We discuss the etiology of a delayed spinal cord injury after epidural anesthesia without paresthesia. The description of such a case in an awake, adult patient who underwent a Whipple resection is provided. An epidural was performed at approximately the T8-9 interspace with the patient in the sitting position after 1 mg of midazolam was administered. On the first attempt, a dural puncture occurred. The patient did not report any paresthesia or pain. The needle was withdrawn and a second attempt was made one interspace lower. At this level, the epidural catheter was advanced into the epidural space uneventfully. Postoperatively, the patient suffered decreased motor function in the right leg. Magnetic resonance imaging revealed high signal intensity within the spinal cord, indicating cord edema compatible with direct needle trauma. An extradural fluid collection consistent with a hematoma was also noted. Although it may be impossible to confirm if the spinal cord injury was a result of direct needle trauma, hematoma, or a combination of needle trauma and hematoma, these events clearly raise the important question of whether an awake patient will always report paresthesia secondary to spinal cord trauma.
IMPLICATIONS: This case reminds anesthesiologists that we should not simply assume paresthesia will always occur and be reported if a needle encroaches on the spinal cord even in an awake patient.
*Department of Anesthesiology and Pain Medicine University of Alberta, Edmonton, Alberta, Canada, and †Department of Anesthesia, University of Western Ontario, London, Ontario, Canada.
Accepted for publication February 15, 2005.
Supported, in part, by Education and Research Fund, Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada and Department of Anesthesia, University of Western Ontario, London, Ontario, Canada. Ban C.H. Tsui is a recipient of Clinical Investigatorship Award, Alberta Heritage Foundation for Medical Research, Alberta, Canada.
Address correspondence and reprint requests to Ban C.H. Tsui, MSC, MD, FRCP(C), Department of Anesthesiology and Pain Medicine, 8–120 Clinical Sciences Building, Edmonton, Alberta, Canada T6G 2G3. Address e-mail to email@example.com.