1 Nuffield Department of Anaesthetics, Oxford Radcliffe Hospitals Trust, Oxford, UK. 2 Department of Neurology, Royal Berkshire Hospital, Reading, UK. 3 Department of Neurology, Oxford Radcliffe Hospitals Trust, Oxford, UK. 4 Department of Radiology, Oxford Radcliffe Hospitals Trust, Oxford, UK. 5 Department of Neurosurgery, Oxford Radcliffe Hospitals Trust, Oxford, UK. 6 Department of Anaesthetics, Royal Berkshire Hospital, Reading, UK *Corresponding author: The Stone Barn, Gravel Lane, Drayton OX14 4HY, UK
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Accepted for publication: April 18, 2002
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Abstract |
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Br J Anaesth 2002; 89: 51417
Keywords: ligament, posterior spinal; complications, ligament rupture; equipment, masks anaesthesia
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Introduction |
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The laryngeal mask airway (LMA) has been advocated to fill the gap between the tracheal tube and the face mask. Brimacombe and colleagues16 reviewed the advantages and disadvantages of the LMA and found that the LMA is, in general, easier to place and better tolerated than the tracheal tube. However, neurovascular morbidity has been recorded with the LMA. Hypoglossal,17 lingual18 19 and recurrent laryngeal20 nerve injuries have been noted and occlusion of the lingual artery21 leading to tongue cyanosis has also been recorded, but we have been unable to find any reports of spinal cord problems associated with the use of the LMA.
We describe the case of a patient who developed tetraplegia during surgery due to unrecognized instability of the cervical spine despite the fact that direct laryngoscopy was not used. We discuss the reasons for this occurrence.
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Case report |
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At induction he was given midazolam, propofol, fentanyl and atracurium and a size 5 LMA was inserted. The insertion of the LMA was described as straightforward by the anaesthetist and did not involve any untoward movements of the neck or jaw thrust. The ultimately successful surgery was complicated by the presence of adhesions and lasted for 75 min. The lowest non-invasive systolic blood pressure recorded during the anaesthetic was 100 mm Hg. The LMA was removed with jaw opening but without head movement in recovery. The patient complained of abdominal pain, for which he was treated with opiate and a non-steroidal anti-inflammatory drug. He was transferred to the ward after 30 min. At no time during or after the operation was the patients neck flexed or extended.
Approximately 1 h after the patient had been returned to the ward it was noted that he had difficulty in moving his legs and there was no sensation to pain or touch in his abdomen. A weak cough was noted but there was good air entry into the lungs bilaterally. Shortly thereafter he was seen by a consultant neurologist, who noted no movement in the legs and weakness of elbow extension together with weakness of the left arm distally. The level of sensation to pinprick was C5/6 on both sides with poor joint position sense in his left little finger. Joint position and vibration sense was absent in both legs. The patient was managed with a cervical collar and urinary catheterization, and an MRI scan was performed. A consultant neuroradiologist reported these images as showing a rupture of the posterior spinal ligament with haematoma cord compression. The disc was not protruding. The patient was admitted to ITU where methylprednisolone 3 g was given over 15 min. He was then transferred to the regional neurological centre, where he underwent C5/6 discectomy with insertion of a wedge of bone. At operation, a completely ruptured and very oedematous posterior spinal ligament was found at the site. Since that time the patient has made little recovery and he remains effectively tetraplegic. He has undergone further uncomplicated surgery for small bowel obstruction due to herniation of bowel through a hole in the mesentery.
After the laparoscopic cholecystectomy, the patients wife admitted that the patient had visited his general practitioner on the day before surgery as he was experiencing weakness in his legs and had had some difficulty in walking. He was also suffering from severe neck pain, necessitating him sleeping upright on the night before surgery in a chair. However, there was no history of trauma to the neck. He had failed to inform the anaesthetist of these facts, as he was worried that his surgery would again be cancelled.
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Discussion |
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Hypotension27 can cause cervical cord damage even in normal patients. In our patient, the use of the laparoscope and carbon dioxide for insufflation of the abdomen would reduce venous return and hence cardiac output, although there is evidence that blood pressure increases during laparoscopic cholecystectomy.2830 Additionally, an increase in the spinal and epidural venous pressure would increase the cerebrospinal fluid pressure, causing a decrease in the spinal arterial perfusion pressure. No periods of hypotension were observed throughout the course of the operation, but in the case of this patient the blood flow to the cervical spine might have been compromised as a result of the surgical technique. Some workers31 believe that an element of induced hypertension may be beneficial but this view must be tempered as animal work has indicated that increased oedema and haemorrhage of the cord are a possibility.32
Rupture of the posterior longitudinal ligament (PLL) in the cervical spine is also reported as a consequence of accidental trauma to the neck. Hyperflexion of the cervical spine can cause injury to the middle column of the spine (consisting of the posterior vertebral body, the posterior longitudinal ligament and the posterior annulus fibrosus) together with the posterior column of the spine (consisting of the posterior elements of the spine, the ligamentum flavum, the interspinous ligaments, the supraspinous ligament and the facet joint capsules). Hyperextension causes injury to the anterior column of the spine (consisting of the anterior vertebral body, the anterior longitudinal ligament and the anterior annulus fibrosus) and the middle column.33 However, another process by which rupture of the PLL may occur is in conjunction with hypertrophy and ossification of the PLL.34 Interestingly, glucose intolerance is a risk factor for ossification of the PLL in Japanese men35 and our patient had diet-controlled diabetes mellitus.
This case serves to highlight the fact that any degree of neck manipulation in a patient with an unstable cervical spine may be hazardous.
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References |
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