Background and Aims Etiologic evaluation of postoperative neurologic lesions after regional techniques can be challenging. We present a case of a neurologic lesion after a gynecologic procedure under combined epidural and general anesthesia.
Methods Forty-one-year-old female, ASA I, scheduled for abdominal hysterectomy. Epidural catheter was placed before surgery at L3-L4: linear and atraumatic technique, without pain/paresthesia and a negative 0.375% ropivacaine test dose. The surgery lasted 2h in supine position. Gosset retractors were used.
In postoperative care unit, a 0.2% ropivacaine bolus (10 ml) was performed and 0.16% ropivacaine epidural perfusion (5.2 ml/h) was connected. Motor block at discharge: Bromage II.
Results Twenty-four-hours after surgery epidural perfusion was stopped due to proximal right inferior limb paresthesia and hemiparesis. These complaints persisted and a formal neurological evaluation was performed, documenting decrease segmental strength and allodynia at L3-L4 distribution and hypoesthesia at L5 dermatome.
Radiologic evaluation (head/lumbar spine CT and MRI) excluded acute complications. Electromyography revealed decreased motor response on right femoral nerve territory: absent motor activity on vastus-medialis and rectus-femoris muscles; mild signs of active denervation.
Physical rehabilitation resulted in progressive improvement of motor deficit. Two months after, hypoesthesia of L2-L4 territory persisted.
Conclusions Radiculopathy is a complication of 2.19/10000 epidurals. It can be a consequence of mechanical lesions or neurotoxicity. With a linear epidural technique and normal imaging, the first seems unlikely, but neurotoxicity cannot be excluded. On the other hand, the use of static retractors can cause mechanical or ischemic femoral nerve lesions. Regardless of the etiology, early recognition and implementation of motor rehabilitation programs are crucial.
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