Diplopia: A Complication of Dural Puncture
Nishio, Isuta M.D., Ph.D.*; Williams, Brian A. M.D., M.B.A.†; Williams, John P. M.D.‡
DIPLOPIA or extraocular muscle paralysis (EOMP) after dural puncture has been reported occasionally, primarily in the neurology and ophthalmology literature. Because there seems to be a window period before diplopia manifests after dural puncture, the patient and physician may not always believe that the symptom is secondary to dural puncture, particularly when it occurs after resolution of a post–dural puncture headache (PDPH). Diplopia can be so disturbing that it may prompt the patient to seek immediate medical attention. Many patients have been referred to neurologists or ophthalmologists for extensive investigation. Therefore, it is not surprising that anesthesiologists may be unaware of this complication. 1
The first case of diplopia after dural puncture was reported by Quincke more than 100 yr ago. 2
Nonetheless, the latest major anesthesia textbooks describe little, if any, of this complication. It is important that anesthesiologists, emergency physicians, neurologists, and ophthalmologists recognize and communicate findings related to this distressing complication.
Materials and Methods
To compile case reports of EOMP associated with dural puncture, we performed a computerized search of the medical literature in English, Spanish, French, German, and Japanese from 1966 through December 20, 2002 using PubMed §
and the OVID search engine (Ovid Technologies, New York, NY). Key words used included dural puncture
, lumbar puncture
, spinal anesthesia
, spinal puncture
, spinal injection
, epidural anesthesia
, abducens nerve
, oculomotor nerve
, and trochlear nerve
. Forty-four related articles were identified, and 41 reports were obtained. Four reports were excluded from the review because of either insufficient descriptions of the cases or confounding factors, such as medicine or underlying disease, that could have otherwise contributed to EOMP. 3–6
An additional 12 reports were obtained after hand-searching reference lists of retrieved reports and review articles. A total of 94 reported cases and one of our own were analyzed for this review (table 1
The reported incidence of EOMP after dural puncture varies from 1 in 400 to 1 in 8,000. 7–9
These incidence reports were either from retrospective reviews of spinal anesthesia in 1947 7
and 1961 8
or diagnostic lumbar punctures in which larger spinal needles were often used. 9
Spinal anesthesia was found to be the most frequently reported procedure involved (47%), followed by myelography (18%), diagnostic lumbar puncture (12%), epidural anesthesia/injection (11%), continuous spinal anesthesia (4%), and other dural puncture procedures (9%).
Affected Cranial Nerves
Although other cranial nerve palsies can occur after lumbar puncture, the abducens nerve (cranial nerve VI) is affected in the majority of cases (92–95%). 7,10
Nearly 80% of the cases are unilateral. 7
Abducens palsy can coexist with oculomotor (cranial nerve III) or trochlear (cranial nerve IV) nerve palsies. Multiple coexisting cranial nerve palsies can be masked by a large esotropia, making the exact diagnosis of these cranial nerve palsies difficult. 11
Age and Sex
Extraocular muscle paralysis has been reported in patients aged 17–69 yr (mean age, 42 yr). Perhaps the largest survey of EOMP associated with spinal anesthesia was by Thorsen 7
in 1947. He reported that 80% of the patients were younger than 50 yr and 30% of the patients were younger than 30 yr, although most of the patients who had spinal anesthesia were older than 30 yr.
The incidence of PDPH in women has been reported to be twice as high as in men. 12
This sex pattern does not hold true for EOMP: Thorsen 7
(1947) reported a predilection of abducens nerve palsy for men, whereas Hayman and Wood 10
(1942) stated that women were more susceptible. In our review, no significant sex predilection of this complication was found (male vs.
The window period for EOMP to manifest is 1 day to 3 weeks after dural puncture, but it most often presents 4–10 days after dural puncture (mean, 7 days; median, 6 days) (table 1
and fig. 1
). This finding is consistent with classic reports. 7,10
EOMP associated with dural puncture is almost always preceded by PDPH, but EOMP can occur either before or after the headache subsides. If the cranial nerve (III, IV, or VI) palsy is isolated, is preceded by PDPH, and occurs within 3 weeks after dural puncture with no other neurologic deficits, it is likely that cranial nerve palsy is a postdural puncture complication. Diagnosis of this complication is based purely on clinical presentation, and there is no specific test for its accurate diagnosis.
