title: Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy.
abstract: OBJECTIVE
  We describe a complication of epiduroscopy with encephalopathy and rhabdomyolysis associated with the contrast medium iotrolan.
  
  
  METHODS
  A 76-yr-old man with failed back surgery syndrome underwent epiduroscopy. Sufficient lysis could not be achieved in the epidural space above the level of L4 due to dense adhesions and scar tissue. After epidural injections of iotrolan and mepivacaine, he developed motor weakness and hypoesthesia in both legs, which lasted for three hours. He also became confused, agitated, disoriented, and developed neck stiffness and tremors involving the head and legs. Computed tomography revealed diffuse contrast enhancement within the intracranial cerebrospinal fluid (CSF) spaces, indicating an intraoperative dural tear. Marked increases in serum creatinine phosphokinase and myoglobin indicated subsequent acute rhabdomyolysis. Crystalloid infusion and semi-recumbent positioning facilitated iotrolan absorption from the CSF, and the patient recovered uneventfully.
  
  
  CONCLUSIONS
  Dural tear during epiduroscopy may allow access of contrast media into the CSF. Neurotoxicity secondary to iotrolan within the CSF was a likely contributing factor to the encephalopathy and subsequent rhabdomyolysis. This is an instructive example of the importance of diagnosing inadvertent dural tear during epiduroscopy under iotrolan, for avoidance of adverse events such as encephalopathy and rhabdomyolysis.
authors.affiliation: Department of Anesthesiology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. mizuno_ju4@yahoo.co.jp
authors.forename: Ju
authors.initials: J
authors.lastname: Mizuno
authors.forename: Tobias
authors.initials: T
authors.lastname: Gauss
authors.forename: Masahiro
authors.initials: M
authors.lastname: Suzuki
authors.forename: Masakazu
authors.initials: M
authors.lastname: Hayashida
authors.forename: Hideko
authors.initials: H
authors.lastname: Arita
authors.forename: Kazuo
authors.initials: K
authors.lastname: Hanaoka
mesh_terms: D000208:Acute Disease; D000368:Aged; D001927:Brain Diseases / Q000139:chemically induced*; D003287:Contrast Media / Q000009:adverse effects*; D004388:Dura Mater / Q000293:injuries*; D004569:Electroencephalography / Q000187:drug effects; D004724:Endoscopy / Q000009:adverse effects*; D004824:Epidural Space; D006801:Humans; D008297:Male; D012206:Rhabdomyolysis / Q000139:chemically induced*; D014283:Triiodobenzoic Acids / Q000009:adverse effects* / Q000134:cerebrospinal fluid
chemical_list: D003287:Contrast Media; D014283:Triiodobenzoic Acids; C033300:iotrolan