Hemiplegia and retrobulbar neuritis after subarchnoid block

Abstract

A 25 year old man was given a subarachnoid anaesthetic for repair of hydrocele. He developed left-sided hemiplegia and retrobulbar neuritis three hours rafter the procedure. He recovered 45 days later after steroid therapy. There was some residual neurological deficit. The differential diagnosis is discussed.KEY WORDS: ANAESTHESIA, subarachnoid; COMPLICATIONS, BRAIN, hemiplegia, retrobulbar neuritis.THE ADMINISTRATION of subarachnoid anaesthesia for pelvic and lower abdominal operations has become so common, particularly in a developing country such as India, that its safety is taken for granted. Large series have been reported without major complication t'z yet various monographs 3'4 suggest that neurological complications are not at all uncommon. This is the report of a patient who developed hemiplegia and retrobulbar neuritis three hours after subarachnoid block. CASE REPORTA right handed 25 year old sedentary worker was admitted to our hospital 30th March 1980 for repair of hydrocele of six months duration. He had been in good health until the early part of 1975, when he was operated under general anaesthesia for peptic ulcer and had made an uneventful recovery. The present operation took place under subarachnoid block the day after admission.Preoperative assessment and laboratory investigation did not reveal any abnormality. There was no history suggestive of diabetes, hypertension, syphilis, collagen or neurological disease, muscular weakness, convulsions, myocardial infarction, vaccination, upper respiratory tract infection. There was no family history of neurological disease. He was not premedicated. The subarachnoid puncture was done at the L2/3 interspace with a 21 gauge needle and 1.5 ml of lidocaine five per cent was injected. The intraoperative course was uneventful.Half an hour after conclusion of the operation he experienced severe pain in the cervical region and a generalized throbbing headache, not related to posture. Three hours later focal convulsive movements were noticed followed by numbness and weakness of the left upper extremity and after six hours the left lower extremity became involved along with diminution of vision in the left eye. He remained fully conscious during this period. He was incontinent of urine but not of faeces.On examination he was found to be febrile with temperature of 38.4~ The left eye was tender and the field of vision constricted. Neurologically there was hemianaesthesia below the 4th cervical dermatome, hypotonia and areflexia of the left extremities with grade II power in the left lower and none in the left upper extremity. The left plantar reflex was doubtful. Laboratory and radiological investigation were normal. Dexamethasone 4 mg was given intramuscularly thereafter every six hours. On the fifth postoperative day there was still complete hemianaesthesia but with brisk reflexes on the left side. By the 18th postoperative day the vision in the left eye had become reduced to finger counting at a distance of two metres. Only thirty per cent sensation was...