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LETTER TO THE EDITOR
Year : 2018  |  Volume : 11  |  Issue : 5  |  Page : 456-457  

Diagnostic dilemma of severe excruciating low backache in pediatric patient following spinal anesthesia


Department of Anaesthesia, B J Medical College and Sassoon General Hospital, Pune, Maharashtra, India

Date of Web Publication5-Sep-2018

Correspondence Address:
Kalpana V Kelkar
Department of Anaesthesia, B J Medical College and Sassoon General Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_39_18

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How to cite this article:
Tandale SR, Kelkar KV, Abhade SR, Gadre VN. Diagnostic dilemma of severe excruciating low backache in pediatric patient following spinal anesthesia. Med J DY Patil Vidyapeeth 2018;11:456-7

How to cite this URL:
Tandale SR, Kelkar KV, Abhade SR, Gadre VN. Diagnostic dilemma of severe excruciating low backache in pediatric patient following spinal anesthesia. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Dec 5];11:456-7. Available from: https://www.mjdrdypv.org/text.asp?2018/11/5/456/240383



Dear Sir,

Neurological complications after spinal anesthesia must be suspected in patients developing neurological sign and symptoms and must be evaluated and investigated thoroughly to prove or disprove the diagnosis.

A 10-year-old male, weighing 30 kg, was operated for circumcision under uneventful subarachnoid block in the supine position. 1.8 cc of hyperbaric bupivacaine (0.5%) was injected in sitting position with 25G spinal needle. No adverse events were noted during puncture, during surgery, and in immediate postoperative period. Vital signs were within normal level (pulse rate between 78 and 106 bpm and mean arterial pressure between 60 and 70 mmHg). Recovery from sensory and motor block was normal. The patient was shifted to respective ward after he has passed urine. Ten hours after surgery, the patient developed sudden-onset severe excruciating pain in low back radiating to buttocks, thigh, and calf bilaterally with tingling numbness in both lower limbs and was unable to lie down due to pain. The patient denied history of fever, neck pain, neck stiffness, photophobia headache, and tenderness at puncture site. Urgent orthopedic consultation was sought for the same and shifted to high-dependency unit for further care. The patient received intravenous diclofenac and tramadol 30 mg and oral chlorzoxazone 250 mg for analgesia twice a day. Neurological evaluation revealed sensory and motor examination within normal limits. The patient was kept under observation, and the need of magnetic resonance imaging (MRI) lumbosacral spine in event of further deterioration of symptoms was explained. Due to inadequate pain relief, in spite of round-the-clock analgesics patient was posted for MRI lumbosacral spine which happens to be within normal limits. Oral analgesics were continued with verbal reassurance to parents and the patient. Pain and tingling numbness subsided completely over 1 week, and the patient was discharged home.

Incidence of neurological complication in central neuraxial blockade is reported to be between 1/1000 and 1/1,000,000, higher with spinal than for epidural anesthesia.[1] A variety of causes have been explained for the same in literature.[2] The most probable cause of neurological complications seems to be transient neurological symptoms (TNS) in our patient. However, early diagnosis of few important, devastating condition and intervention should be ensured for better outcome and recovery.

Transient neurologic symptoms (TNSs) after spinal anesthesia are defined as back pain radiating to buttocks, thighs, hips, and calves, occurring within 24 h after recovery from otherwise uneventful spinal anesthesia. The incidence is 3%–4%[3] and the symptoms last for about 1–3 days, but neurophysiologic evaluation does not show pathologic findings. Incidence is higher with hyperbaric lignocaine (11.9%) than with hyperbaric bupivacaine (1.3%).[4] The type and preparations of the local anesthetic drug (baricity, concentration, additives, or preservatives) are most often discussed as the underlying cause of TNS.[5] Epidural steroid treatment is effective in these patients who are resistant to nonsteroidal anti-inflammatory drugs, amitriptyline, and gabapentin.[4]

Cauda equina syndrome in early stage presents with low backache, sciatica, lower-limb motor weakness and sensory deficits, saddle anesthesia along with bladder, and bowel dysfunction.[6] Treatment necessitates surgical decompression of nerve root to prevent permanent damage.

Spinal hematoma is rare unless the patient has a traumatic needle placement, coagulopathies, or taking anticoagulant drug. They present with sudden-onset, sharp back and leg pain with numbness, weakness bladder, and bowel dysfunction. Guarded neurological recovery is seen following surgical decompression within 8–12 h.[1]

Arachnoiditis is another rare complication and may appear as transient nerve root irritation, cauda equina, and conus medullaris syndrome. It may result due to traumatic puncture, local anesthetics, detergents, or antiseptics which are unintentionally injected into spinal canal.[1]

The purpose of above write-up is to make anesthesiologist and surgeon aware of potentially devastating condition about neurological complication following spinal anesthesia. Earlier neuroimaging of the spine should be done in suspected neurological complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agarwal A, Kishore K. Complications and controversies of regional anaesthesia: A review. Indian J Anaesth 2009;53:543-53.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Kim SH, Song GS, Son DW, Lee SW. Neurologic complication following spinal epidural anaesthesia in a patient with spinal intradural extramedullary tumor. J Korean Neurosurg Soc 2010;48:544-6.  Back to cited text no. 2
    
3.
Anju G, Usha S. Spinal anaesthesia in children: A review. J Anaesthesiol Clin Pharmacol 2014;30:10-8.  Back to cited text no. 3
    
4.
Cöcelli LP, Erkutlu I, Karakurum G, Avci N, Gül R, Oner U, et al. Transient neurologic syndrome after spinal anesthesia with epidural steroid treatment. Curr Ther Res Clin Exp 2009;70:316-22.  Back to cited text no. 4
    
5.
Eberhart LH, Morin AM, Kranke P, Geldner G, Wulf H. Transient neurologic symptoms after spinal anesthesia. A quantitative systematic overview (meta-analysis) of randomized controlled studies. Anaesthesist 2002;51:539-46.  Back to cited text no. 5
    
6.
Crowther ER. Slow onset cauda equine syndrome: A case report. J Can Chiropr Assoc 1993;37:203-9.  Back to cited text no. 6
    




 

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