Coma after combined spinal-epidural anaesthesia
Ankara Turkey
* E-mail: arzuhct{at}hotmail.com
Editor—Although neurological complications due to spinal drainage after regional anaesthesia are very rare,1 we would like to report a patient who had no neurological signs before operation but became comatose after combined spinal-epidural anaesthesia (CSE).
An 82-yr-old female patient was admitted with a right hip fracture. Previous medical history included hypertension for 30 yr, a colostomy 12 yr previously due to colon cancer, and a left hip fracture 6 yr ago. On physical examination, she had poor general status, normal conscious level, and complete orientation. All the routine preoperative test results were within normal limits other than a raised blood urea of 14 mmol litre–1 and a creatinine of 260 µmmol litre–1. Neurological examination was normal. CSE was chosen as the anaesthetic technique and she was informed about the operation. With the patient in the right lateral decubitus position, a 25G needle was inserted at the L2/3 interspace at first attempt, clear cerebrospinal fluid flow was observed, and 1.6 ml bupivacaine 0.5% was given intrathecally, and an epidural catheter inserted. The sensory block rose to T10 and surgery was carried out. She was discharged to the ward after the operation. After an uneventful test dose, postoperative epidural analgesia was maintained with an infusion of bupivacaine 0.125% at 5 ml h–1. On the second postoperative day, the patient became agitated, disorientated, dyspnoeic, and tachipnoeic, and was transferred to the intensive care unit. A pulmonary CT discounted pulmonary thromboembolism, but the appearance suggested active infection so sulbactam–ampicillin was started for the presumed diagnosis of aspiration pneumonia. Haloperidol was given for the delirium. There were no pathological changes or localization signs on neurological examination, although confusion developed on the third postoperative day. The patient became comatose and required tracheal intubation on the fifth postoperative day. Cranial MRI showed a 5–6 cm mass in the left frontal lobe suggestive of a meningioma with diffused oedema surrounding it, causing central herniation. After treatment of the oedema, a further MRI scan showed a meningioma with a haemorrhagic component, and diffused oedema and increased middle line shift were observed. The patient did not respond to therapy and died on the18th postoperative day.
Lumbar puncture is contraindicated in patients with raised intracranial pressure because it increases the pressure gradient between supratentorial and infratentorial compartments, thus risking herniation.2 Our patient had no symptoms of increased intracranial pressure before operation. The intracranial mass and herniation were identified on MRI taken after the rapid deterioration in consciousness of the patient. It was thought in this case that the intracranial pressure gradient after CSE anaesthesia caused herniation. Hilt and colleagues3 used epidural catheters for the treatment of pain in patients with increased intracranial pressure, and noted that local anaesthetic solutions given epidurally caused dramatic increases in intracranial pressure. Epidural anaesthesia-related increase in intracranial pressure can be very detrimental, especially in patients who had increased intracranial pressure previously.2 4 5
Regional anaesthesia techniques are extremely reliable when they are used appropriately, but there is always some risk of complications. In this case, we want to remind others of the possibility of an undiagnosed intracranial mass if the patient's mental status deteriorates after CSE.
References
1 Grady RE, Horlocker TT, Brown RD, the Mayo Perioperative Outcomes Group. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anaesthesia. Anesth Analg (1999) 88:388–92.
2 Chater SN, Greig AJ, Sugden JC. Epidural anaesthesia in the presence of a cerebral tumour. Anaesthesia (1987) 42:433–4.[Medline]
3 Hilt H, Gramm HJ, Link J. Changes in intracranial pressure associated with extradural anaesthesia. Br J Anaesth (1986) 58:676–80.
4 Su TM, Lan CM, Yang LC, Lee TC, Wang KW, Hung KS. Brain tumour presenting with fatal herniation following delivery under epidural anaesthesia. Anesthesiology (2002) 96:508–9.[CrossRef][Web of Science][Medline]
5 Goroszeniuk T, Howard RS, Wright JT. The management of labour using continuous lumbar epidural analgesia in a patient with a malignant cerebral tumour. Anaesthesia (1986) 41:1128–9.[CrossRef][Web of Science][Medline]
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