British Journal of Anaesthesia, 2004, Vol. 92, No. 1 146-148
© 2004 The Board of Management and Trustees of the British Journal of Anaesthesia
Case Reports |
Postoperative nerve irritation syndrome after epidural analgesia in a six-year-old child
1 Department of Anaesthesiology, Sahel General Hospital, Beirut, Lebanon. 2 Department of Anaesthesiology, Centre Clinical, 2 Chemin de Frégeneuil, 16800 Soyaux, France. 3 Department of Anaesthesiology and Critical Care, Bicetre Hospital, 78 rue du General Leclerc, 94275 Le Kremlin Bicetre, France
*Corresponding author: Department of Anaesthesiology, Sahel General Hospital, Lebanese University, Airport Avenue, PO Box 99/25 Ghobeiry, Beirut, Lebanon. E-mail: doczeidan@hotmail.com
Accepted for publication: September 1, 2003
 |
Abstract |
|---|
 Top Abstract IntroductionCase reportDiscussionReferences |
|---|
Morbidity after paediatric epidural anaesthesia is unusual. We report a case of transient nerve root irritation occurring after epidural analgesia for radical nephrectomy in a 6-yr-old boy who received a continuous infusion of bupivacaine 0.1%. The epidural catheter was inserted within the L2–L3 interspace under general anaesthesia. Several possible causes are discussed. Mechanical irritation of nerve roots by the epidural catheter in the epidural space is the most likely cause.
Br J Anaesth 2004: 92: 146–8
Keywords: analgesic techniques, epidural; complications, nerve irritation; surgery, paediatric
|
Introduction |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
Epidural analgesia is considered one of the most effective techniques for relieving pain after major abdominal surgery. In addition, there is sustained enthusiasm among paediatric anaesthetists for the use of regional analgesia in the perioperative period. Serious complications related to the use of regional anaesthesia may occur,1 but they are exceptional, especially in children.2
We report a case of transient postoperative neurological symptoms in a 6-yr-old child who was receiving epidural analgesia after renal surgery.
|
Case report |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
A 6-yr-old male child weighing 21 kg with a diagnosis of nephroblastoma was scheduled for right radical nephrectomy. Anaesthesia was induced through a face-mask with sevoflurane 3% in a 50% nitrous oxide–oxygen mixture followed by i.v. thiopental 5 mg kg–1, sufentanil 0.1 µg kg–1 and atracurium 0.5 mg kg–1. After tracheal intubation, the child was positioned in the left lateral decubitus position. The epidural space was easily located with a 19 G Tuohy needle (Portex®, Keene, NH, USA) using the loss of resistance to saline technique. The insertion of a 23 G single end-hole catheter through the L2–L3 interspace was uneventful and the tip was left 5 cm inside the epidural space. After injecting a 1 ml test dose (bupivacaine 0.25% with epinephrine 10 µg) through the catheter to rule out accidental intravascular positioning, a continuous infusion throughout surgery of bupivacaine 0.1% was started at the rate of 0.3 mg kg–1 h–1. Morphine was added to the epidural infusion at a rate of 6 µg kg–1 h–1 after operation. It was planned to use this mixture for 48 h. The surgical procedure was uneventful and the child did not require any additional intraoperative opioids. Incisional pain at rest or during movement was minimal in the recovery room. Motor block was absent in the lower limbs and the sensory block was symmetrical.
On the morning of the first postoperative day, the child was anxious and restless, and suffered from severe pain in the right groin, radiating to the anterior surface of the thigh. Neurological examination revealed severe pain in the right lower quadrant of the abdomen with sensory loss on the anterior surface of the right thigh, suggesting a lesion in the L2 dermatome. No motor deficit was noticed and all deep tendon reflexes were present. The epidural catheter, the drug dosage and the infusion rate were checked. The local anaesthetic infusion was stopped and the epidural catheter was removed.
A parenteral opioid-based regime and bed rest were sufficient to relieve the pain and a complete neuro logical recovery was seen within 24 h, without any further complaint.
|
Discussion |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
The epidural-induced side-effects most often seen in children are nausea, vomiting, local erythema, motor block, and a leak at the insertion site. In contrast to adults,3 regional blocks in paediatrics are generally performed under general anaesthesia, which is less likely to lead to accidental nerve damage. However, the incidence of transient neural injury in children is exceptional (2/2396 patients), as demonstrated in a French survey.2 In our patient, several hypotheses may be advanced to explain this complication. First, the risk of undiagnosed intraneural injection through the epidural catheter is possible and could explain such severe pain. However, this is probably not the explanation in this instance as the epidural infusion was used for the first 24 h after operation without complaint. Secondly, an epidural infusion for 24 h may increase the local concentration of bupivacaine in a particular area of the epidural space, especially if a terminal end-hole catheter has been used, as in our case, leading to a direct and localized neurotoxic effect of the local anaesthetic. This is less likely with a multiple-hole catheter.4 Transient neurological symptoms often occur after spinal anaesthesia5 6 and are characterized by painful sensations in the low back and buttocks, radiating to the lower limbs. Pain appears hours after complete recovery from anaesthesia and usually disappears in the next few days.5 6 Transient neurological symptoms occur much more rarely after epidural analgesia, although this syndrome has been reported in adults7 and children.8 Local anaesthetics injected into the epidural space may undergo transmeningeal transfer into the cerebrospinal fluid,9 mostly via the arachnoid villi in the dural cuff region.10 11 Repeated injections or continuous infusions may result in increased intrathecal concentrations of the local anaesthetic in the spinal fluid causing this neurotoxic effect even after epidural analgesia. The lithotomy position6 is associated with a higher incidence of transient neurological symptoms in comparison with the supine position, which may be a result of stretching of the lumbosacral nerves, rendering them vulnerable to the toxic potential of local anaesthetics. In our case, surgical trauma and/or surgical retractors might have stretched the low thoracic (T10, T11, T12) and high lumbar (L1, L2) nerve roots during surgical dissection of a large tumour, thus contributing to this postoperative complication.
