Epidural analgesia can significantly improve respiratory function in patients who have suffered blunt chest trauma.1 The severe pain and agitation that may follow these injuries can lead to a variety of complications including pneumonia, hypoxia, atelectasis, and the prolonged need for invasive mechanical ventilation.2 Methods of pain control include opioids, nonopioid analgesics, regional nerve blocks, and epidural analgesia. Epidural analgesia is an invasive method of pain control that may significantly improve patient outcomes by decreasing need for systemic opioids, which can cause respiratory depression, and by improving the overall efficacy of pain relief.
Balancing these benefits are the rare but severe complications that can be associated with catheter placement or removal. These complications include direct spinal cord trauma, cord compression from epidural hematoma or abscess, chemically induced subarachnoiditis, spinal cord ischemia, and vascular injury.3 The incidence of persistent and severe neurological complications after epidural analgesia ranges from 0.006% to 0.03%.4 Risk factors that increase the likelihood of these complications include coagulopathy, thrombocytopenia, traumatic/difficult needle insertion, and advanced age.3 Epidural placement in a sedated patient can also increase the risk of complications because there is no way to ascertain paresthesias to monitor for unintended neurological injury.
We describe an elderly patient who required thoracic epidural placement for the treatment of pain due to rib fractures after chest trauma. The patient had suffered several episodes of desaturation and ventilator dyssynchrony requiring intermittent paralysis. After epidural placement and attempts to replace a nonfunctioning catheter, the patient developed acute quadriparesis of unknown etiology and underwent a thorough workup to determine the cause. Although he was at increased risk for neurological complications from epidural placement, it is important to consider other contributing factors when creating a differential diagnosis. Written Health Insurance Portability and Accountability Act authorization was obtained to publish this case report.
An 80-year-old man presented to the emergency department after sustaining multiple traumatic injuries from a high-velocity impact. His injuries included T1–T9 rib fractures, right-sided flail chest, and multiple thoracic vertebral fractures. He was intubated in the trauma bay, and a right-sided chest tube was placed. His international normalized ratio was 2.7, and his platelet count was approximately 70,000. Over the next few days, the patient became increasingly difficult to mechanically ventilate; he suffered frequent episodes of desaturation, required intermittent paralysis due to ventilator dyssynchrony, and was eventually started on inhaled nitric oxide for treatment of hypoxia.
On hospital day 4, the intensive care unit (ICU) staff requested thoracic epidural placement due to inadequate ventilation causing suboptimal oxygenation and inability to wean from the ventilator. The thrombocytopenia and coagulopathy present on admission had been corrected by the administration of fresh frozen plasma, vitamin K, and platelets before epidural placement attempt. No formal neurological examination could be obtained due to the patient’s agitation and need for sedation, but he was moving all extremities (though not purposefully).
A thoracic epidural was placed at the T6 and T7 interspace with the patient in left lateral decubitus position. A paramedian approach was performed without difficulty. Twelve hours later, the epidural catheter was noted to be partially displaced by the depth of placement markers at the skin insertion site. Seven attempts at replacing the epidural in lateral decubitus position were unsuccessful at the T7 and T8 level due to inability to enter the epidural space (only bone was encountered), and the procedure was aborted. The attempts were not traumatic, and no unexpected bleeding was noted. Approximately 12 hours later, after the patient had been weaned from sedation, he was noted to have new-onset quadriparesis. The patient’s upper extremities were completely flaccid, but his lower extremities could withdraw only to a deeply painful stimulus. The cause for this sudden-onset quadriparesis was unknown, but was temporally associated with the epidural placement attempt. Neurology and neurosurgery evaluated the patient, and a computed tomography (CT) of the spine was performed due to the patient’s pacemaker precluding a magnetic resonance imaging (MRI) scan. The CT study indicated changes concerning for possible epidural hematoma at C6. The next day, after cardiology had determined that the patient’s pacemaker was compatible with an MRI study, he underwent MRI of the cervical spine that did not show an epidural hematoma, but demonstrated diffuse spondylosis, localized cord edema, and significant spinal stenosis at C5 and C6 and C6 and C7 (Figure 1). Central cord syndrome (CCS) secondary to the original traumatic injury was determined to be the most likely diagnosis at that point. The patient was maintained on strict cervical collar precautions and received daily physical and occupational therapy. His quadriparesis improved significantly by the time of discharge to an acute rehabilitation hospital. He was ambulating with a rolling walker with supervision. Although he still had generalized weakness, he was able to perform activities of daily living with minimal to moderate assistance. Several months after discharge from the acute rehabilitation facility, he was able to walk short distances independently and was able to use his upper extremities functionally, but with continued weakness which limited his independence in activities of daily living.
