Damage to the conus medullaris following spinal anaesthesia

Abstract

SummaryNon-invasive positive pressure ventilation has previously been used successfully to treat both acute and chronic ventilatory failure secondary to a number of conditions, including scoliosis. We report two patients in whom it was used, on three separate occasions, to treat acute ventilatory failure following corrective spinal surgery. Non-invasive positive pressure ventilation may be useful postoperatively in high-risk patients undergoing major spinal surgery in an attempt to prevent intubation and its attendant complications. Non-invasive positive pressure ventilation (NIPPV) has been used in the treatment of both acute and chronic ventilatory failure secondary to a wide number of conditions, including chronic obstructive pulmonary disease (COPD) [1], neuromuscular disease [2], thoracoplasty and scoliosis [3]. When NIPPV is used in chronic ventilatory failure due to scoliosis, the benefits include improved arterial blood gases, improved quality of life and decreased hospital stay [4,5]. Approximately 80% of patients are alive on treatment 5 years after the initiation of non-invasive ventilation [4,5]. A number of studies have included small numbers of patients in whom NIPPV has been used to treat acute or chronic ventilatory failure secondary to scoliosis [6].Acute ventilatory failure can develop following corrective surgery for scoliosis, especially in those patients with poor pre-operative pulmonary function. Surgical intervention may be deemed contraindicated for patients with extremely limited respiratory reserve. We describe two cases of ventilatory failure following corrective surgery, in whom treatment with NIPPV obviated the need for intubation and conventional mechanical ventilation. Case history 1An 11-year-old boy with severe congenital scoliosis, first noted when aged 6 months, was admitted for corrective spinal surgery. At the age of 4 years, he had undergone anterior disectomies and excision of the vertebral end plates of the mid-thoracic spine. Unfortunately, this attempt to arrest spinal growth did not succeed and his scolotic deformity progressed. He was otherwise well and was on no medication.Pre-operatively, his main complaints were of back ache and exertional fatigue. Occasionally he experienced breathlessness on exertion but was able to play football. Examination revealed no signs of right heart failure or pulmonary hypertension and no neurological abnormality. His ECG and overnight oximetry were normal; his chest X-ray showed no parenchymal disease. Pre-operative lung function and arterial blood gases are shown in Table 1.He underwent the first stage of a Leatherman anterior wedge resection, which consists of an anterior transthoracic excision of a congenital thoracic hemivertebra via a ribexcising thoracotomy. He was electively ventilated via a tracheal tube on the intensive care unit (ICU) for 6 h postoperatively. He was extubated and observed overnight before transfer to a high-dependency unit (HDU) facility the next day, at which time oxygen saturation was 96% on 40% oxygen by a ...

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“…Recently, two case series from Great Britain documented spinal cord trauma after spinal or combined spinal/epidural anesthesia. 13,14 In one study, the level of puncture recorded on the anesthetic record was two or three segments lower than the subsequent damage as shown by MRI. Of note, no patient's conus medullaris was situated below L1.…”

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“…It is important to identify levels accurately and to choose a level below conus medullaris during spinal anesthesia to prevent spinal cord trauma. 11 Broadbent et al demonstrated that even experienced anesthesiologists estimate the intervertebral level inaccurately by palpation in 71% of cases; they tend to estimate the level as higher than the actual, and their estimate could be as many as four spaces higher. 12 Tuffier's line, an anatomical landmark widely used for this purpose, does not always bear a constant relationship to an individual vertebral level or the interspace.…”

“…Ceci permet d'éviter un traumatisme au niveau de la moelle épinière. 11 Broadbent et coll. ont démontré que, dans 71 % des cas, même des anesthésiologistes d'expérience estimaient de façon erronée le niveau intervertébral par palpation; en effet, ils ont tendance à estimer le niveau comme étant plus élevé qu'en réalité, et leurs estimations peuvent s'écarter du niveau réel jusqu'à quatre espaces plus haut.…”

Complicações neurológicas determinadas pela anestesia subaracnóidea

“…Patients referred pain at needle insertion or local anesthetic injection. In all cases, pencil point bevel needles were used (Whitacre) and puncture was performed in L 2 -L 3 or L 1 -L 2 interspace 14 . When pencil point needles are used, it is necessary to further introduce it in the spinal space to obtain cerebral spinal fluid (CSF).…”