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Background and Aims The development of neurological symptoms after regional anesthesia constitute primary anesthesia-related complication. However other, even life-threatening conditions, should not be overlooked.

Methods Case report

Results A 73-year-old male, ASA 3, was scheduled for perianal fistula repair under spinal anesthesia. Medical history included heart failure, COPD, ischemic stroke without any neurological deficit, and chronic atrial fibrillation, treated with rivaroxaban 20mg qd, stopped four days before surgery without bridging. Previous general anesthesia was complicated with severe post-operative delirium. Clinical examination on the day of surgery revealed mitral systolic murmur and mild wheezing, METs <4. Ambulatory surgery was performed under spinal anesthesia and recovery was uneventful without signs of residual nerve block. Patient received rivaroxaban 6 hours post-surgery, against medical advice, and, within 2 hours, developed acute back and abdominal pain with paraplegia and was admitted to the ER. Neurological examination revealed complete motor and sensibility loss of the lower limbs. Lumbar-spinal MRI was performed, with no signs of epidural hematoma. Transient neurological symptoms were suspected. During the following 12 hours, mobility and sensibility of the legs presented mild fluctuation, related to the patient’s body posture. CT-angiogram revealed acute abdominal aortic obstruction. The patient underwent open aortic surgery and was transferred to the ICU, where he deceased the next day due to multiple organ dysfunction.

Conclusions In any patient presenting with acute onset neurological symptoms after spinal anesthesia, and epidural hematoma has been ruled out, other causes should be examined, including vascular obstruction or aneurysm, even if considered unrelated to anesthesia. A multidisciplinary approach is necessary.