Magnetic resonance imaging of the brain has occasionally shown signs of cerebrospinal fluid (CSF) volume depletion and intracranial hypotension, such as diffuse pachymeningeal enhancement, descent of the brainstem, and subdural fluid collections. 9,13,14
However, these findings are not specific for EOMP after dural puncture and can be seen in spontaneous intracranial hypotension. 15–17
There may be no abnormality found 18–21
when magnetic resonance imaging is performed after PDPH resolution.
The differential diagnosis of acquired EOMP is varied, such as neoplasm, ischemia, trauma, aneurysm, multiple sclerosis, encephalitis and myasthenia gravis. The greatest proportion of abducens nerve palsies are of unknown origin; however, the overall spontaneous recovery rate is close to 80%. 22,23
Despite the good prognosis of the nerve palsy as well as the low yield and low specificity of diagnostic studies for this complication, magnetic resonance imaging of the brain may still be of value to rule out other serious conditions that require treatment. Indeed, subdural hematoma or hygroma can rarely occur after dural puncture, from tearing of the bridging dural veins associated with acute intracranial hypotension. 24–28
Subdural hematoma should be included in the differential diagnosis if prolonged PDPH loses the postural dependence of symptoms and/or is accompanied by other neurologic signs.
Treatment and Prognosis
An epidural blood patch is highly effective for PDPH, with the reported success rate being as high as 93% for the first attempt, 29
but it has consistently failed to show efficacy in treating EOMP after dural puncture. 13,18,30–32
Abducens palsy is associated with a favorable outcome in general, and its prognosis after dural puncture is even better. In our review, 80 of 90 patients (89%) fully recovered in 2 weeks to 8 months (table 1
). The majority of those recovered within 6 months (figs. 2 and 3
), consistent with classic reports. 7,10
Conservative treatment (such as an eye patch or prism glasses) is generally adequate to minimize the patient’s discomfort. Isolated abducens palsy in the absence of other neurologic signs or symptoms should be observed for improvement for 8 months. Further investigation is unwarranted if the deficit resolves spontaneously.
In our review, EOMP cases that lasted more than 8 months were found to be permanent. No apparent trend was found among the cases of permanent EOMP, probably because of a small number of cases and the lack of detailed description in some of the reports (e.g.
, size and type of dural puncture needle). Corrective surgery on the extraocular muscles, such as recession of the medial rectus muscle, was performed in some patients, allowing them to resume social activities or previous occupations. 13,33,34
However, some suggest that surgical correction be postponed until at least 18 months have lapsed, considering cases of protracted recovery. 35,36
Indeed, some patients became asymptomatic after several months to years, although residual hyperdeviations persisted. 37–39
The decision should be individualized based on the duration (at least longer than 8 months) and severity of symptomatic EOMP as well as the risks and benefits of the corrective surgery.
Etiology and Proposed Pathologic Mechanisms
Similar to PDPH, intracranial hypotension due to CSF leakage is the generally accepted cause of cranial nerve palsies after dural puncture because this complication can occur after diagnostic lumbar puncture where no medication is injected into the intrathecal space. Spontaneous intracranial hypotension with orthostatic headache that occasionally presents as diplopia (commonly abducens nerve palsy) supports the hypothesis. 15–17
The brain descends caudad with upright posture, and the CSF “cushion” for the brain is displaced. This downward traction could damage some of the cranial nerves that anchor the brain in the skull.
The time course (of weeks to months) for the cranial nerve palsies with good prognosis suggests neurapraxia (focal segmental demyelination) or axonotmesis (axonal interruption and Wallerian degeneration with preservation of supporting tissue framework) as a potential pathologic mechanism. 40
Even after axonotmesis, electrical activity and conductivity may be present in the axonotmetic distal stump for a day or two, but the axon then quickly becomes unresponsive with degeneration. 41,42
This may explain why an epidural blood patch is not effective in treating the cranial nerve palsies. There are both functional disturbances and structural lesions in the nerve by the time the nerve palsy manifests.
Preferential damage to the abducens nerve can be explained by its anatomic course. As the nerve emerges into the subarachnoid space from the caudal pons, it immediately ascends the clivus, crosses branches of the basilar artery, and pierces the dura mater. Then, the nerve bends at nearly a right angle over the petrous apex of the temporal bone. 43,44
The abducens nerve runs in the direction of the typical caudad displacement of the brain with intracranial hypotension. As a result, traction associated with changes in intracranial pressure is fully transmitted to the nerve. The nerve can be stretched by caudal displacement of the pons, and it also may be compressed at the dura, petrous apex, or basilar artery if (1) the penetration aperture for the nerve in the dura or petrous apex is sharply edged or (2) branches of the basilar artery are well developed.
