Arq. NeuroPsiquiatr. vol.33 número3

PARAPLEGIA A N D INTRACRANIAL H Y P E R T E N S I O N

FOLLOWING E P I D U R A L A N E S T H E S I A

REPORT OF FOUR CASES

FREDERICO A . D . K L I E M A N N

There are, now, m a n y reported cases of irreversible neurologic syndrome

caused by spinal (subarachnoid) a n e s t h e s i a

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and some about t h e

perhaps less frequent complications of epidural anesthesia

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.

A v e r y complete revision of 32 verified cases of arachnoiditis post spinal

anesthesia w a s m a d e by S c h w a r t z and B e v i l a c q u a

. N e u r o l o g i c

complica-tions w e r e present in 17 of 1 1 . 5 7 4 spinal anesthesia

in 84 cases of 1 0 . 4 4 0

and in 37 of 1 0 . 0 9 8 anesthesias

in three different series, b u t only the l a s t

t w o series of patients w e r e followed up. Severe, irreversible situations,

ho-wever, are m u c h less frequent and occurred in no patient of t h e s e three

series.

H e l l m a n n

reports no neurologic complication in 2 6 . 1 2 7 cases of epidural

anesthesia in his obstetrical series, and t w o cases of severe neurological

complications in his surgical series; again, follow-up of patients is not

spe-cified. Bonica e t a l .

describe one case of serious neurologic complication

a m o n g 3 . 6 3 7 peridural blocks.

E v e n in more recent papers, t h e pathogenesis of neurologic sequellae

of both epidural and subarachnoid anesthesias is discussed and not c l e a r

.

Chemical contaminants w e r e experimentally s h o w n

to be able to produce

severe arachnoiditis and clinical paraplegia in m o n k e y s and could be the

causal a g e n t in some clinical situations. Increased concentration of t h e

anes-t h e anes-t i c a g e n anes-t w a s also demonsanes-traanes-ted anes-to produce, in experimenanes-tal animals,

neurologic syndromes similar to t h e observed in clinical situations

>

.

Treat-m e n t of neurologic sequellae is usually unsuccessful and Treat-m o s t cases are

irreversible.

F r o m t h e D e p a r t m e n t o r I n t e r n a l M e d i c i n e . D i v i s i o n of N e u r o l o g y , F a c u l t y of M e d i c i n e of P o r t o A l e g r e , F e d e r a l U n i v e r s i t y of R i o G r a n d e do Sul, a n d I n s t i t u t o d e N e u r o c i r u r g i a , P o r t o A l e g r e , B r a s i l .

Acknowledgments — T h e a u t h o r w i s h e s t o e x p r e s s h i s t a n k s t o D r . F e l i z b e r t o

D u r i n g t h e last four years, six patients w i t h severe neurologic disabilities

following epidural anesthesia w e r e s e e n a t t h e I n s t i t u t e of Neurosurgery,

P o r t o Alegre. T h e present report concerns four of t h e s e patients in w h o m

good information w a s obtained about t h e a n e s t h e t i c procedure and close

observation about evolution w a s possible.

R E P O R T OF FOUR CASES

CASE 1 — F . Z . , w h i t e , m a l e , a g e 63, w a s in good h e a l t h u n t i l J u l y 24, 1970, w h e n o p e r a t e d o n for i n g u i n a l hernia, u n d e r e p i d u r a l a n e s t h e s i a . H e w a s pre-m e d i e a t e d w i t h V a l i u pre-m 10 pre-m g and put in t h e left l a t e r a l position. P u n c t u r e w a s m a d e in L2-L3, by t h e resident, under s u p e r v i s i o n of t h e a n e s t h e s i o l o g i s t , w i t h T-16 n e e d l e . A s c e r t a i n m e n t of e p i d u r a l s p a c e w a s reported to be difficult, but no a r a c h n o i d p e r f o r a t i o n w a s reported. E p i d u r a l t r a y w a s c l e a n e d in w a t e r a n d a u t o c l a v e d . The a n e s t h e t i c a g e n t w a s L i d o c a i n e 2 % , 400 m g , w i t h a d r e n a l i n e , 1:160.000. T h e o p e r a t i o n w a s u n e v e n t f u l and no h y p o t e n s i o n occurred d u r i n g surgery. I m m e d i a t e l y a f t e r surgery, t h e p a t i e n t f e l t tired a n d slept, j u s t to a w a k e , 2 or 3 h o u r s later, w i t h v e r y s e v e r e p a i n s in both l e g s . H e required s e v e r a l a n a l g e s i c i n j e c t i o n s d u r i n g t h e n e x t 10 h o u r s a n d n e x t m o r n i n g h e c o m p l a i n e d of n u m b n e s s in b o t h l e g s and c h i e f l y in s a d d l e area, r e t e n t i o n of urine, c o n s t i p a -tion a n d w e a k n e s s in both l o w e r limbs.