Mechanical irritation of the nerve root by the epidural catheter is the most likely explanation of the postoperative pain in this child, especially as the symptoms disappeared completely after removal of the epidural catheter. One contributing factor could have been the length of the epidural catheter introduced into the epidural space (5 cm), which might have been too long in this 21 kg child. One study in obstetric patients has shown that 5 cm is the optimal distance that the epidural catheter should be threaded into the epidural space and that a greater distance may lead to asymmetrical analgesia.12 In another obstetric study, epidural catheters threaded for only 2 cm were associated with a greater incidence of dislodgement, especially in prolonged labour.13 This study suggests that, when a catheter is sited for postoperative pain relief over several hours, a relatively long part of the catheter should be threaded into the epidural space. Unfortunately, however, there are no studies assessing the optimal length of epidural catheter to be introduced into the epidural space in adults or children for postoperative analgesia. Dalens14 has recommended insertion of the epidural catheter for 2 cm in children. We would concur that insertion of an epidural catheter for more than 2 cm in children should be avoided as this might lead to mechanical nerve root irritation. In this child a painful complaint highlighted the problem. But the incidence of painless symptoms or other minor neural events could be underestimated. They cannot be easily diagnosed unless regular postoperative follow-up is undertaken as part of a quality assurance programme. Moreover, pain or paraesthesia may occur during needle placement or insertion of the epidural catheter, highlighting the risk of potential problems, but these symptoms will be hidden by general anaesthesia in paediatric practice.
Thus we believe that the increasing use of regional anaesthesia in paediatric surgery should encourage anaesthetists to seek silent neurological injuries in the postoperative period.
|
References |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
1 Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia. Anesthesiology 1997; 87: 479–86[CrossRef][Web of Science][Medline]
2 Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French Language Society of Pediatric Anesthesiologists. Anesth Analg 1996; 83: 904–12[Abstract]
3 Fischer HB. Regional anaesthesia—before or after general anaesthesia? Anaesthesia 1998; 53: 727–9[CrossRef][Web of Science][Medline]
4 Collier CB, Gatt SP. Epidural catheters for obstetrics. Terminal hole or lateral eyes? Reg Anesth 1994; 19: 378–85[Medline]
5 Schneider M, Ettin J, Kaufeman M, et al. Transient toxicity after hyperbaric subarachnoid anesthesia with 5% lidocaine. Anesth Analg 1993; 76: 1154–7
6 Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anesthesia: an epidemio logic study of 1,863 patients. Anesthesiology 1998; 89: 633–41[CrossRef][Web of Science][Medline]
7 Freedman JM, Rudow MP. Bilateral buttock and leg pain after lidocaine epidural. Anesth Analg 1999; 88: 1188
8 Bourlon-Figuet S, Dubousset AM, Benhamou D, Mazoit JX. Transient neurologic symptoms after epidural analgesia in a five-year-old child. Anesth Analg 2000; 91: 856–7
9 Frumin MJ, Schwartz H, Burns JJ et al. Sites of sensory blockade during segmental spinal and segmental epidural anesthesia in man. Anesthesiology 1953; 14: 576–83[Web of Science][Medline]
10 Shantha TR, Evans JA. The relationship of epidural anesthesia to neural membranes and arachnoid villi. Anesthesiology 1972; 37: 543–57[Web of Science][Medline]
11 Shantha TR. Spinal nerve root is one of the preferred routes for transfer of drugs to the nerve roots and spinal cord from the epidural space. Anesthesiology 1992; 77: 216–8[CrossRef][Web of Science][Medline]
12 Beilin Y, Bernstein HH, Zucker-Pinchoff B. The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space. Anesth Analg 1995; 81: 301–4[Abstract]
13 D’Angelo R, Berkebile BL, Gerancher JC. Prospective examination of epidural catheter insertion. Anesthesiology 1996; 84: 88–93[CrossRef][Web of Science][Medline]
14 Dalens BJ. Regional anesthetic techniques. Section III: Anesthetic management and techniques. In: Bissonnette B, Dalens BJ, eds. Pediatric Anesthesia. Principles and Practice. New York: McGraw-Hill, 2002; 529–75
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||