Coexisting harlequin and Horner syndromes after high thoracic paravertebral block
Editor—I read with interest the article entitled ‘Coexisting harlequin and Horner syndromes after high thoracic paravertebral anaesthesia’.1 I recently witnessed a very similar presentation of this rarely reported condition when asked to review a patient with a low thoracic epidural block, in the recovery room following elective urinary diversion and formation of ileal conduit. A thoracic epidural was sited at the T10/11 vertebral space using an 18 G Tuohy needle in the sitting position. Loss of resistance to saline was elicited at 5 cm and the catheter passed with ease. A test dose of levobupivacaine 0.5% (4 ml) was followed by a continuous infusion of levobupivacaine 0.125% with fentanyl 2 µg ml–1 at 8 ml h–1. General anaesthesia was then induced. During surgery, various degrees of Trendelenburg positioning with lateral tilt to facilitate operative access to deep pelvic structures were requested. On transfer to the recovery room the patient was noted to have developed a well-demarcated hemifacial flushing with sweating involving her right side. Sensory blockade involving T4–L1 dermatomes was identified with ethyl chloride. No other neurological deficit was noted. This colour change last approximately 8 h and resolved without consequence. The epidural continued for a further 24 h.It seems likely that intraoperative positioning allowed sufficient rostral/unilateral spread of local anaesthetic agents to involve preganglionic fibres arising from the contralateral upper thoracic (T2–4) sympathetic branches. Absence of sympathetic oculomotor signs (ptosis or meiosis) suggests no involvement of T1. Patient positioning during prolonged surgery may be a risk factor during the use of regional anaesthesia.
Dunfermline, Scotland
E-mail: sicrawley{at}doctors.org.uk
References
1 Burlacu CL and Buggy DJ. Coexisting harlequin and Horner syndromes after high thoracic paravertebral anaesthesia. Br J Anaesth 2005; 95:822–4
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