A t t h i s t i m e , n e u r o l o g i c e x a m i n a t i o n s h o w e d r e d u c t i o n of a l l kinds of s e n s a t i o n from L 3 t o L5 a n d a n e s t t h e s i a from L5 d o w n to S5, b i l a t e r a l l y a b s e n t a n k l e jerks, e x t e n s o r p l a n t a r r e s p o n s e s ; m o t o r s t r e n g t h w a s r e d u c e d in e x t e n s o r s of t o e s a n d feet and e x t e r n a l r o t a t i o n of feet. N o f a s c i c u l a t i o n s and no pains. L u m b a r p u n c t u r e r e v e a l e d c o l o u r l e s s fluid u n d e r n o r m a l pressure, c o n t a i n i n g 120 c e l l s per ml, and 300 m g of protein per 100 m l . B a c t e r i o l o g i c e x a m i n a t i o n w a s n e -g a t i v e . On t h e a s s u m p t i o n t h i s w a s a n a s e p t i c s p i n a l cord i n f l a m m a t i o n s e c o n d a r y t o epidural a n e s t h e s i a , oral corticoid t r e a t m e n t w a s s t a r t e d w i t h D e c a d r o n 12 m g a day, p r o g r e s s i v e l y r e d u c i n g dose u n t i l D e c e m b e r 1970. I n A u g u s t , 7, 1970, cerebrospinal fluid (CSF) e x a m i n a t i o n s h o w e d : p r o t e i n 149 m g per 100 CU. MM., 15 c e l l s per ml, i n c r e a s e d a l b u m i n / g l o b u l i n r e l a t i o n in C e l l o g e l p r o t e i n o g r a m . T h e p a t i e n t ' s s i t u a t i o n i m p r o v e d s l o w l y d u r i n g t h e n e x t four m o n t h s : o n t h e b e g i n -n i -n g of S e p t e m b e r t h e u r e t h r a l c a t h e t e r c o u l d be t a k e -n off a-nd h e w a s a b l e t o p a s s u r i n e w i t h s o m e difficulty, by a b d o m i n a l c o m p r e s s i o n . H i s g a i t i m p r o v e d and h e w a s a b l e t o d r i v e his car. S e n s a t i o n w a s n o r m a l t o pinprick t o L5, a n d reduced f r o m L5 t o S5. V i b r a t i o n w a s reduced a t t h e a n k l e s and proprioception s h o w e d s o m e errors a t t h e t o e s .

I n D e c e m b e r , 1970, CSF c o n t a i n e d 5 c e l l s per CU. MM. and 120 m g procein per 100 m l . CSF c u l t u r e w a s n e g a t i v e , E.S.R. 8, n o r m a l h e m o g r a m and s e r u m p r o t e i n o g r a m ; i r r e l e v a n t l u m b a r a n d s a c r a l s p i n e X - R a y . Urine i n f e c t i o n w a s pre-s e n t pre-s i n c e A u g u pre-s t a n d n o t y e t cured. A pre-s h i pre-s pre-s i t u a t i o n w a pre-s pre-s t a t i o n a r y t h e p a t i e n t decided t o s e e a n o t h e r n e u r o l o g i s t , by w h o m P a n t o p a q u e m y e l o g r a p h y w a s indicated a n d done, and l a t e r s a i d to h a v e s h o w n "cord atrophy".

