Neurological deterioration after spinal anaesthesia: a rare mode of presentation of spinal tumours

INTRODUCTION

Spinal/epidural anaesthesia is well tolerated with low rate of attendant complications.¹ It is the widely preferred mode of anaesthesia in performing caesarean section and a number of orthopaedic procedures in the lower extremities.² Neurological deterioration following spinal anaesthesia is infrequent but could be devastating to the patient.³ It may be due to injury to the nerve root or a low-lying cord, spinal epidural hematoma, or drug- and dosage-related complications.^3,4 Less frequent is the deterioration in the presence of a previously undiagnosed spinal tumour.^1,3 Even less reported is neurological deterioration in the presence of intradural-extramedullary tumours.^5,6 We presented a patient with previously undiagnosed thoracic meningioma who developed numbness and paraplegia following spinal anaesthesia for caesarean section.

CASE REPORT

A 29 year old woman who had spinal anaesthesia for emergency caesarean section because of obstructed labor at a peripheral hospital. She developed paraparesis and numbness of the lower limbs five hours after the surgery. Thoracic spine MRI showed a contrast enhancing extramedullary tumour at the level of fourth thoracic vertebra. She was referred to one of the neurosurgical centres in the country but presented to the traditional healers instead. Her symptoms progressed and she became paraplegic after two weeks. She presented to our hospital with spastic paraplegia and bisphincteric dysfunction 2 years after onset of symptoms. The sensory level was T4. We performed T4-5 laminectomies and gross total tumour excision. The tumour histology was meningothelia meningioma. She has made some neurological improvement 3 months after surgery. The power in the lower limbs is now grade 1-3. She is currently undergoing physiotherapy.

DISCUSSION

Spinal tumours are relatively rare, accounting for 1-3 percent of all central nervous system tumours.⁷ They can be classified as extradural, intradural-extramedullary, or intradural-intramedullary. Spinal tumours may present with motor, sensory or autonomic deficits as a result of spinal cord or nerve root compression. Rarely, neurological deterioration following lumbar puncture may be the first presentation of a previously undiagnosed spinal tumour.^3,6 The earliest report of this phenomenon was by Eaton et al 1940 who reported sudden paralysis following lumbar puncture in a patient with an extramedullary spinal tumour.⁸

Several mechanisms have been proposed for this deterioration. Elsberg proposed that the removal of the CSF buffer between the tumour and the spinal cord caused one to fall on the other leading to injury to the cord.⁹ Nicholson reported the obstruction of cerebrospinal fluid by space occupying lesions as the cause of neurological complications. He proposed that the injected drug cannot be diluted and stagnated with consequent accumulation of drug which can cause neurological toxicity.¹⁰ Impaired venous drainage from the spinal cord below the level of spinal cord tumour due to engorged epidural veins exacerbated by lumbar puncture has also been suggested as the mechanism for neurological deterioration in this setting by Hollis.¹¹

Jooma et al coined the term spinal coning in 1984.¹² They described spinal cord dysfunction in four patients with spinal cord tumours following insertion of shunt for hydrocephalus. Though deterioration followed ventricular shunting in their patients, they suggested that the term can be used for neurological deterioration following removal of CSF below the spinal lesion as well. Spinal coning results from the movement of spinal tumour and spinal cord relative to each other due to sudden change of pressure differences above and below the level of block, which may cause impaction of the tumour against the cord and subsequent neurological deterioration.¹²

Spinal cord tumours may present with motor, sensory or autonomic symptoms but may sometimes be asymptomatic.^3,6 Our patient had not reported any symptom before she had spinal anaesthesia. It will not be cost effective or universally possible to obtain spinal MRI for all patients undergoing spinal or epidural anaesthesia. We suggested detailed neurological evaluation before and after spinal anaesthesia with a view to identifying signs of spinal cord compression so as to prevent post procedural deterioration or enable prompt intervention.

Our case also highlighted the role being played by poor health literacy and poverty in the outcome of neurological diseases in developing countries. Our patient was promptly diagnosed and referred to a neurosurgical centre before the establishment of our unit. She however presented to traditional healers because of financial constraint. She only came to us when there was no improvement in her symptoms after 2 years despite deployment of fast financial resources for the traditional care. Although the health system in the resource challenged countries of the world is far from ideal and specialist care centres especially neurosurgical ones are not universally accessible, a functional health insurance scheme will go a long way in improving accessibility of a larger proportion of the population to better health care.

CONCLUSION

Although rare, neurological deterioration following spinal anaesthesia may be the first presenting features of a spinal cord tumour. All physicians managing patients undergoing this procedure should be aware of this fact. A detailed neurological evaluation before and after spinal anaesthesia will go a long way in pre procedural diagnosis of patients at risk and prompt intervention in patients with post spinal anaesthesia neurological deterioration.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Campbell PG, Birknes JK, Sharan AD, Harrop JS, Vaccaro AR, Ratliff JK. Hemorrhage into an occult spinal ependymoma after epidural anesthesia. Open Surg J. 2008; 2: 18-20
2. 2. Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev. 2004;2004(2):003765.
3. 3. Krishnan P, Roychowdhury S. Spinal coning after lumbar puncture in a patient with undiagnosed giant cervical neurofibroma. Ann Indian Acad Neurol. 2013;16(3):440-2.
4. 4. Iwashita K, Shigematsu K, Higa K, Nitahar K. Spontaneous recovery of paraplegia caused by spinal epidural hematoma after removal of epidural catheter. Case Rep Anesthesiol. 2014;2014:291728.
5. 5. Kim SH, Song GS, Son DW, Lee SW. Neurologic complication following spinal epidural anesthesia in a patient with spinal intradural extramedullary tumor. J Korean Neurosurg Soc. 2010;48(6):544-6.
6. 6. Dureja J, Singh I, Kad N, Bhai V, Thakur A, Lal J. Paraparesis following spinal anesthesia in a patient with an undiagnosed spinal tumour. Acta Anaesthesiol Taiwan. 2008;46(2):86-90.
7. 7. Avramov T, Kyuchukov G, Kiryakov I, Obreshkov N, Handjiev D, Nedelko R. Results of spinal tumours surgery. J IMAB. 2009;1:84-8.
8. 8. Eaton LM, Craig WM. Tumor of the spinal cord: sudden paralysis following lumbar puncture. Proc Staff Meet Mayo Clin. 1940;15:170-2.
9. 9. Elseberg CA. Surgical diseases of the spinal cord, membranes and nerve roots. London: HK Lewis; 1942: 598.
10. 10. Nicholson MJ, Everson UH. Neurologic complications of spinal anesthesia. J Am Med Assoc. 1946;132(12):679-85.
11. 11. Hollis PH, MAlis LI, Zappulla RA. Neurological deterioration after lumbar puncture below complete spinal subarachnoid block. J Neurosurg. 1986;64(2):253-6.
12. 12. Jooma R, Hayward RD. Upward spinal coning: impaction of occult spinal tumours following relief of hydrocephalus. J Neurol Neurosurg Psychiatry. 1984;47(4):386-90.