Acute bacterial transverse myelitis, secondary to an epidural catheter, developed in a 49-year-old man who underwent surgery for carcinoma of the left lung. Left pneumonectomy was performed under combined general and epidural (Th6-7) anesthesia. The operative procedure, anaesthesia and early postoperative course were uneventful. On the fifth postoperative day, the patient developed neurological deficits consistent with high-level paraplegia. Elevated inflammatory parameters along with the results of cerebrospinal fluid analysis and magnetic resonance imaging were suggestive of acute transverse bacterial myelitis of the dorsal part of the spinal cord secondary to epidural analgesia. Despite prompt antibiotic therapy, anti-oedema treatment and rehabilitation, the neurological deficit failed to resolve

Mojca Drnovsek Globokar

Vesna Novak Jankovic

Vesna Paver Erzen

English

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 29www.signavitae.comTransverse myelitis following general and thoracic epidural anaesthesiaABSTRACTAcute bacterial transverse myelitis, secondary to an epidural catheter, developed in a 49-year-old man who underwent surgery for carcinoma of the left lung. Left pneumonectomy was performed under combined general and epidural (Th6-7) anesthesia. The operative procedure, anaesthesia and early postoperative course were uneventful. On the fifth postopera-tive day, the patient developed neurological deficits consistent with high-level paraplegia. Elevated inflammatory parameters along with the results of cerebrospinal fluid analysis and magnetic resonance imaging were suggestive of acute transverse bacterial myelitis of the dorsal part of the spinal cord secondary to epidural analgesia. Despite prompt antibiotic therapy, anti-oedema treatment and rehabilitation, the neurological deficit failed to resolve. MOJCA DRNOVSEK GLOBOKAR  (  ) • VESNA PAVER ERZEN •VESNA NOVAK JANKOVIC Clinical Department of Anesthesiology and Intensive TherapyUniversity Medical Centre LjubljanaZaloska 7. 1000 Ljubljana, SloveniaPhone: +386 1 522 2234Fax:  +386 1 522 2234E-mail: mojca.drnovsek@kclj.si MOJCA DRNOVSEK GLOBOKAR • VESNA PAVER ERZEN • VESNA NOVAK JANKOVICCASE REPORT   SIGNA VITAE 2010; 5(2): 29 - 31Keywords:  epidural anaesthesia, paraplegia, transverse myelitisIntroductionEpidural analgesia provides effec-tive relief of acute postoperative pain and reduces postoperative morbid-ity and mortality. Transverse myelitis is an infrequent complication of central nervous system blockade. Individual cases  have been reported in connec-tion with spinal, epidural and even gen-eral anaesthesia. Case reportA 49-year-old professional driver was scheduled to undergo a left pneumon-ectomy for planocellular carcinoma of the left main bronchus. Preoperative evaluation revealed that the patient had been treated for hypertension for 15 years and hyperlipidaemia for the pre-vious month. He reported smoking 20 cigarettes per day for 20 years and occasional use of alcohol. There was no history of allergy, and he had no previous surgery. He was obviously overweight (166 cm, 93 kg). Preopera-tive laboratory findings were within nor-mal limits. Chest radiography revealed decreased ventilation of the entire left lung, absence of clear infiltrates and a mild mediastinal shift to the left. Elec-trocardiography (EKG) demonstrated sinus rhythm with signs of Wolff-Par-kinson-White syndrome (WPW sy) and a normal QRS axis. Respiratory func-tion tests showed the following values: forced vital capacity (FVC) 3880 ml (85%), forced expiratory volume in 1 s (FEV 1) 3180 (65%), Tiffeneau index (TI) 78%. Carbon dioxide diffusion was within normal limits.On the day of surgery, an intravenous line, an arterial cannula for invasive blood pressure monitoring, and a cen-tral venous catheter were inserted in the induction room and premedication with midazolam 1 mg i.v. and fentanyl 0.05 mg i.v. was administered. Using a ster-ile procedure and a loss-of-resistance technique with an 18-gauge Tuohy nee-dle, an epidural catheter was inserted at the Th6-7 level. Due to the patient’s adiposity and degenerative changes of the spine, which were diagnosed only after the operation, detection of the epidural space and catheter inser-tion presented considerable technical difficulties. It was accomplished after five unsuccessful attempts. Through the catheter,  80 mg of lidocaine was administered as a test dose, followed by preemptive analgesia with 4 mg of morphine  in 10 ml of saline and after that 25 mg of bupivacaine was admin-istered via epidural catheter.  General anaesthesia was induced by intravenous application of midazolam 2 mg, fentanyl 0.1 mg, propofol 200 mg and vecuronium 8 mg. It was main-tained with intravenous propofol, fenta-nyl and vecuronium. Ventilation of the right lung with 100% oxygen was per-formed with a Draeger Cato ventilator via a right double-lumen tube Portex, 41 Fr. The intraoperative course was uneventful.Postoperatively, the patient was trans-ferred to the intensive care unit of the Department of Thoracic Surgery.  