C o m m e n t : a c u t e l u m b o - s a c r a l m y e l o p a t h y w i t h i n f l a m a t o r y f i n d i n g s in CSF, o c c u r r i n g i m m e d i a t e l y a f t e r epidural a n e s t h e s i a . P a r t i a l i m p r o v e m e n t d u r i n g n e x t four m o n t h s .

no blood or CSF c a m e . E p i d u r a l t r a y prepared by a u t o c l a v a t i o n , i n c l u d i n g Li-docaine. S y r i n g e s and n e e d l e s p r e v i o u s l y w a s h e d a n d c l e a n e d w i t h d e t e r g e n t and t h e n w a s h e d in w a t e r . L i d o c a i n e 1.5%, 300 m g , w i t h a d r e n a l i n e 1:320.000 injected in 5 m i n u t e s . I m m e d i a t e l y on b e i n g turned to supine position, p a t i e n t w a s u n a b l e to m o v e l e g s and trunk, and felt n u m b n e s s up to upper limbs. She also reported difficulty in s w a l l o w i n g and got e x t r e m e l l y a n x i o u s . Blood pressure 90 x 60, no respiratory depression. Three to four h o u r s after a n e s t h e s i a , she c o m p l a i n e d of pricking and t i n g l i n g s e n s a t i o n s , from h e a d d o w n to l o w e r limbs, i m m e d i a t e l y followed by v e r y i n t e n s e p a i n s in both l e g s and trunk, d u r i n g t h e n e x t 6 hours.

S o m e days l a t e r her l e g s s e e m e d to be w e a k and s h e fell frequently. By N o v e m b e r , she s t a r t e d n o t i c i n g n u m b n e s s in her feet, w h i c h increased v e r y s l o w l y d u r i n g t h e n e x t four m o n t h s . I n February, 1971, s h e h a d a n k l e c l o n u s and difficulty in p a s s i n g urine.

She w a s first seen in March, 10, 1971. N e u r o l o g i c e x a m i n a t i o n s h o w e d : marked r e d u c t i o n in f l e x i o n and e x t e n s i o n of t h e t o e s and i n t e r n a l r o t a t i o n of t h e feet. S l i g h t r e d u c t i o n of e x t e r n a l r o t a t i o n and dorsal flexion of both feet. B i l a t e r a l e x t e n s o r p l a n t a r r e s p o n s e s and a n k l e c l o n u s and + + + s y m m e t r i c a l k n e e jerks. Upper superficial abdominal r e f l e x e s p r e s e n t and l o w e r a b d o m i n a l s absent. P i n -prick s e n s a t i o n m a r k e d l y reduced from T 1 0 to L4 but spared in L5 and p e r i n e u m . Vibration reduced in both k n e e s and a n k l e s and proprioception a b s e n t in t h e toes. T h e s i t u a t i o n w a s i n d i c a t i v e of a m y e l o p a t h y w i t h upper l e v e l in T10, but s p a r i n g of pain s e n s a t i o n from L5 d r o w n s u g g e s t e d a c e n t r a l cord lesion, possibly r e l a t e d to anterior spinal artery obstruction. A l u m b a r p u n c t u r e w a s performed but no fluid o b t a i n e d . A m y e l o g r a p h y w i t h p o s i t i v e c o n t r a s t w a s done by s u b -o c c i p i t a l r-oute and s h -o w e d a p a r t i a l st-op in T9 and c -o m p l e t e st-op in T10. Sub-occipital CSF w a s normal. Chiefly in v i e w of t h e posibility of a p r e e x i s t i n g c e n t r a l cord tumor, a l a m i n e c t o m y w a s performed in March, 1971, and disclosed a n i n t e n s e p r o l i f e r a t i v e arachnoiditis, c o n t a i n i n g s o m e w h i t i s h c y s t s of fluid; cord w a s narrowed, pale, and c o m p l e t e l y impossible to be liberated from t h e arachnoid. B o t h cord and roots w e r e e n m e s h e d by a thick, fibrous tissue. After surgery, p a t i e n t ' s n e u r o l o g i c s i t u a t i o n c o n t i n u e d to deteriorate, s l o w l y but progressively. She w a s g i v e n oral Prednisone, s t a r t i n g w i t h 60 m g a d a y and reduced s l o w l y to 10 m g in June.