Ikeda et al.45,46
have shown that a combination of nerve stretch and compression even to a mild degree can be more detrimental to a nerve than either alone, causing severe axonotmesis, with not only Wallerian degeneration but also retrograde degeneration from the injured site (“dying-back degeneration”). The wide variation in duration of the nerve palsies may be associated with varying degrees of nerve injuries from mild neurapraxia with conduction block to severe axonotmesis with extensive degeneration.
After EOMP occurs, little can be done to change its course. Therefore, prevention is of great importance. Vandam and Dripps 47
reported in their survey of 10,098 patients undergoing spinal anesthesia that diplopia (secondary to probable abducens nerve palsy) occurred only in patients who underwent continuous spinal anesthesia with a 16-gauge needle. The incidence of EOMP was high (1:140). Because intracranial hypotension associated with CSF leakage seems to play a major role in the pathogenesis, minimizing CSF leakage with smaller, pencil-point needles should reduce the risk of EOMP. However, EOMP can occur after otherwise uncomplicated spinal anesthesia using a 25-gauge Whitacre needle. 48
Bed rest has been advocated in cases of dural puncture by some clinicians. However, a recent meta-analysis failed to show that bed rest after dural puncture was better than immediate mobilization in reducing the incidence of PDPH. 49
Bed rest can be associated with a higher incidence of PDPH in particular patient groups. 50,51
In theory, however, upright posture may exacerbate compression–stretch injury of the abducens nerve by promoting further caudad displacement of the brain. Because of the low incidence of EOMP, it seems unlikely that the value of routine bed rest in an effort to prevent EOMP will ever be determined.
Does early application of an epidural blood patch after dural puncture prevent cranial nerve palsy from occurring by restoring intracranial pressure? There are no studies to support this idea, nor is such a study feasible because of the low incidence of this complication. EOMP could occur shortly after an epidural blood patch procedure for PDPH because of the slow manifestation of EOMP. In this circumstance, the blood patch procedure may be blamed for abducens nerve palsy if diplopia was not recognized as a complication of dural puncture. On the other hand, a blood patch can actually cause EOMP and/or aggravate neurologic symptoms in a patient with PDPH or spontaneous intracranial hypotension when the mass effect of the coexisting subdural hematoma can no longer be compensated by the disappearance of CSF leak by the patch. 28,52
A thorough history and physical examination assessing signs or symptoms suggestive of subdural hematoma is mandatory before an epidural blood patch procedure, and close observation after the procedure is strongly recommended. Should mental status changes or any neurologic signs/symptoms manifest, the patient will need immediate medical attention and imaging studies.
Although the current incidence of EOMP after dural puncture is unknown, it can occur with smaller pencil-point spinal needles. Abducens nerve involvement is most often unilateral. EOMP seems to be very rare in elderly patients, and male and female patients seem to be equally vulnerable. EOMP usually occurs 4–10 days after dural puncture but can manifest as late as 3 weeks. Full recovery can generally be expected in 2 weeks to 8 months, although permanent cases have rarely been reported. Anesthesiologists, emergency physicians, neurologists, and ophthalmologists should be aware of this complication and communicate the information so that early diagnosis can alleviate patient anxiety. The exact pathophysiology is unclear, but a nerve lesion such as neurapraxia or axonotmesis caused by stretch and/or compression secondary to intracranial hypotension due to CSF leakage is the generally accepted mechanism. Treatment is supportive except for persistent or permanent cases, for which corrective surgery may be necessary. An epidural blood patch does not seem to be an effective treatment, whereas the benefit of a prophylactic blood patch is unknown. Avoiding, if possible, or minimizing CSF leakage associated with dural puncture may be the only measure for now to potentially minimize the risk of this rare but distressing complication.
§ PubMed [database online]. Available at: http://www.ncbi.nlm.nih.gov
. Accessed October 9, 2003. Cited Here...