Post-30 www.signavitae.comoperative pain was adequately control-led with an epidural mixture of morphine hydrochloride 0.1 mg/ml, bupivacaine 0.5 mg/ml, and clonidine 1.5 g/ml, administered at a rate of 1-2 ml/h. Before scheduled therapeutic proce-dures of respiratory therapy, analgesia was supplemented with intramuscu-lar diclofenac 75 mg.  The pain score, assessed on a visual analogue scale (VAS), ranged between 2 and 4. The epidural catheter was removed on the second postoperative day because of pruritus.On the fifth postoperative day, the patient developed signs of paralyt-ic ileus, associated with formication and progressive paresis in the lower extremities. He had fever and com-plained of severe abdominal and lum-bar pain. On neurological examina-tion, voluntary movement in the lower extremities was preserved only in the toes, and most reflexes were absent, with the exception of the left patel-lar and the right Achilles reflex. There was loss of sensation below seventh thoracic vertebra level and inconti-nence of urine and feces was present. Meningeal signs were absent. Mag-netic resonance (MR) imaging of the spine displayed a hyperintense signal in the central part of the spinal cord at the level of the third to fifth thoracic vertebra, suggestive of myelopathy or myelitis, there were no signs of spinal cord compression. A cerebrospinal fluid (CSF) sample revealed increased protein 9.15 g/L ( normal 0.15-0.45 g/L), a normal glu-cose value  2.5 mmol/L ( normal 2,5-3,9 mmol/L) and an increased leuko-cyte count  762 x 106/L ( normal less than 5 x 106/L) , mainly on account of neutrophilic granulocytes 666 x 106/L, lymphocytes 75 x 106/L, monocytes 21 x 106/L. Inflammatory blood param-eters were increased WBC 19.4 x 109 , CRP 264 mg/L.  At the same time blood glucose was 6.1 mmol/l (normal 3.6-6.1 mmol/l).  Gram stain and sub-sequent culture of CSF were negative. A tentative diagnosis of acute bacterial transverse myelitis was made accord-ing to laboratory findings and good antibiotic response, despite negative culture of the CSF.The patient was placed on empirical antibiotic treatment with vancomycin 1g/12 h i.v. and ceftazidime 2 g/8 h i.v. and anti-oedemic therapy with dexam-ethasone 8 mg/8 h i.v. On this regimen he was transferred to the Department of Infectious Diseases. The inflamma-tory parameters decreased and the fever subsided. A control CSF sample showed a decrease in protein 2.25 g/L, leukocyte count 7 x 106/L and glucose level to 2.9 mmol/L. Despite intensive physical therapy and electrical stimu-lation, muscle wasting soon became apparent in the legs and thighs. A fol-low-up MR scan of the spinal cord dis-played hydromyelia. Electromyography demonstrated an upper motor neuron lesion.The patient was transferred to the Rehabilitation Institute of the Republic of Slovenia, Department for injuries and diseases of the spinal cord, where he remained for 18 weeks. The patient achieved complete independence in all daily activities. At the end of therapy, he could walk with crutches and climb stairs using the handrail. Muscle wast-ing was present in his left leg and thigh resulting in weakness of the left lower extremity.  DiscussionEpidural analgesia is an effective meth-od of pain relief following thoracotomy. Major lung resection, in particular pul-monectomy, carries a high risk of res-piratory complications. Effective anal-gesia in the postoperative period is essential to ensure the patient’s active cooperation in respiratory therapy. Although the method is invasive and carried out in immediate proximity of the central nervous system, serious complications with permanent neuro-logical squeal are  rather uncommon. The incidence in the USA being as low as 1:10,0000.  (1)  The main causes of neurological complications follow-ing neuroaxial blockade are needle trauma and local anaesthetic neurotox-icity. (1) According to Bromage three broad categories of complications may be distinguished following neuraxial anaesthesia: Post-anaesthetic squeal directly attrib-utable to anaesthetic causesSequelae solely attributable to non-anaethetic causesA group where anaesthesia is an inci-dental but possibly a contributing fac-tor. (2)Difficult, traumatic puncture of the epidural space may lead to the devel-opment of an extradural haematoma, which can act as a nidus for infection. (3) Infections of the epidural space and spinal cord secondary to epidural anaesthesia occur in 0.4% and 0.7% of cases, respectively, and mostly take the form of paraspinal or epidural abscess with spinal cord compression, or inflammation of the meningeal mem-branes. (2-5) Some studies suggest a disproportionately high association of thoracic epidural catheters with epi-dural abscesses most probably due to difficult insertion and traumatic punc-tion. (2)Acute transverse myelitis (ATM) has an incidence of 1-4: 1.000 000 people per year, affecting individuals of all ages with no sex or familiar predisposition. (5) One third of patients recover with lit-tle or no neurologic sequelae, one third with moderate degree and one