I n A u g u s t 1971, she w a s t a k e n to B o s t o n (U.S.A.) and s e e n at t h e Mass. S e n e r a l H o s p i t a l . A t t h i s t i m e she p r e s e n t e d a c o m p l e t e spastic p a r a p l e g l i a w i t h b i l a t e r a l a n k l e and k n e e clonus, e x t e n s o r p l a n t s a n d p a r a l y s i s from t h e l o w e r a b d o m i n a l s d o w n ; sensory a n e s t h e s i a w i t h l e v e l in T 1 0 for a l l m o d a l i t i e s of s e n -sation. She w a s still a b l e to control bladder and b o w e l s . Suboccipital fluid showed n o r m a l c h e m i c a l and c y t o l o g i c e x a m i n a t i o n s . I n v i e w of t h e p r o g r e s s i v e l y wor-s e n i n g wor-s i t u a t i o n , m e t h y l predniwor-solone a c e t a t e (Depo-Medrol) 40 m g , w a wor-s injected a t t h e suboccipital level in A u g u s t 27, 3 0 and S e p t e m b e r 3. A t t h a t date, o n l y 1 cc of f a i n t l y turbid CSF could be a s p i r a t e d and t h e r e w a s a q u e s t i o n of l o c u l a t i o n w i t h a d h e s i o n s at t h a t point. It w a s felt t h a t further i n s t i l l a t i o n s of Depo-Medrol w e r e not l i k e l y to be of v a l u e .

A f t e r c o m p l e t i n g p a r a p l e g i a w i t h s e n s o r y and m o t o r l e v e l in T10 t h e pa-tient's s i t u a t i o n stabilized and is m u c h t h e s a m e after 2 a n d 1 / 2 years. She is still able to control urine. S h e d e v e l o p e d u r i n a r y infection, c o n t r o l l e d w i t h diffi-c u l t y d u r i n g last year.

CASE 3 — L . M . M . , 25 y e a r s old, w h i t e f e m a l e , w a s in perfect h e a l t h u n t i l D e c e m b e r 1972, w h e n r e c e i v e d epidural a n e s t h e s i a for c e s a r e a n delivery. T h i s w a s u n e v e n t f u l . P r e m e d i c a t e d w i t h V a l i u m 10 m g . P u n c t u r e in L3-L4, w i t h n u m b e r 10 Crawford needle. P a t i e n t s e a t e d . I d e n t i f i c a t i o n of epidural s p a c e by l o s s of r e s i s t a n c e . N o b a c k flow of fluid w h e n n e e d l e t u r n e d to t h e four a n g l e s . E p i d u r a l t r a y prepared by a u t o c l a v a t i o n ; s y r i n g e s a n d n e e d l e s p r e v i o u s l y w a s h e d w i t h de-t e r g e n de-t a n d de-t h e n w i de-t h w a de-t e r . L i d o c a i n e 2 % , 3 6 0 m g , w i de-t h a d r e n a l i n e 1:160.000, w a s s l o w l y i n j e c t e d . On b e i n g t u r n e d t o s u p i n e position, p a t i e n t reported n u m b n e s s in both l o w e r limbs. A s h y p o t e n s i o n w a s o b s e r v e d , s h e w-as put in T r e n d e l e m b u r g position and t r e a t e d w i t h M e t a r a m i n o l and o x y g e n . A f e w h o u r s after c e s a r e a n , she h a d i n t e n s e p a i n s in both l e g s and l o w back, w h i c h a l l e v i a t e d o n l y after t h e third a n a l g e s i c i n j e c t i o n .