Acute-onset paralysis after epidural catheter placement can result from spinal cord compression, neurotoxicity, or trauma. Few case reports exist of long-term neurological injury after epidural placement. The cornerstone of management for acute neurological injury after epidural placement is early diagnosis via physical examination and MRI, followed by early neurosurgical intervention if necessary.4,5
Critically ill patients with chest trauma can provide many challenges for clinicians including maintenance of adequate ventilation. Techniques to limit ventilator dyssynchrony include multimodal analgesia, regional nerve blocks, and thoracic epidural analgesia. Of these options, only epidural analgesia results in a decreased rate of pulmonary infection and a reduced duration of mechanical ventilation.1
In this patient, multiple challenges were encountered, not only with the placement of the epidural catheter, but also with medical management in the ICU. The ICU team preferred to avoid opioids for analgesia because of the associated sedation and respiratory depression because the goal was to have the patient spontaneously ventilating and awake enough to extubate. Nonsteroidal anti-inflammatory drugs were not considered an appropriate option because of associated platelet dysfunction because the patient had thrombocytopenia. Regional nerve blocks (such as intercostal, erector spinae, paravertebral, serratus plane, etc) were a reasonable option to provide analgesia with minimal sedating side effects, but our institution did not have physicians trained in those techniques at the time. Epidural analgesia has been shown to decrease the rate of nosocomial pneumonia and reduce the duration of intubation in patients with rib fractures.6 However, a meta-analysis by Carrier et al7 found no significant benefit in outcomes with epidural analgesia for rib fractures compared to other analgesics.8
Patient positioning for epidural placement was difficult in part because of his intubated and sedated state. His sedation and ventilator support also precluded verbal feedback during epidural placement, preventing detection of potential neurological injury. Some case reports suggest avoiding epidural placement in a sedated patient.9 In 1 case, the patient had epidural placed after multiple attempts while under general anesthesia for knee surgery and awoke with a T5 paraplegia that did not resolve. Subsequent imaging demonstrated an air bubble in the spinal cord, and resultant spinal cord infarction thought to have occurred during epidural placement.10 The authors supported avoidance of epidural puncture above the termination of the spinal cord in asleep patients.10 An editorial challenged this idea, stating that the incidence of such complications is incredibly rare.11 Another editorial reiterated that the complication rate was exceedingly rare and that, in pediatric patients, the considerations are different because most children will not tolerate epidural placement unless sedated.12 Horlocker et al13 reviewed 4298 patients who had received lumbar epidural during general anesthesia and did not find any neurological complications related to the epidural. In study by Horlocker et al13 and a case report by Bromage and Benumof,10 the epidurals were placed for elective procedures to provide postoperative pain relief. In our case, the epidural was placed in a critically ill patient in an attempt to improve his medical status. Risk-to-benefit ratio should be considered when placing an epidural in a sedated patient.
We did not review cervical spine imaging before epidural placement so did not have knowledge of preexisting cervical spine stenosis. We did review CT thoracic spine that demonstrated transverse process fractures at T9–T11, but they were below the planned site of epidural placement. Perhaps knowledge of the cervical spine stenosis would have allowed us to consider CCS as a differential diagnosis once the patient presented with weakness. Moreover, the patient’s pacemaker made it difficult to obtain an emergent MRI, thus delaying the imaging study most likely to be able to eliminate the diagnosis of epidural hematoma.
While the timing of epidural placement correlated with the patient’s acute paresis, it is important to consider the various other potential etiologies for quadriplegia in a patient with severe traumatic injuries. CCS is caused by traumatic injury causing hyperextension of the cervical spinal cord, usually in patients with preexisting spondylosis.14 It is characterized by symmetrical motor weakness, greater in the upper versus lower extremities (Figure 2), and a variable degree of sensory loss below the level of injury.15 It is more prevalent in the elderly given the higher incidence of degenerative vertebral changes and in males. It has been speculated that the incidence of CCS may increase as the population ages and remains more physically active for longer than previous generations. Considering the mechanism of injury in our patient and the likely preexisting cervical spinal stenosis seen on MRI, a hyperextension injury was a plausible diagnosis. Such risk factors should be seriously considered before placement of neuraxial anesthesia.
