Poster 52: Paraparesis With Cauda Equina Syndrome Following Postoperative Epidural Catheter Placement: A Case Report

Abstract

Setting: 1000-bed community academic hospital. Patient: A 60-year-old man who underwent elective bilateral total knee arthroplasty secondary to advanced degenerative joint disease. Case Description: The patient is a fully independent, retired mechanic. His procedure was performed without complications. An epidural catheter was placed postoperatively for pain control. On postoperative day 1, he complained of pain and numbness in bilateral lower extremities. The catheter was adjusted and the epidural volume was increased. 36 hours postoperatively, he had progressive sensory deficits, weakness, and bowel and bladder incontinence. A magnetic resonance imaging (MRI) revealed a thin, but long, segment noncompressive epidural/subdural hemorrhage posteriorly from L2-L4. His postoperative anticoagulation was discontinued. Repeat MRI on postoperative day 13 showed resolution of the hematoma, but demonstrated diffuse subtle enhancement and thickening of the cauda equina and nerve roots. His stay was further complicated by left lower-extremity deep venous thrombosis and inferior vena cava filter placement, orthostatic hypotension, subluxation of the right patella, and effusion and drainage of the right patella. Assessments/Results: On admission to the rehabilitation unit, he had only trace movement in the lower extremities, reduced sensation bilaterally, and lower motor neuron neurogenic bowel and bladder. After a 5-week rehabilitation stay, he was ambulating 21m with a rolling walker, was stand-by assist for transfers, had managed a bowel regimen and was able to perform intermittent straight catheterization. Discussion: Paraparesis after elective procedures is rare, but has been documented in surgery of the aorta from anterior spinal artery infarct, spinal procedures from bleeding, or epidural injections from bleeding or anesthetic neurotoxicity. Conclusions: This patient did have evidence of epidural/subdural hematoma; however, this was a noncompressive lesion. The enhancement and thickening of the cauda equina and clinical picture point to an etiology of large volume anesthesia causing neurocompressive injury leading to neurotoxic effects from his epidural catheter pump.