New Neurological Insult with an Indwelling Epidural: A Case Report

79 y/o male, ASA Class 3, with multiple medical problems presented postoperatively to the thoracic intensive care unit after an uncomplicated abdominal aortic aneurysm repair. Past medical history was significant for 52 pack year history, benign prostatic hypertrophy, diverticulosis and glaucoma. An epidural catheter was placed preoperatively at T9-10. The patient was extubated POD 1, after an uneventful night. Epidural ran continuously overnight with an infusion of bupivicaine 0.0625% / hydromorphone 10 mcg/ml at a rate of 5 ml per hour. In the morning the patient complained of mild lower extremity numbness and weakness, right greater than left. Neurologic examination revealed reduction in motor function in the right (2/5) and left (3/5) lower extremities from the hips down. Patchy areas of sensory loss were also identified in both extremities. The epidural was immediately stopped and an urgent MRI with/without contrast ordered. Acute ischemia/infarct was identified at the L1 level. Patient was followed and, after one year, is now able to ambulate in a two wheeled walker with significant gain in motor skills. Differential diagnosis of new onset motor weakness following epidural placement must include epidural hematoma, spinal cord trauma or spinal cord ischemia or infarct. Spinal cord ischemia presenting as paraplegia or paraparesis following abdominal aortic aneurysm repair has a reported incidence of 1:400. Conservative treatment is recommended, focusing on permissive hypertension, diuresis, and in some cases placement of a lumbar spinal drain to increase spinal perfusion, accompanied by aggressive physical therapy and rehabilitation. Routine use of local anesthetic containing epidural solutions in sedated/intubated patients in the intensive care setting may lead to delayed identification of spinal cord ischemia following abdominal aortic aneurysm repair.