Spinal cord injury in a child after single-shot epidural anesthesia.

Abstract

N early 20 years have passed since the earliest reports appeared regarding the feasibility and effectiveness of thoracic epidural analgesia (TEA) in infants and children (1,2). TEA has gained tremendous popularity and is now routinely practiced by many anesthesiologists around the world (3–8). Nevertheless, studies comparing the benefits of epidural analgesia with conventional systemic analgesia in pediatric patients are few (9,10). Further investigations are required to demonstrate the superiority of TEA over conventional systemic analgesia as well as other forms of regional analgesia in various clinical scenarios. Also, despite the increasing experience with pediatric TEA, little is known about the absolute risks of this procedure, especially with regard to spinal cord injuries resulting in temporary or permanent neurologic deficits. In the largest and only prospective study of morbidity associated with pediatric regional anesthesia, 135 thoracic epidurals were performed and none of these children experienced a complication (5). In the other reports also, no serious complications were reported (1–4,6–8). However, it cannot be concluded that TEA is without risk of spinal cord injury based on the few existing reports because the total number of children receiving TEA in these reports is small and spinal cord injuries are expected to occur infrequently, similar to the rate of occurrence in adults (11). Although rare, these complications can be devastating. At the present time, our knowledge of spinal cord injuries associated with TEA and lumbar epidural analgesia in children is limited to a few case reports. Spinal cord hematoma, transient paresthesias, paraplegia, and injury to sacral parasympathetic nerves caused by an intraspinal hematoma have all been reported in association with lumbar epidural analgesia (5,7,12–14). Epidural abscess and transient neurologic symptoms are the only neurologic complications reported in association with thoracic epidural anesthesia in children (15,16). In this issue of Anesthesia & Analgesia, Kasai et al. (17) report on the case of a child with temporary bilateral lower-extremity neurologic deficits associated with spinal cord injury after a single-shot thoracic epidural block performed during general anesthesia for emergency appendectomy. This case report is important because it reminds us that there are serious risks associated with TEA in children and that we must carefully weigh the risks and benefits of this procedure in any child considered to be a candidate for TEA. In the absence of clinical data demonstrating the risks and benefits of TEA, adherence to the recommendations of experts and the exercise of sound clinical judgement are mandatory. This report also focuses our attention on several other issues, including a newly proposed mechanism of injury in an anesthetized child, options to consider after encountering a dural puncture during attempted epidural placement, the evaluation of a child with unexpected pain and sensory and motor deficits in the lower extremities after combined general and regional anesthesia, and the practice of performing regional anesthesia in anesthetized children. Do the benefits of single-shot TEA provided by Kasai et al. (17) outweigh the risks in this child? The stated purposes for performing the block were to provide effective perioperative analgesia, to reduce the volume of local anesthetic required as compared with the volume that would be required if epidural analgesia were performed at the lumbar or caudal levels, and to avoid the use of muscle relaxants and opioid analgesics. Epidural analgesia is rarely considered for children with acute appendicitis undergoing emergency appendectomy at my institution for several reasons. First, this surgery is performed laparoscopically or via a small incision in the right lower quadrant and is not associated with severe or prolonged postoperative pain. Excellent postappendectomy analgesia is Accepted for publication September 12, 2002. Address correspondence and reprint requests to John B. Rose, MD, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, 34th & Civic Center Blvd., Philadelphia, PA 19104. Address e-mail to rose@email.chop.edu.