Transient hemiplegia in posterior instrumentation of scoliosis.
METHODS
A case of transient hemiplegia during posterior correction and instrumentation of scoliosis in an 18-year-old woman.


OBJECTIVE
To present a case of transient hemiplegia most probably resulting from an arteriovenous fistula.


BACKGROUND
Neurologic impairment in spinal surgery is a feared complication. Common reasons are direct or indirect trauma to neural elements, intraoperative hypotension, ischemia, bleeding, metabolic dysbalances, or drug effects. Review of the literature did not reveal any case of transient hemiplegia similar to the presented one in which none of the mentioned pathologies could be found.


METHODS
An 18-year-old woman with a right long thoracic lordoscoliosis measuring 67 degrees Cobb angle and a marfanoid phenotype underwent posterior correction and transpedicular instrumentation from T3 to L2. After uneventful correction of the deformity through rod rotation, the wake-up test revealed a right-sided hemiplegia without facial asymmetry or other neurologic abnormalities affecting structures above the spinal cord. The rods were removed, the pedicle screws left in place, and the patient was turned on her back. Within 30 minutes after extubation, the neurologic deficits disappeared completely. Extensive diagnostic workup, including magnetic resonance angiography, did not show any pathologic findings explaining the transient hemiplegia. Two weeks later, the surgical correction was completed. After rod rotation again, right-sided hemiplegia was found in the wake-up test. Leaving the correction and after finalizing surgery, the patient was turned on her back and a 5 x 3-cm mass became apparent in her right sternocleidomastoid region. Color-coded duplex sonography revealed an arteriovenous fistula between the right external carotid artery and the right internal jugular vein. After extubation, the mass disappeared and within minutes all neurologic functions returned to normal again.


CONCLUSIONS
Spine surgeons should be aware of arteriovenous malformations as a potential cause of neurologic disturbances.
Schulte
Tobias L
TL
Department of Orthopedics, University Hospital of Münster, Münster, Germany. dr.tobias.schulte@web.de
Lerner
Thomas
T
Berendes
Elmar
E
Bürkle
Hartmut
H
Kiefer
Reinhard
R
Hackenberg
Lars
L
Liljenqvist
Ulf
U
D000015:Abnormalities, Multiple / Q000235:genetics; D000293:Adolescent; D001164:Arteriovenous Fistula / Q000150:complications* / Q000000981:diagnostic imaging; D006332:Cardiomegaly / Q000150:complications; D002342:Carotid Artery, External / Q000002:abnormalities* / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D005260:Female; D006429:Hemiplegia / Q000175:diagnosis / Q000209:etiology*; D006801:Humans; D016268:Internal Fixators; D007431:Intraoperative Complications / Q000175:diagnosis / Q000209:etiology*; D007601:Jugular Veins / Q000002:abnormalities* / Q000000981:diagnostic imaging; D008141:Lordosis / Q000150:complications / Q000601:surgery; D008279:Magnetic Resonance Imaging; D008945:Mitral Valve Prolapse / Q000150:complications; D012600:Scoliosis / Q000150:complications / Q000235:genetics / Q000601:surgery*; D013116:Spinal Cord / Q000098:blood supply; D013119:Spinal Cord Injuries / Q000175:diagnosis; D013123:Spinal Fusion / Q000295:instrumentation; D013127:Spinal Nerves / Q000293:injuries; D018615:Ultrasonography, Doppler, Color