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Neuropathies masquerading as an epidural complication

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Abstract

Purpose

The purpose of this report is to emphasise the role of the Acute Pain Service in managing local anaesthetic epidural infusions for postoperative pain management, the importance of vigilant monitoring, and to offer some guidelines to using local anaesthetic epidural infusions.

Clinical features

A 34-yr-old man with long-standing insulin dependent diabetes mellitus underwent a total proctocolectomy for inflammatory bowel disease. A T9–10 epidural catheter was placed pnor to induction of general anaesthesia. Postoperatively, a continuous epidural infusion of fentanyl/bupivacaine was used for postoperative pain management. Total lithotomy time was four hours. On day four he was noted to have complete right sided femoral and left sided lateral femoral cutaneous nerve of thigh neuropathies. A computensed tomography scan and a magnetic resonance imaging excluded a central lesion. Electromyelography confirmed peripheral nerve injuries.

Conclusion

This patient’s neurological deficits were not due to the epidural analgesia. However, epidural infusion of local anaesthetic caused a delay in recognising a potential neurological complication. When using local anaesthetic epidural infusions, it is important to exclude other causes of motor block before attributmg it to the local anaesthetic.

Résumé

Objectif

Ce compte rendu vise à souligner le rôle d’un service de gestion de la douleur aiguë sous l’aspect de la prise en charge des perfusions épidurales d’anesthésiques locaux administrées pour le traitement de la douleur postopératoire; rappeler l’importance d’une surveillance étroite; proposer des lignes de conduite sur l’utilisation des perfusions épidurales d’anesthésiques locaux.

Éléments cliniques

Un homme de 34 ans souffrant d’un diabète insulino-dépendant de longue date subissait une colectomie totale pour une maladie inflammatoire intestinale. Un cathéter épidural était installé à T9–10 avant l’induction de l’anesthésie générale. En postopératoire, une perfusion continue de fentanyl/bu≪vacaïne était mise en marche pour soulager la douleur postopératoire. La position de lithotomie avait été maintenue pendant quatre heures. Le quatrième jour, on décelait des neuropathies graves du nerf fémoral droit et du nerf fémorocutané latéral gauche de la cuisse. La tomographie informatisée et l’imagene par résonance magnétique éliminaient la présence d’une lésion centrale. Lélectromyographie confirmait que les lésions nerveuses étaient pénphénques.

Conclusion

Dans le cas présent, les déficits neurologiques n’étaient pas en rapport avec l’analgésie épidurale. Cependant, la perfusion épidurale d’un anesthésique local a retardé le diagnostic d’une complication neurologique. Avec les perfusions épidurales d’anesthésiques locaux, il est important d’éliminer les autres causes de bloc moteur avant de les attribuer aux anesthésiques.

References

  1. 1

    Zimmerman D L, Stewart J. Postoperative pain management and Acute Pain Service activity in Canada. Can J Anaesth 1993; 40: 568–75.

  2. 2

    Lee A, Simpson D, Whitfield A, Scott DB. Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. Br J Anaesth 1988; 60: 845–50.

  3. 3

    Flanagan HL, Fanciullo G, Walsh D, Ferrante FM. Safety and efficacy of post-operative continuous epidural narcotic-local anesthetic infusions on surgical floors. Anesthesiology 1993; 79: A794.

  4. 4

    Schug SA, Cann J, Fry RA. Continuous epidural infusion of a bupivacaine-fentanyl-mixture for postoperative pain relief: a follow-up of 425 patients. Reg Anesth 1992; 17: 3S77.

  5. 5

    Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.

  6. 6

    Mϕiniche S, Hjortsϕ N-C, Blemmer T, Dahl JB, Kehlet H. Blood pressure and heart rate during orthostatic stress and walking with continuous postoperative thoracic epidural bupivacaine/morphine. Acta Anaesthesiol Scand 1993; 37: 65–9.

  7. 7

    Scratcherd T, Grundy D. The physiology of intestinal morility and secretion. Br J Anaesth 1984; 56: 3–18.

  8. 8

    Udassin R, Eimerl D, Schiffman J, Haskel Y. Epidural anesthesia accelerates the recovery of postischemic bowel motilty in the rat. Anesthesiology 1994; 80: 832–6.

  9. 9

    Bredtmann RD, Herden HN, Teichmann W, et al. Epidural analgesia in colonic surgery: results of a randomized prospective study. Br J Surg 1990; 77: 638–42.

  10. 10

    Schnitzler M, Kilbride MJ, Senagore M. Effect of epidural analgesia on colorectal anastomotic healing and colonic motility. Reg Anesth 1992; 17: 143–7.

  11. 11

    Mattle H, Sieb JP, Rohner M, Mumenthaler M. Nontraumatic spinal epidural and subdural hematomas. Neurology 1987; 37: 1351–6.

  12. 12

    Schmidt A. Nolte H. Subdural and epidural haematomas following spinal, epidural or caudal anaesthesia. (German) Anaesthesist 1992; 41: 276–84.

  13. 13

    Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG. Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position. Anesthesiolgy 1994; 81: 6–12.

  14. 14

    Brasch RC, Bufo AJ, Kreienberg PF, Johnson GP. Femoral neuropathy secondary to the use of a self-retaining retractor. Dis Colon Rectum 1995; 38: 1115–8.

  15. 15

    Al Hakim M, Katirji MB. Femoral mononeuropathy induced by the lithotomy position: a report of 5 cases with a review of the literature. Muscle Nerve 1993; 16: 891–5.

  16. 16

    A report by the ASA Task Force on Pain Management, Acute Pain Section. Practice guidelines for Acute Pain Management in the perioperative setting. Anesthesiology 1995; 82: 1071–81.

  17. 17

    Christopherson R, Beattie C, Frank SM, et al. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 1993; 79: 422–34.

  18. 18

    Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991; 73: 696–704.

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Correspondence to Larry Kahn.

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Kahn, L. Neuropathies masquerading as an epidural complication. Can J Anaesth 44, 313 (1997). https://doi.org/10.1007/BF03015371

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Keywords

  • Epidural Analgesia
  • Epidural Catheter
  • Femoral Nerve
  • Motor Block
  • Epidural Infusion