1. Day CJ, Shutt LE: Auditory, ocular, and facial complications of central neural block: A review of possible mechanisms. Reg Anesth 1996; 21: 197–201
2. Koeppen AH: Abducens palsy after lumbar puncture. Proc Wkly Semin Neurol 1967; 17: 68–76
3. Robles R: Cranial nerve paralysis after spinal anesthesia. Northwest Med 1968; 67: 845–7
4. Levesque P, Marsepoil T, Ho P, Venutolo F, Lesouef JM: Multiple sclerosis revealed by spinal anesthesia. Ann Fr Anesth Reanim 1988; 7: 68–70
5. Bohrer H, Goerig M: Abducens paresis after spinal anesthesia. Anasthesiol Intensivmed Notfallmed Schmerzther 1994; 29: 438–9
6. Haughton AJ, Chalkiadis GA: Unilateral paediatric subdural catheter with oculomotor and abducens nerve palsies. Paediatr Anaesth 1999; 9: 543–8
7. Thorsen G: Neurological complications after spinal anesthesia. Acta Chir Scand 1947; 95: 1–272
8. Greene NM: Neurologic sequelae of spinal anesthesia. A nesthesiology 1961; 22: 682–95
9. Thomke F, Mika-Gruttner A, Visbeck A, Bruhl K: The risk of abducens palsy after diagnostic lumbar puncture. Neurology 2000; 54: 768–9
10. Hayman IR, Wood PM: Abducens nerve paralysis following spinal anesthesia. Ann Surg 1942; 115: 864–8
11. King RA, Calhoun JH: Fourth cranial nerve palsy following spinal anesthesia: A case report. J Clin Neuroophthalmol 1987; 7: 20–2
12. Spencer HC: Postdural puncture headache: What matters in technique. Reg Anesth Pain Med 1998; 23: 374–9
13. Follens I, Godts D, Evens PA, Tassignon MJ: Combined fourth and sixth cranial nerve palsy after lumbar puncture: A rare complication. A case report. Bull Soc Belge Ophtalmol 2001; 281: 29–33
14. Dumont D, Hariz H, Meynieu P, Salama J, Dreyfus P, Boissier M: Abducens palsy after an intrathecal glucocorticoid injection. Rev Rhum Engl Ed 1998; 65: 352–4
15. Ferrante E, Savino A, Brioschi A, Marazzi R, Donato MF, Riva M: Transient oculomotor cranial nerves palsy in spontaneous intracranial hypotension. J Neurosurg Sci 1998; 42: 177–9
16. Mokri B: Spontaneous intracranial hypotension. Curr Neurol Neurosci Rep 2001; 1: 109–17
17. Brady-McCreery KM, Speidel S, Hussein MA, Coats DK: Spontaneous intracranial hypotension with unique strabismus due to third and fourth cranial neuropathies. Binocul Vis Strabismus Q 2002; 17: 43–8
18. Szokol JW, Falleroni MJ: Lack of efficacy of an epidural blood patch in treating abducens nerve palsy after an unintentional dura puncture. Reg Anesth Pain Med 1999; 24: 470–2
19. Montalban J, Titus F, Molins A, Codina Puiggros A: Bilateral paralysis of the VI cranial nerves following myelography with metrizamide. Neurologia 1988; 3: 80–1
20. Richer S, Ritacca D: Sixth nerve palsy after lumbar anesthesia. Optom Vis Sci 1989; 66: 320–1
21. Niedermuller U, Trinka E, Bauer G: Abducens palsy after lumbar puncture. Clin Neurol Neurosurg 2002; 104: 61–3
22. Richards BW, Ray Jones FJ, Younge BR: Causes and prognosis in 4278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 1992; 113: 489–96
23. King AJ, Stacey E, Stephenson G, Trimble RB: Spontaneous recovery rates for unilateral sixth nerve palsies. Eye 1995; 9: 476–8
24. Benzon HAT: Intracerebral hemorrhage after dural puncture and epidural blood patch: Nonpostural and noncontinuous headache. A nesthesiology 1984; 60: 258–9
25. Velarde CA, Zuniga RE, Leon RF, Abram SE: Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Reg Anesth Pain Med 2000; 25: 76–8
26. Suess O, Stendel R, Baur S, Schilling A, Brock M: Intracranial haemorrhage following lumbar myelography: Case report and review of the literature. Neuroradiology 2000; 42: 211–4
27. van den Berg JSP, Sijbrandy SE, Meijer AH, Oostdijk AHJ: Subdural hygroma: A rare complication of spinal anesthesia. Anesth Analg 2002; 94: 1625–7
