Transverse myelitis following combined spinal-epidural anesthesia

Corresponding author: Youn Hee Lim, M.D., Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, College of Medicine, Inje University, 761-1, Sanggye 7-dong, Nowon-gu, Seoul 139-707, Korea. Tel: 82-2-950-1173, Fax: 82-2-950-1323, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Transverse myelitis is an inflammatory or demyelinating disease of the spinal cord, which causes bilateral hypoesthesia and motor weakness, a decrease in deep tendon reflex spasticity of the extremities, and urination and defecation problems in the areas lower than affected spinal segment, without any observation of spinal cord injury, spinal lesion, or tumor, and no observation of pressure on the spinal cord [1]. We report our experience of transverse myelitis that occurred after spinal­ epidural combined anesthesia for caesarian section with a lite­ rature review. A 37­year­old pregnant woman (height 162 cm, weight 72 kg) with no specific medical history and no abnor­ malities was performed spinal­epidural combined anesthesia in the L 3­4 epidural space with intrathecal administration of 5% bupivacaine 7 mg for caesarean delivery at 39 + 1 weeks. Vital signs were stable with no specific event during this procedure and surgery. Fifteen minutes before the end of the surgery, fentanyl 50 μg and 1% lidocaine 40 mg were injected into the epidural space with N/S 2 ml for post­operative analgesia. For patient controlled analgesia, fentanyl 350 μg + 0.5% chirocaine 50 mg + N/S 83 ml were combined and connected to the epidural catheter with the following settings: basal rate 2 ml/ hr, bolus 1 ml/hr, and lockout time 30 min. Thirty minutes after transported into the recovery room, the anesthesia was up to T12, and the patient was moved to a general ward after confir mation of stable vital signs. Two days after surgery, the epidural catheter was removed. But the patient continuously complained of hypoesthesia and motor weakness in the left lower extremities. The condition gradually worsened to both sides so a lumbar and thoracic MRI was performed, but no abnormalities were found. Four days after surgery, WBC count was 30 cell/mm and protein was 91 mg/dl in the cerebrospinal fluid examination. Except that, abnormal finding was not seen. The patient was IV injected with methylprednisolone 1,000 mg as a steroid pulse therapy for 5 days for suspicion of transverse myelitis. Five days after surgery, in the somatosensory evoked potential examination, bilateral peripheral conduction distur­ bance was observed in the posterior tibial nerve. The lumbar magnetic resonance imaging performed 7 days after surgery was normal like before, and brain MRI was normal. Ten days after surgery, motor power of lower extremities slightly increased. Thus, mobility was recovered and prednisolone 40 mg was orally administered from that day. Twenty­two days after surgery, an electrophysiology test’s results showed radiculopathy in the L3­S1 region on both sides. Steroid therapy was stopped and walking practice was performed along with physical therapy. Six months after surgery, the right side displayed nearly normal motor function. The left side showed grade III hip joint flexion and grade IV extension, grade IV knee joint flexion and extension, and grade II ankle joint dorsiflexion and grade III extension. Approximately 7 months after the surgery, the patient was discharged. The prevalence of transverse myelitis is 4.6 per million in the United States, and mostly develops in young adults and middle­aged people regardless sex. Most of this disease is idiopathic but it can accompany vascular malformation or autoimmune disease such as multiple sclerosis, systemic lupus erythematosis. Also myelitis symptoms developed from preceding virus infections such as Ebstein­ Barr virus, cytomegalovirus was reported. As seen in our case,