Background and Aims Paraplegia after neuraxial anesthesia is very rare (0,00001%).1 Common causes are needle trauma, vascular injury, spinal ischemia and neurotoxicity from local anesthetic or antiseptic agents.2,3
Methods We report a case of a 68-year-old man who underwent a TURP procedure under spinal anesthesia. His medical history included follicular lymphoma stage III, for which he received intravenous Obinutuzumab maintenance treatment every 2 months. Uneventful spinal puncture was performed at L4-L5 with 2 mL hyperbaric bupivacaine 0,5%. Four hours postoperatively, the patient’s motor function had not yet returned. An urgent MRI scan revealed an acute transverse myelitis from level T6 to the conus medullaris. Despite high-dose steroids treatment, the patient still suffers from hypoesthesia and motor deficit.4
Results In-depth history of our patient revealed similar prior episodes of neurological dysfunction after Obinutuzumab treatment. Since other causes of paraplegia, such as epidural hematoma, ischemia, needle trauma or spinal dural arteriovenous fistula, were excluded, we suspected an acute worsening of an underlying Obinutuzumab related transverse myelitis, caused by exposure to a local anesthetic agent with neurotoxic abilities. This phenomenon is known as the ‘double crush syndrome’. Acute transverse myelitis is a (sub)acute inflammation of the spinal cord, causing motor and/or sensory deficits depending on the involved spinal tracts, that has been associated with certain drugs, such as monoclonal antibodies. To our knowledge, this is the first described case of Obinutuzumab-related neurological damage after spinal anesthesia.4
Conclusions Caution is warranted when performing neuraxial anesthesia in patients using monoclonal antibodies, in whom we suggest evaluation of pre-existing neurological symptoms.
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