28. Kardash K, Morrow F, Beique F: Seizures after epidural blood patch with undiagnosed subdural hematoma. Reg Anesth Pain Med 2002; 433–5
29. Safa-Tisseront V, Thormann F, Malassine P, Henry M, Riou B, Coriat P, Seebacher J: Effectiveness of epidural blood patch in the management of post–dural puncture headache. A nesthesiology 2001; 95: 334–9
30. Dunbar SA, Katz NP: Failure of delayed epidural blood patching to correct persistent cranial nerve palsies. Anesth Analg 1994; 79: 806–7
31. Heyman HJ, Salem MR, Klimov I: Persistent sixth cranial nerve paresis following blood patch for postdural puncture headache. Anesth Analg 1982; 61: 948–9
32. De Veuster I, Smet H, Vercauteren M, Tassignon MJ: The time course of a sixth nerve paresis following epidural anesthesia. Bull Soc Belge Ophthalmol 1994; 252: 45–7
33. Espinosa J, Giroux M, Johnston K, Kirkham T, Villemure JG: Abducens palsy following shunting for hydrocephalus. Can J Neurol Sci 1993; 20: 123–5
34. Johnson R, Lyons G, Bamford J: Visual problems following dural puncture. Postgrad Med J 1998; 74: 47–58
35. Naito H, Takasaki M, Takahashi T: Case of paralysis of the abducent nerve and the trigeminal nerve after spinal anesthesia. Geka Chiryo 1970; 23: 473–6
36. Walsh FB: Ophthalmic complications of neurodiagnositic procedures, Clinical Neuro-ophthalmology, Edited by Walsh FB. Baltimore, Williams & Watkins, 1969, pp 2504–10
37. Fairclough WA: Sixth-nerve paralysis after spinal analgesia. BMJ 1945; 2: 801–3
38. Tseng HC, Ku YC: Paralysis of extraocular muscle following spinal anesthesia. Chin Med J 1950; 68: 81–4
39. Newmark HI, Levin N, Apt RK, Wax JD: Esotropia: Unusual complication of myelography and pneumoencephalography. Am J Neuroradiol 1981; 2: 278–81
40. Seddon HJ: Three types of nerve injury. Brain 1943; 66: 237–88
41. Karnes WE: Disease of the seventh cranial nerve, Peripheral Neuropathy. Edited by Dick PJ, Thomas PK, Lambert EH. Philadelphia, WB Saunders, 1975, pp 570–603
42. Ge XX, Spector GJ, Carr C: The pathophysiology of compression injuries of the peripheral facial nerve. Laryngoscope 1982; 92: 1–15
43. Bennett JL, Pelak VS: Palsies of the third, fourth, and sixth cranial nerves. Ophthalmol Clin North Am 2001; 14: 169–83
44. Sowka J: Neurogenic diplopia: Paralysis of cranial nerves III, IV, and VI. Optom Clin 1996; 5: 53–6
45. Ikeda K, Tomita K, Tanaka S: Experimental study of peripheral nerve injury during gradual limb elongation. Hand Surg 2000; 5: 41–7
46. Ikeda K, Yokoyama M, Tomita K, Tanaka S: Vulnerability of the gradually elongated nerve to compression injury. Hand Surg 2001; 6: 29–35
47. Vandam LD, Dripps RD: Long-term follow-up of patient who received 10,098 spinal anesthetics. JAMA 1965; 16: 586–91
48. Vial F, Bouaziz H, Adam A, Buisset L, Laxenaire MC, Battaglia A: Oculomotor paralysis and spinal anesthesia. Ann Fr Anesth Reanim 2001; 20: 32–5
49. Thoennissen J, Herkner H, Lang W, Domanovits H, Laggner A, Müllner M: Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. CMAJ 2001; 165: 1311–6
50. Fassoulaki A, Sarantopoulos C, Andreopoulou K: Is early mobilization associated with lower incidence of postspinal headache? A controlled trial in 69 urologic patients. Anaesthesiol Reanim 1991; 16: 375–8
51. Thornberry E, Thomas T: Posture and post-spinal headache. Br J Anaesth 1988; 60: 195–7
52. Mikawa S, Ebina T: Spontaneous intracranial hypotension complicating subdural hematoma: Unilateral oculomotor nerve palsy caused by epidural blood patch. No Shinkei Geka 2001; 29: 747–53
53. Levine J: Paralysis of an extraocular muscle after spinal anesthesia. Arch Ophthalmol 1930; 4: 516–20
54. Biggam J: Paralysis of ocular muscle following spinal anesthesia. Br J Ophthalmol 1932; 16: 552–4
