A 14-year-old, hearing impaired boy, whose weight was 37 kg, presented to the orthopaedic department with the complaint of left lower limb deformity since birth. A diagnosis of congenital talipes equinovarus of left foot was made. The right foot was normal. He was scheduled for a closing wedge osteotomy. He had undergone uneventful anaesthesia for cochlear implant surgery at the age of 3 years. The rest of his pre-anaesthetic evaluation was normal. General anaesthesia along with insertion of epidural catheter for perioperative analgesia was planned. General anaesthesia was induced with injection fentanyl 80 μg plus injection propofol 50 mg given intravenously. An i-gel size 3 was then inserted and anaesthesia was maintained using oxygen in air and sevoflurane. Under anaesthesia, a 20 G Tuohy needle was inserted at L3–L4 level in the lateral decubitus position in a single attempt with all asepsis (2% chlorhexidine with 70% alcohol). After confirmation of loss of resistance (using air), the epidural catheter was inserted in a single attempt and fixed at 7 cm from the skin (2.5 cm was depth of epidural from skin and 4.5 cm was left in situ). After a negative test dose, 3 ml of injection bupivacaine (0.25%) was given through the epidural catheter, followed by a bupivacaine infusion (0.125%) at the rate of 5 ml per hour. The surgery was conducted in the supine position, was uneventful, and lasted about 90 min. After the patient regained consciousness, the i-gel was removed. The patient was comfortable with no pain at the surgical site. The next morning, he complained of numbness in his contralateral (right) foot. There was some sensory deficit, but the patient was responsive to pain and no motor deficit was present. The epidural infusion was stopped and the catheter was removed. However, the motor power started reducing gradually in the limb, the ankle jerk was absent, and the patient developed a foot drop after 48 h.
Magnetic resonance imaging of the spine could not be done as the child had a cochlear implant in situ. Neurology consultation was done and later, nerve conduction studies were done. The nerve conduction studies showed abnormalities in both tibial as well as common peroneal nerves suggesting involvement at the level of the nerve roots or lumbar plexus. The patient was managed conservatively with steroids and physiotherapy. He made a gradual recovery during the next 6 months. The motor power recovered completely in the lower limb but he still had occasional paraesthesiae in the calf and shin area.
Foot drop is a well-recognised, although uncommon complication of spinal anaesthesia. This complication is rarer still with epidural anaesthesia. Interestingly, we found just a single report of foot drop as a complication of epidural anaesthesia in the paediatric age group. A large cohort study of 339 epidural catheters in children did not report even a single case of foot drop. The proposed causes of nerve injury in epidural anaesthesia are direct trauma to the nerve roots or spinal cord by the needle or catheter, spinal cord infarction, spinal haematoma, chemical arachnoiditis, and inadvertent subarachnoid injection. In our case, the likely possibilities included an epidural haematoma and direct damage to the nerve roots by the catheter. The risk of direct injury is greater if the bevel of the needle is transverse to the nerve fibre. The development of paraesthesiae on advancing the needle or catheter is an indication of nerve root impingement but is not helpful when epidural anaesthesia is combined with general anaesthesia as is usual in children.
Although central block can cause foot drop by affecting the nerve roots, peroneal nerve injury because of the intraoperative tourniquet or direct pressure during prolonged urological surgeries may be misinterpreted as foot drop caused by epidural anaesthesia. In these circumstances, nerve conduction studies would help to pinpoint the diagnosis.
Awareness regarding this rare consequence of epidural anaesthesia in children will be useful for anaesthesiologists dealing with both paediatric and adult cases.
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