Abducens palsy after lumbar drain placement: a rare complication in endoscopic skull base surgery.

OBJECTIVES/HYPOTHESIS To study reports of abducens nerve palsy following dural puncture procedures and to discuss possible etiologic theories, treatment, and prognosis. STUDY DESIGN Systematic review of peer-reviewed literature. METHODS A systematic literature review was conducted (PubMed, 1950 to September 2011) for cases of sixth cranial nerve palsy following dural puncture procedures. RESULTS We report a case of abducens nerve palsy following lumbar drain placement for endoscopic trans-sphenoidal pituitary macroadenoma resection. Sixth nerve palsy was noted immediately after surgery. Postoperative computed tomography and magnetic resonance imaging revealed no injury to the nerve or surrounding structures. A systematic literature review conducted for cases of abducens nerve palsy following dural puncture procedures found 22 studies (17 case reports and five case series). Twenty-eight patients with temporary or permanent abducens nerve palsy were reported. Procedures included diagnostic lumbar puncture, spinal anesthesia, intrathecal catheterization, and shunting. Traction and local ischemia due to intracranial hypotension at the petroclival junction were proposed as causes of palsy. CONCLUSIONS Lumbar puncture procedures carry a rare risk of abducens nerve palsy from ischemic or traction injury. Routine use of lumbar drain during endoscopic skull base surgery is not without risk, and need for its placement should be carefully determined. Knowledge of such rare complications is helpful in risk-benefit analysis as endoscopic skull base techniques gain popularity.