55. Robinson HM: Abducens palsy (with subsequent recovery) following lumbar puncture. Am J Syph 1945; 29: 422–3
56. Steinberg B, Bishop HF: Abducens nerve palsy following spinal anesthesia. A nesthesiology 1946; 7: 296–8
57. Rose AT, Pritzker S: Paralysis of the abducens nerve following spinal anesthesia. N Engl J Med 1947; 237: 52
58. Parke WM: Abducens nerve palsy following spinal anesthesia: A case report. A nesthesiology 1948; 9: 440–1
59. Bryce-Smith R, Macintoch RR: Sixth-nerve palsy after lumbar puncture and spinal anesthesia. BMJ 1951; 1: 275–6
60. Kennedy RJ, Lockhart G: Presis of the abducens nerve following spinal anesthesia. A nesthesiology 1952; 13: 189–92
61. Liegl O: Neuroophthalmological complications through liquor leakage after surgical operation on the spinal canal for diagnostic i. e. therapeutic purposes. Klin Monatsbl Augenheilkd 1977; 171: 526–30
62. Seyfert S, Mager J: Abducens palsy after lumbar myelography with water-soluble contrast media. J Neurol 1978; 219: 213–20
63. Huismans H: Neurological complication after spinal anesthesia: Abducens palsy. Klin Monatsbl Augenheilkd 1979; 174: 735–8
64. Gupta MK, Goldstein JH, Madhukar S: Epidural anesthesia and VI nerve palsy. Ann Ophthalmol 1980; 12: 571–2
65. Insel TR, Kalin NH, Risch SC, Cohen RM, Murphy DL: Abducens palsy after lumbar puncture. N Engl J Med 1980; 303: 703
66. Miller EA, Savino PJ, Schatz NJ: Bilateral sixth-nerve palsy: A rare complication of water-soluble contrast myelography. Arch Ophthalmol 1982; 100: 603–4
67. Arne JL, Salvaing P, Calvet JM, Bec P, Gasset, Plante H: Paralysis of the 6th nerve following peridural anesthesia. Bull Soc Ophtalmol Fr 1982; 82: 1451–3
68. Moster ML, Savino PJ, Sergott RC, Bosley TM, Schatz NJ: Isolated sixth-nerve palsies in younger adults. Arch Ophthalmol 1984; 102: 1328–30
69. Perlman EM, Barry D: Bilateral sixth-nerve palsy after water-soluble contrast myelography. Arch Ophthalmol 1984; 102: 968
70. Salazar Garcia F, Villalonga Morales A, Luis Alfaro M, Anglada Casas T, Gonzalez Machado JL, Nalda Felipe MA: Paralysis of the 6th cranial pair during intradural anesthesia. Rev Esp Anestesiol Reanim 1985; 32: 193–4
71. Hotton J, Hummel, MO: Oculomotor paralysis following spinal anesthesia. Cah Anesthesiol 1986; 34: 613–5
72. Justo Firvida E, Lado Lado F, Casal Iglesias L, Rial Vidal C: Paralysis of the 6th cranial nerve after intradural anesthesia. An Med Interna 1989; 6: 274
73. Whiting AS, Johnson LN, Martin DE: Cranial nerve paresis following epidural and spinal anesthesia. Trans Pa Acad Ophthalmol Otolaryngol 1990; 42: 972–3
74. Bell JA, Dowd TC, McIlwaine GG, Brittain GP: Postmyelographic abducent nerve palsy in association with the contrast agent Iopamidol. J Clin Neuroophthalmol 1990; 10: 115–7
75. Balseiro Gomez J, Morlan Garcia L, Martinez-Sarries J, Martinez-Martin P: Chronic bilateral paresis of the sixth nerve following lumbar puncture. Neurologia 1991; 6: 345
76. Dierking GF, Koch J: Abducens paresis, a rare complication to spinal analgesia. Ugeskr Laeger 1991; 153: 1662
77. Bell JA, McIllwaine GG, O’Neill D: Iatrogenic lateral rectus palsies: A series of five postmyelographic cases. J Neuroophthalmol 1994; 14: 205–9
78. Dinakaran S, Desai SP, Corney CE: Case report: Sixth nerve palsy following radiculography. Br J Radiol 1995; 68: 424
79. Brocq O, Breuil V, Grisot C, Flory P, Ziegler G, Euller-Zieger L: Diplopia after peridural and intradural infiltrations of prednisolone. Presse Med 1997; 26: 271
80. Romero Aroca P, Domenech Calvet J, Martin Begue N, del Castillo Dejardin D: Paresis of the sixth nerve following spinal anesthesia. Rev Clin Esp 2000; 200: 109–10
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