Guillain-Barre syndrome after lumbar epidural block

Corresponding author: Yong-Hyun Cho, M.D., Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, 40-12, Cheongnyangni-dong, Dongdaemun-gu, Seoul 131-868, Korea. Tel: 82-2-966-1616, Fax: 82-2-968-2394, 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 Guillain-Barre syndrome (GBS) is an acute demyelinating polyneuropathy characterized by weakening of muscular strength on both sides of the body and ascending paralysis of the body, and displays a prevalence rate of 0.6-4 out of 100,000 persons per year [1]. Clinical appearance mostly begins with weakening of muscular strength in the distally located lower limb and progresses to the proximal muscles including the trunk, neck, and face over several days [2]. Here, we report a case of GBS that occurred after a lumbar epidural block along with a literature review. A 26-year-old man who visited the pain clinic at our hospital presented with an aggravation of radiating pain to the right lower limb. The patient was diagnosed with lumbar herniated intervertebral disc between the 5th lumbar and 1st sacral vertebrate with magnetic resonance imaging (MRI) done at our hospital about a year ago. The patient was injected with a mixture consisting of 2 ml of 1% mepivacaine, 1 ml of triamcinolone (40 mg/ml), and 5 ml of normal saline into the epidural space with a 22-gauge epidural Tuohy needle between the 5th lumbar and 1st sacral vertebrate. Although the radiating pain to the right lower limb improved, he revisited the emergency ward of our hospital with a feeling of powerlessness in both lower limbs that increasingly worsened 4 days after the epidural block. During the motor test, grade III-IV hip joint flexion, grade IV hip joint extension on both sides, grade II knee joint flexion, grade IV knee joint extension on both sides, and grade II dorsi-flexion of the ankle joint on both sides were observed. Reflex test demonstrated findings of areflexia in the knees and Achilles tendon on both sides. The patient had diarrhea several times 10 days before visiting the pain clinic at our hospital, which improved without any particular treatment. An MRI was taken to reconfirm the extent of the lumbar herniated intervertebral disc, which displayed findings of reduction in the extent of the lumbar herniated intervertebral disc compared to the MRI taken a year ago. While the test was being done, the patient complained of a sensory abnormality around his lips, and the patient was transferred to the department of neurology at a higher-ranking hospital with suspicion of GBS. Cerebrospinal fluid (CSF) analysis resulted in findings of increased levels of proteins to 121 mg/dl (normal level, 15-45 mg/dl). In the nerve conduction test, terminal latency in the peroneal nerve and posterior tibial nerve on both sides was prolonged while compound muscle action potential amplitude and conduction velocity were within normal range. F-wave latency was prolonged in the posterior tibial nerve. Having been diagnosed with GBS, the patient was administered immunoglobulin for 5 days. The patient was discharged after having shown improvement after 10 days of treatment in the hospital. If it is GBS, then an immune reaction is the cause of this disease. Approximately 2/3 of patients affected by this disease have a past history of infection in the respiratory or gas tro intestinal system 6 weeks prior to the occurrence of poly neuropathy [1]. For a diagnosis of GBS, findings of a gradual lowering of muscular strength in the upper and lower limbs within 4 weeks accompanied by areflexia under physical examination are essential. CSF analysis could be useful. In addition, findings such as a reduction in the motor nerve conduction velocity and extension of the F-wave latency could be found with a nerve conduction test. Intravenous immunoglobulin and plasma exchange are efficacious treatments. Supportive care during and following hospitalization is also crucial [2]. Steiner et al. [3]