She w a s w e l l for a b o u t t h i r t y days, w h e n s h e s t a r t e d f e e l i n g pins a n d n e e d l e s , and t h e n n u m b n e s s in b o t h feet, w h i c h g r a d u a l l y i n v o l v e d h e r l e g s and t h i g h s . In b e g i n n i n g of M a r c h s h e s t a r t e d w i t h daily, i n t e n s e h e a d a c h e s , a c c o m p a n i e d by s w e a t i n g a n d dizziness. A t a b o u t t h e s a m e t i m e she n o t i c e d g a i t d i s t u r b a n c e s a n d l o s s of p o w e r in b o t h lower limbs. N o b o w e l or bladder d i s t u r b a n c e . For 10 d a y s before a d m i s s i o n , h e a d a c h e episodes w e r e a l s o a c c o m p a n i e d by t r a n s i t o r y b i l a t e r a l b l i n d n e s s l a s t i n g 1 to 3 m i n u t e s .

She w a s a d m i t e d to t h e D e p a r t m e n t of I n t e r n a l Medicine, H o s p i t a l de Cli-nicas, P o r t o A l e g r e , o n March, 27, 1973. S h e h a d no s y s t e m i c c o m p l a i n t s or d i s t u r b a n c e s ; w e i g h t 7 3 k g . N e u r o l o g i c e x a m i n a t i o n : slow, h o r i z o n t a l n y s t a g m u s to b o t h d i r e c t i o n s ; isochoric p u p i l s r e a c t i n g n o r m a l l y . H y p o e s t h e s i a for p a i n a n d t e m p e r a t u r e in t h e r e g i o n of t h e r i g h t m a x i l l a r y n e r v e . P o w e r m a r k e d l y reduced in both l o w e r limbs, c h i e f l y o n t h e right, w h e r e t h e r e w a s c o m p l e t e p a r a l y s i s of e x t e n s i o n of t o e s a n d foot a n d of e x t e r n a l r o t a t i o n of t h e foot; l o s s of p o w e r w a s l e s s m a r k e d in t h e s a m e g r o u p s o n t h e l e f t ; f l e x i o n of b o t h l e g s a n d t h i g h s w a s b i l a t e r a l l y r e d u c e d w h e r e a s e x t e n s i o n w a s n o r m a l . S e n s a t i o n w a s r e d u c e d for t o u c h and p a i n from T4, a n d a b s e n t from T 6 d o w n ; v i b r a t i o n a b s e n t from T4. D e e p r e f l e x e s in t h e u p p e r a n d l o w e r l i m b s + + + b i l a t e r a l l y ; e x t e n s o r p l a n t a r r e f l e x e s b i l a t e r a l l y . I n t e n s e b i l a t e r a l p a p i l o e d e m a w a s p r e s e n t .

E v i d e n t l y , t h i s w a s a g r a d u a l l y p r o g r e s s i n g m y e l o p a t h y , w i t h a m o r e s e v e r e lesion in T4. T h e h i s t o r y m a d e c l e a r t h a t it w a s a n a s c e n d i n g lesion, a n d s h e h a d s i g n s of i n v o l v e m e n t of i n t r a c r a n i a l s t r u c t u r e s a n d i n t r a c r a n i a l h y p e r t e n s i o n a s w e l l . T h e s i t u a t i o n w a s v e r y s u g g e s t i v e l y r e l a t e d t o e p i d u r a l a n e s t h e s i a a n d a s c e n d i n g a r a c h n o i d i t i s w a s a n o b v i o u s d i a g n o s i s . L u m b a r p u n c t u r e w a s performed but no fluid o b t a i n e d . Cysternal p u n c t u r e w a s t h e n m a d e , w i t h p a t i e n t in s e a t e d position, a n d clear, c o l o u r l e s s fluid s h o w e d n o r m a l c y t o l o g i c a l and c h e m i c a l f i n d i n g s . Other l a b o r a t o r y e x a m i n a t i o n s : h e m o g r a m , E.S.R., s e r u m p r o t e i n o g r a m , w e r e n o r m a l . V.D.R.L. a n d t u b e r c u l i n t e s t n e g a t i v e .

these o c c a s i o n s . A carotid a n g i o g r a p h y w a s done a n d s h o w e d s y m m e t r i c a l h y -d r o c e p h a l u s .

