title: Spinal artery syndrome masked by postoperative epidural analgesia.
abstract: OBJECTIVE
  We report a case of a patient who developed a postoperative anterior spinal artery syndrome that was masked by the use of epidural analgesia. We wish to alert other anaesthetists that the use of epidural anaesthesia in this setting may mask the symptoms and delay the diagnosis of this rare complication.
  
  
  METHODS
  The patient was a 22-yr-old obese man with metastatic testicular carcinoma who underwent a left-sided thoracoabdominal retroperitoneal tumour resection. A lumbar epidural catheter was placed preoperatively for pain management. Postoperatively, the patient developed bilateral lower extremity weakness, which was at first attributed to epidural administration of local anaesthetics. Despite discontinuation of the local anaesthetics, the symptoms persisted. Further work-up led to the diagnosis of anterior spinal artery syndrome. The patient was sent to a rehabilitation hospital and had a partial recovery.
  
  
  CONCLUSIONS
  Anterior spinal artery syndrome can occur following retroperitoneal surgery. It is important to recognize the potential for this complication when postoperative epidural analgesia is contemplated, especially following a left-sided surgical dissection. The use of epidural local anaesthetics immediately after surgery delays the diagnosis of a postoperative neurological deficit. Moreover, when the deficit is recognized the epidural itself may be falsely blamed for postoperative paraplegia. If epidural analgesia is used, opioids may be preferred over local anaesthetics in the immediate postoperative period to prevent masking of an anterior spinal artery syndrome.
authors.affiliation: Department of Anesthesiology, University of Southern California School of Medicine, Los Angeles, USA.
authors.forename: S M
authors.initials: SM
authors.lastname: Linz
authors.forename: C
authors.initials: C
authors.lastname: Charbonnet
authors.forename: M S
authors.initials: MS
authors.lastname: Mikhail
authors.forename: N
authors.initials: N
authors.lastname: Vadehra
authors.forename: V
authors.initials: V
authors.lastname: Zelman
authors.forename: R L
authors.initials: RL
authors.lastname: Katz
authors.forename: D
authors.initials: D
authors.lastname: Thangathurai
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D006801:Humans; D008297:Male; D009373:Neoplasms, Germ Cell and Embryonal / Q000601:surgery*; D010149:Postoperative Pain / Q000188:drug therapy; D010243:Paralysis / Q000209:etiology / Q000628:therapy; D011183:Postoperative Complications / Q000175:diagnosis / Q000628:therapy*; D013118:Spinal Cord Diseases / Q000209:etiology* / Q000628:therapy; D013736:Testicular Neoplasms / Q000601:surgery*