CCS can be managed conservatively with spine immobilization and rehabilitation therapy and has a favorable prognosis, consistent with the outcome achieved in our patient.14 Many patients will recover motor function spontaneously, and others experience improvement within 6 weeks. Lower extremity motor function usually recovers first, followed by bladder control, and finally upper extremity motor function. Finger dexterity and fine motor hand movement are the final deficits to recover. The pathology of the cervical cord injury also influences prognosis because hemorrhage or ischemia on MRI scanning is associated with worse outcomes than cases involving simple cord edema. In cases where there is significant cord compression, residual motor weakness after a period of recovery, or new neurological deterioration, surgical intervention should be considered.
In conclusion, this case describes a complex trauma patient with multiple medical problems in whom the potential benefits of epidural analgesia were felt to outweigh the risks after blunt chest injury. The steps that were required to assess a subsequent change in neurological status are outlined as well as some of the challenges that were encountered. An important diagnosis that must be considered in similar patients, CCS, is described. Although we did not find any case reports of CCS causing quadriparesis subsequent to epidural placement, patients receiving epidural analgesia for rib fractures often have other traumatic injuries which may cause spinal cord edema. Therefore, CCS should be carefully considered in these patients. Spine imaging should be reviewed before neuraxial anesthesia placement to identify those at higher risk for CCS. Patients with blunt chest trauma can have multiple causes of neurological deficit, especially when elderly, and a stepwise approach to diagnosis and management should be followed.
Christopher Haydel, MD, contributed to this article.
Name: Meera N. Gonzalez, MD.
Contribution: This author helped design, draft, edit, review, and revise the manuscript.
Name: Anish Sethi, DO.
Contribution: This author helped design, draft, and edit the manuscript.
Name: Jason McGavin, MD.
Contribution: This author helped draft and edit the manuscript.
Name: Gaurav Trehan, MD.
Contribution: This author helped review the manuscript.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
1. Richter T, Ragaller M. Ventilation in chest trauma. J Emerg Trauma Shock. 2011;4:251–259.
2. Mackersie RC, Shackford SR, Hoyt DB, Karagianes TG. Continuous epidural fentanyl analgesia: ventilatory function improvement with routine use in treatment of blunt chest injury. J Trauma. 1987;27:1207–1212.
3. Miller RD, Cohen NH, Eriksson LI, Fleisher LA, WienerKronish JP, Young WL. Miller’s Anesthesia. 2015.Philadelphia, PA: Elsevier Saunders.
4. Fischer HBJ. Regional anesthesia - before or after general anesthesia? Anaesthesia. 1998;53:727–729.
5. Yu H, Fan S, Yang H, Tang T, Zhou F, Zhao X. Early diagnosis and treatment of acute or subacute spinal epidural hematoma. Chin Med J (Engl). 2007;120:1303–1308.
6. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;132:426–430.
7. Carrier FM, Turgeon AF, Nicole PC, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anesth. 2009;56:230–242.
8. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009;56:412–418.
9. Kao MC, Tsai SK, Tsou MY, Lee HK, Guo WY, Hu JS. Paraplegia after delayed detection of inadvertent spinal cord injury during thoracic epidural catheterization in an anesthetized elderly patient. Anesth Analg. 2004;99:580–583.
10. Bromage PR, Benumof JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med1998;23:104–107.
11. Krane EJ, Dalens B, Murat I, Murrell D. The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med. 1998;23:433–438.
12. Rosenquist RW, Birnbach DJ. Epidural insertion in anesthetized adults: will your patients thank you? Anesth Analg. 2003;96:1545–1546.
13. Horlocker TT, Abel MD, Messick JM, Schroeder DR. Small risk of serious neurological complications related to lumbar epidural catheter placement in anesthetized patients. Anesth Analg2003;96:1547–1552.
14. McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30:215–224.
15. Brooks NP. Central cord syndrome. Neurosurg Clin N Am. 2017;28:41–47.