Interesting case report published recently in Anesthesia and Analgesia.
A nerve stimulator guided interscalene nerve block was placed for rotator cuff repair. Patient underwent an uneventful general anesthetic in the sitting position for the surgical procedure. MAP was between 60-79 during the case.
Two hours after surgery the patient was found to have weakness in both lower extremities and the left upper extremity, complete sensory and motor block in the right upper extremity, bilateral ptosis. There was no loss of consciousness or cardiopulmonary compromise.
How could you explain these findings? Intrathecal? Epidural? Subdural injection? Spinal cord hypoperfusion?
Patient recovered completely within 72 hrs.
Link to case report:
http://www.anesthesia-analgesia.org/cgi/content/abstract/109/4/1341
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Interesting case. Outpatient, arthroscopic rotator cuff repair. Normal patient(some HTN)Uneventful block(ISB with NStim resulting in excellent dense block), uneventful anesthetic( lma/sevo ppv, beach chair, reasonable MAP over the course of surgery), uneventful emergence, patient is about to go home and…. presents with ptosis and quadro-paresis only 2 hours after the case,remains AAOx3 and hemodinamically stable, no respiratory problems. Pt is admitted to the Hospital, neurology consulted, functional study and MRI ordered. MRI is negative and everything back to normal in 72 hours without any treatment.
Enigma. Can not explain it. MRI probably could only reliably rule out intraspinal or intraneural injection with retrograde dissection or acute stroke. Subdural, epidural, intrathecal will look normal on MRI. From all mentioned Subdural can most likely present like this but the time frame is very unusual. May be some type of “hysteria” , but then again an experienced neurologist should have distinguished that on the exam. Very strange.