Post Spinal Anesthesia Intramedullary Injury

A young lady  2months after undergoing Caesarean section  complaints of both lower limbs weakness with non-specific distribution . In he history, during the  epidural anesthesia for caesarean, she experienced severe shooting pain in to the Right lower limb, which resolved with medication. MRI shows longitudinal  ill defined  cord signal abnormality possibly hydrosyrinx from D11 to conus with no bleed, expansion or arachnoiditis  or epidural collections. Submitted by Dr MGK Murthy and Mr Hari Om.

Epidural anaesthesia  is one of the safest procedures, but occasional complications are known. This case represents possibly

(i) inadvertent injection of local anesthetic  in to low lying   variant radiculomeduallry artery  branch, feeding the anterior spinal artery , leading to vascular injury

The other possibilities include

(ii) direct intradural administration of LA leading to chemical injury

(iii) direct long needle injury to the cord in high injection

(iv)hypotension injury to the cord during the procedure

(v) post infective sequelae (myelomalacia)

(vi)unusual epidural venous plexus injection leading to venous hypertension and infarction

(vii) unrelated to the procedure and incidental finding due to other  causes including trauma, Chiari malformation etc

Post Spinal Anesthesia Syrinx-MRI

This is 25 year old who was operated for appendicitis in the peripheral centre followed by right sided monoparesis. MRI revealed focal syrinx-myelomalacia at D11-L1 levels towards right side. Attempting to use higher lumbar intervertebral spaces for access to the subarachnoid space or epidural space may lead to inadvertent puncture of the lower dorsal spaces; this makes the procedure of spinal anesthesia at this level prone for spinal cord injury, with subsequent risk of development of myelomalacic syrinx in the conus and epiconus region of the spinal cord.