third with severe disability. (5)  It is character-ized by acutely or subacutely develop-ing symptoms of motor, sensory and autonomic nervous dysfunction, with a clearly defined rostral sensory bor-der of dysfunction. A diagnosis of ATM requires confirmation of inflammation within the spinal cord. Spinal MRI and CSF analysis are the diagnostic proce-dures for ATM. For ATM diagnosis the following are required: • Abnormal gadolinum enhancement of the spinal cord at MRI or • CSF pleocythosis or• Elevated CSF IgG index According to an etiologic scheme, ATM could be classified into six groups related to:1. Multiple sclerosis2. systemic disease (SLE; Sjorgen, anti-fosfolipid sy) 31www.signavitae.com3. delayed radiation myelopathy4. spinal cord infarction5. parainfections6. idiopathic In parainfectious ATM, IgM serology is positive or IgG levels are fourfold or greater on two successive tests for a specific infectious agent.The etiology of acute-onset transverse myelitis remains unknown. In 30-60% of patients there is an antecedent respira-tory, gastrointestinal or systemic illness. Neurological injury may be associated with direct infection or remote infection followed by a systemic response caus-ing neurological damage. Individual sporadic cases of transverse myelitis have been described follow-ing intrathecal pump insertion, spinal, epidural anaesthesia and even after general anaesthesia. (6-9) The cases observed after intrathecal pump inser-tion were caused by Acinetobacter bau-manii. When the condition developed following spinal, epidural or general anaesthesia, the causative agent could not be identified. (6-10)In our patient, the diagnosis of acute bacterial transverse myelitis of the thoracic spinal cord was made on the basis of sudden neurologic disability, CSF analysis and MRI of the spinal cord in association with systemic signs of inflammation. Neurologic deficit appeared quickly with high paraplegia. CSF analysis showed normal glucose, high leucocyte count and increased protein, which is characteristic for bac-terial transverse myelitis. A bacterial pathogen was not identified since the epidural catheter had been removed on account of pruritus three days before the onset of symptoms. Culture of cere-brospinal fluid yielded no organisms. At the time of lumbar puncture, the patient was treated with ciprofloxacin and clin-damycin, which might explain why his cerebrospinal fluid was sterile. Sub-sequently, the antibiotic therapy was changed to ceftazidime and vancomy-cin, which were selected on a purely empirical basis but proved appropriate, leading to a decrease in inflammatory parameters. The suitability of anti-oedema therapy in transverse myelitis is a matter of debate. Our patient received dexamethasone 8 mg/8h i.v. for three weeks. Accord-ing to the literature, higher doses of methylprednisolone (1 g/day for three days, followed by a gradual decrease) have been used with success in a small number of patients. (6-8) Since acute transverse myelitis may have an autoimmune etiology, immunosuppres-sion seems reasonable.In conclusion, difficult, traumatic punc-ture of the epidural space may lead to the development of an extradural haematoma, which can act as a nidus for infection.  A good aseptic tech-nique is of paramount importance. This includes using a sterile gown, sterile gloves and sufficiently large sterile drapes, thoroughly cleaning the skin prior to catheter insertion, allow-ing sufficient time for the disinfectant to exert its antibacterial action. Also during postoperative handling of the epidural catheter, aseptic technique is very important.REFERENCES01.Munnur U, Suresh MS. Backache, headache, and neurologic deficit after regional anesthesia. An Cl North Am 2003;21:1.02.Dawson SJ. Epidural catheter infections. J Hosp Infect 2001;47:3-803.Holt HM, Andersen SS, Andersen O, Gahrn-Hansen B, Siboni K. Infections following epidural catheterisation. J Hosp Infect 1995;30:253-60.04.Brooks K, Pasero C, Hubbard L, Coghlan RH. The Risk of Infection Associated With Epidural Analgesia. Infect Control Hosp Epidermiol 1995;16:725-6.05.Ubogu EE, Lindenberg JR, Werz MA. Transverse myelitis associated with Acinetobacter baumanii intrathecal pump catheter-related infec-tion. Reg Anesth Pain Med 2003;28:470-4.6.Kaur R, Girdhar KK, Banerjee N. Transverse myelitis following spinal anaesthesia-a case report. Indian J Anaest 2002;46(5):476-7.7.Martinez-Garcia E, Pelaez E, Roman JC, Perez-Gallardo A. Transverse myelitis following general and epidural anaesthesia in a paediatric patient. Anaesthesia 2005;60:921-3.8.Gutowski NJ, Davies AO. Tranverse myelitis following general anesthesia. Anaesthesia 1993;48:44-5.9.Watanakunakorn C. E. colli meningitis and septicemia associated with an epidural catheter. Clin Infect Dis 1995;21(3):713-4.10.Berman M, Feldman S, Alter M, Zilber N, Kahane F. Acute transverse myelitis: incidence and etiologic considerations. Neurology 1981;31:966-71.

Transverse myelitis following general and thoracic epidural anaesthesia

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