A v e n t r i c u l o - p e r i t o n e a l s h u n t w a s p l a c e d in April 27, w i t h a m e d i u m pressure R a i m o n d i c a t h e t e r , c o u p l e d to a P o r t n o y v e n t r i c u l a r c a t h e t e r . H e a d a c h e disappeared t h e s a m e d a y a n d s h e h a d no m o r e episodes of b l i n d n e s s so far. O p h t a l m o s c o p i c e x a m i n a t i o n in May 16, s h o w e d "almost c o m p l e t e r e a b s o r p t i o n of r e t i n a l h a e m o r r h a -g e s a n d m a r k e d r e d u c t i o n o£ protrusion of t h e dysks". N o r m a l fundi in J u n e 6.

I n May 5, she s t a r t e d w i t h m o v e m e n t s in left foot; i n t e n s i v e p h y s i o t h e r a p y w a s s t a r t e d after v e n t r i c u l o - p e r i t o n e a l s h u n t w a s p l a c e d . B y A u g u s t 4, s h e h a d f l e x i o n a n d e x t e n s i o n of both l e g s a n d t h i g h s . In October 19 s h e w a s a b l e to w a l k w i t h Canadian c a n e s and l o n g b r a c e s in both l o w e r limbs, a n d in D e c e m b e r 26 she w a s a b l e to w a l k 10 s t e p s w i t h o u t c a n e s a n d braces. Motor power, by t h i s t i m e , w a s o n l y reduced b i l a t e r a l l y in e x t e n s i o n of t h e toes a n d in dorsal f l e x i o n a n d e x t e r n a l r o t a t i o n of t h e feet. V i b r a t i o n w a s felt n o r m a l l y in b o t h l e g s , but p a i n s e n s a t i o n w a s still reduced, a l t h o u g h present, from T6 d o w n . A n k l e c l o n u s w a s n o w a b s e n t . She stopped oral P r e d n i s o n e in October. I n April 23, 1974, p a t i e n t is w a l k i n g alone, w i t h o u t c a n e s , a n d m o t o r p o w e r 3s p r a c t i c a l l y n o r m a l . C o m m e n t : s l o w l y p r o g r e s s i v e a s c e n d i n g m y e l o p a t h y w i t h chief l e v e l in T 4 ; i n c r e a s e d i n t r a c r a n i a l p r e s s u r e a n d episodes of t r a n s i t o r y b l i n d n e s s . A s c e n d i n g s p i n a l a n d i n t r a c r a n i a l a r a c h n o i d i t i s s t a r t i n g o n e m o n t h after "epidural a n e s t h e s i a " . Short l a s t i n g i m p r o v e m e n t a f t e r i n t r a c y s t e r n a l m e t h y l p r e d n i s o l o n e injection, f o l l o -w e d by d e t e r i o r a t i o n u n t i l c o m p l e t e p a r a p l e g i a and b i l a t e r a l c h o k e d d y s k s -w i t h h e m o r r h a g i c foci. I m m e d i a t e d i s a p p e a r a n c e of i n t r a c r a n i a l h y p e r t e n s i o n a n d epi-sodes of t r a n s i t o r y b l i n d n e s s a f t e r v e n t r i c u l o - p e r i t o n e a l s h u n t . Steady, m a r k e d p r o g r e s s i v e r e c o v e r y from p a r a p l e g i a d u r i n g n e x t 12 m o n t h s a f t e r v e n t r i c u l o p e -ritoneal s h u n t .

CASE 4 — H . M . M . , 25 y e a r s old, w h i t e f e m a l e , w a s in p e r f e c t h e a l t h u n t i l October 21, 1973, w h e n r e c e i v e d epidural a n e s t h e s i a for v a g i n a l d e l i v e r y . T h i s w a s her first p r e g n a n c y a n d first e x p e r i e n c e w i t h e p i d u r a l a n e s t h e s i a . D e l i v e r y w a s u n e v e n t f u l . P u n c t u r e w a s d o n e in L 3 - L 4 i n t e r s p a c e , w i t h a T-16 n e e d l e , by a m i d l i n e approach. E p i d u r a l s p a c e h a s b e e n l o c a t e d a f t e r o n e a t t e m p t , and c o n f i r m e d by Gutierrez m e t h o d . X y l o c a i n e 1.2% w i t h a d r e n a l i n e 1:200.000 2 0 m l h a s been i n j e c t e d , a f t e r n e g a t i v e a s p i r a t i o n for fluid. A b o u t 8 m i n . l a t e r t h e p a t i e n t w a s m a r k e d l y dyspneic a n d felt l o w e r l i m b s p a r e s t h e s i a s . S h e r e c e i v e d o x y g e n , t h e r e w a s n o n e e d for v a s o p r e s s o r s a n d t h e d e l i v e r y w a s u n e v e n t f u l w i t h a n e w b o r n in e x c e l l e n t c o n d i t i o n s .

