An MRI showed changes consistent with spinal cord infarction in the lumbar area. There was no abscess or haematoma. As an alternative to the suggestion of avoiding epidurals in cases considered at risk, I now persuade the surgeon to avoid the bean bag. To the list of contributing factors, I would add the elderly and hypertension.
D. Gaylard
Perth, Western Australia
EditorThank you for the opportunity to respond to the comments of Dr Gaylard. We also avoid the hyperlordotic position when the use of a Thompson retractor is used to provide adequate surgical access. However, our article1 implicated hyperlordosis only as a contributing factor to spinal ischaemia in patients with other risk factors that in themselves would merit caution in the use of an epidural. I am not aware of the effect of age in this regard other than by virtue of any accompanying arteriosclerosis. Presumably, hypertension would be similarly implicated.
D. R .D. Roberts
Newcastle-upon-Tyne, UK
References
1 Roberts DRD, Roe J, Baudouin C. Hyperlordosis as a possible factor in the development of spinal cord infarction. Br J Anaesth 2003; 90: 798800