1Department of Neurosurgery, University of Leipzig, Johannisalle 34, D-04103 Leipzig, Germany. 2Department of Neurosurgery and 3Department of Neuroradiology, Medical School Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany*Corresponding author
Accepted for publication: October 16, 2001
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Abstract |
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Br J Anaesth 2002; 88: 43840
Keywords: cancer, spinal neoplasm; anaesthetic techniques, subarachnoid; complications, paraplegia; complications, haemorrhage
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Introduction |
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We present the case of a young female who suffered from complete paraplegia caused by intraspinal haemorrhage from a previously undiagnosed lumbar ependymoma after attempted spinal anaesthesia for Caesarean section.
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Case report |
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Approximately 12 h later, the patient started to complain of mild paraesthesia in both feet and calves. During the night she experienced increasing low back pain radiating into both legs. The next morning she presented with complete paraplegia and anaesthesia from L1, including urinary retention and absent anal sphincter tone. Following emergency referral to our institution a MRI showed extended intraspinal bleeding from Th12 to L2. Approximately 8 h after the patient was found to be paraplegic, a laminotomy from Th12 to L2 was performed. As well as the intradural blood clot, blue-greyish tumour tissue in the conal region was identified and removed with preservation of all neural structures. Neuropathological examination revealed an ependymoma with massive intratumoural haemorrhage.
Postoperatively, no bleeding disorder was found. The patient could not remember any signs suggestive of the neoplasm during her pregnancy. Eight months later, her motor function is slowly improving, allowing her to stand up from the wheelchair without assistance and to walk about 5 m with crutches. She has regained bowel function but bladder function is still absent.
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Discussion |
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The first report of neurological complications in connection with iatrogenic haemorrhage from a spinal neoplasm was by Roscoe and colleagues in 1984.4 They reported a 24-yr-old parturient, who, 3 days after uneventful epidural analgesia at the L2-3 interspace, developed increasing low back pain and bladder dysfunction, together with gradual worsening of motor and sensory function in both legs. In the emergent decompressive laminectomy 17 h after the onset of neurological symptoms, dural perforation of the distended thecal sac was found and an ependymoma with intratumoural haemorrhage was excised. The patient made an almost complete recovery with intact bladder function and ability to walk with leg brace support.
Since then, two additional cases of similar pathology have been described. Bredtmann and colleagues5 reported haemorrhage from a tumour in a 58-yr-old male following uneventful subarachnoid injection of the anaesthetic agent after clear CSF was obtained at the L3-4 level. Starting 6 h later, the patient developed severe low back pain, headaches, and meningism. Laminectomy was performed 3 days after onset of symptoms and an ependymoma at L3-4, together with an intradural blod clot, was removed. The patient recovered completely.
In a 79-yr-old female, several attempts of epidural anaesthesia were performed in vain at the L2-3 and L3-4 interspaces.6 The epidural space could not be located precisely. It was then decided to perform general anaesthesia. Over the next 3 weeks the patient experienced the development of almost complete paraplegia. In the subsequent laminectomy, an ependymoma with massive intratumoural haemorrhage was removed and the patient made a satisfactory recovery of motor and autonomic function. In the last two reports described, both patients retrospectively complained of a history of increasing radicular pain in both legs preoperatively, but these symptoms were not appropriately diagnosed by the responsible physicians.
Reviewing these reports of neurological malfunction following puncture into an undiagnosed lumbar tumour and subsequent haemorrhage, we found that in all four cases (including the one presented in this paper) the haemorrhage arose from an ependymoma. These intradural neoplasms of the cauda equina and conal region are thought to be prone to haemorrhage due to their vascular structure7 and are known to present with spontaneous bleeding.8 Despite the intradural location of ependymomas, the hazards of iatrogenic haemorrhage do not solely occur after spinal anaesthesia; they occur also after epidural anaesthesia. The thecal sac, distended by the tumour, together with a compressed epidural space, is likely to be punctured with subsequent injury of the underlying fragile tumour vessels. In contrast, however, ependymomas do not necessarily bleed after massive manipulation with a spinal needle.9
We found that, in two of the four cases, regional blockade was performed in labour for either analgesia or Caesarean section. In the series of ependymomas of the cauda region described by Schweitzer and colleagues,9 the coincidence of pregnancy and this tumour type has already been described, as two of their six female patients first experienced symptoms during pregnancy. The most common age for ependymomas of the conus and cauda region is the third decade so this association is not surprising. The mean duration of symptoms before diagnosis is 2835 months,9 10 suggesting slow tumour growth. During pregnancy, increased intradural pressure may aggravate the onset of symptoms.
This report draws attention to the need for careful evaluation of symptoms suggesting the presence of a spinal mass, before lumbar puncture, peridural, or spinal anaesthesia is planned. In patients complaining of a history of increasing low back pain, bladder dysfunction, weakness, or paraesthesias of the lower limbs, we strongly recommend postponing the procedure. In an emergency situation, however, spinal anaesthesia should not be attempted and general anaesthesia should be undertaken.
Postprocedural observation always needs to rule out signs of increasing lumbar root compression, even in otherwise healthy young women after delivery. Interestingly, in all cases described, the onset of neurological deterioration was not immediately after the lumbar puncture. First symptoms occurred 6 h after the operation at the earliest and 3 days at the latest. If spinal bleeding is suspected, a MRI of the lumbar and lower thoracic spine is considered the appropriate diagnostic tool.
Prompt surgical evacuation of a symptomatic lumbar haematoma resulting from tumoural bleeding should always be attempted. Even in the presence of severe neurological dysfunction for hours and even weeks, all patients made at least a partial recovery, resulting in significantly diminished morbidity.8
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References |
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