Obstetric epidurals and chronic adhesive arachnoiditis

Talbot, L.

doi:10.1093/bja/aeh566

Cited by 3 publications

(1 citation statement)

References 12 publications

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“…Authors agree that it is a rare entity, although its precise incidence remains uncertain [1][2][3]. Clinically, it has been defined as back pain that increases with activity in the context of uni-or bilateral leg pain, an abnormal neurological examination and MRI changes consistent with the disease [1].…”

Section: Chronic Adhesive Arachnoiditismentioning

confidence: 99%

Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review

et al. 2012

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SummaryA 27-year-old woman developed severe adhesive arachnoiditis after an obstetric spinal anaesthetic with bupivacaine and fentanyl, complicated by back pain and headache. No other precipitating cause could be identified. She presented one week postpartum with communicating hydrocephalus and syringomyelia and underwent ventriculoperitoneal shunting and foramen magnum decompression. Two months later, she developed rapid, progressive paraplegia and sphincter dysfunction. Attempted treatments included exploratory laminectomy, external drainage of the syrinx and intravenous steroids, but these were unsuccessful and the patient remains significantly disabled 21 months later. We discuss the pathophysiology of adhesive arachnoiditis following central neuraxial anaesthesia and possible causative factors, including contamination of the injectate, intrathecal blood and local anaesthetic neurotoxicity, with reference to other published cases. In the absence of more conclusive data, practitioners of central neuraxial anaesthesia can only continue to ensure meticulous, aseptic, atraumatic technique and avoid all potential sources of contamination. It seems appropriate to discuss with patients the possibility of delayed, permanent neurological deficit while taking informed consent. Case reportA 27-year-old woman with no significant medical history and in her first pregnancy underwent spinal anaesthesia for caesarean section for fetal compromise at another hospital at 42 weeks' gestation, after going into spontaneous labour. With the patient sitting, the skin over the L4-5 interspace was cleaned once by a consultant anaesthetist using a SOLU-I.V.Ò MAXI swabstick (Solumed, Laval, Canada) impregnated with 2% chlorhexidine gluconate and 70% isopropyl alcohol. There was no delay between opening the swabstick packaging and its use on the patient's skin. It is not clear whether the swabstick and its packaging were disposed of immediately. The prepared area was allowed to air-dry for 3 min before a 24-G needle (Becton, Dickinson & Company, Franklin Lakes, NJ, USA) was placed at L4-5 on the first attempt by a consultant anaesthetist wearing a sterile surgical gown and gloves, mask and hat, using an aseptic technique. After aspiration of free-flowing, clear cerebrospinal fluid (CSF), 2.5 ml bupivacaine 0.5% with 12.5 lg fentanyl was administered over approximately 15 s. A few seconds after the end of the injection, the patient complained of severe, burning pain in the lower back radiating into the legs bilaterally, worse on the right than the left. The pain began to recede as the block took effect and this was formally assessed 10 min after the

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