L e s s t h a n o n e h o u r after delivery, p a t i e n t s t a r t e d f e e l i n g p i n s and n e e d l e s in both l o w e r limbs, a n d t h e n v e r y i n t e n s e p a i n s i r r a d i a t i n g from t h e p e l v i c girdle t o l o w e r l i m b s . T h e p a i n s w e r e o n l y a l l e v i a t e d by t h e third i n j e c t i o n of P r o p o x i p h e n e , a b o u t 8 h o u r s a f t e r delivery. I n f l u e n c e d by t h e k n o w l e d g e of o t h e r c a s e s , t h e a n e s t h e s i o l o g i s t decided t o c a l l a n e u r o l o g i s t a t t h i s t i m e . F o u r t e e n h o u r s a f t e r e p i d u r a l i n j e c t i o n , t h e p a t i e n t w a s w e l l a n d n e u r o l o g i c e x a m i n a t i o n w a s n o r m a l , s h o w i n g n o t e v e n m e n i n g e a l signs. L u m b a r p u n c t u r e s h o w e d a f a i n t l y turbid fluid u n d e r n o r m a l pressure.

I n v i e w of t h e turbid a s p e c t of t h e fluid, t h i s w a s a l l o w e d t o drop u n t i l 75 m l w e r e t a k e n out, stopped by p a t i e n t ' s h e a d a c h e ; 4 0 m g of m e t h y l - p r e d n i s o l o n e w e r e d i s s o l v e d in 10 a d d i t i o n a l m l of fluid a n d r e i n j e c t e d s l o w l y .

T h e p a t i e n t w a s s e n t h o m e i n October 29 a n d w a s w e l l u n t i l N o v e m b e r 27, w h e n s t a r t e d w i t h h e a d a c h e , c h i e f l y occipital, s o m e t i m e s a c c o m p a n i e d by dizziness. N e u r o l o g i c e x a m i n a t i o n w a s n o r m a l a n d so w e r e o c u l a r fundi. T w o days later, h e a d a c h e w a s s t r o n g a n d incipient b i l a t e r a l p a p i l l e d e m a w a s seen. L u m b a r punc-t u r e s h o w e d clear fluid u n d e r pressure of 3 0 c m w a punc-t e r . M e punc-t h y l - p r e d n i s o l o n e w a s a g a i n injected t w o t i m e s , 40 m g e a c h , u n t i l n o r m a l fluid c a m e . B o t h h e a d a c h e and p a p i l l e d e m a cleared i m m e d i a t e l y . S h e w a s kept u n d e r oral D e x a m e t h a s o n e 4.5 m g a day, u n t i l D e c e m b e r 21, w h e n she stopped D e c a d r o n .

She w a s a d m i t t e d to our Service a s a n urgency, o n D e c e m b e r 29, a f t e r b e i n g t r e a t e d a t home, by a n o t h e r physician, for s o m e days. D u r i n g this time, h e a d a c h e reappeared a n d w a s t h e n a c c o m p a n i e d by v o m i t i n g , l a s s i t u d e , n u m b n e s s a n d w e a k n e s s in both l e g s , trunk, and, in rapid progression, u r i n a r y r e t e n t i o n , p a r a p l e -gia, t r e m o r s in both hands, diplopia, respiratory d i f f i c u l t y a n d c l o u d i n g of cons-ciousness. On e x a m i n a t i o n , s h e h a d b i l a t e r a l s i x t h n e r v e a n d u n i l a t e r a l right, c o m p l e t e third n e r v e paralysis, w i t h m y d r i a s i s a n d ptosis; clouded consciousness, d i a p h r a g m a t i c b r e a t h i n g a n d c o m p l e t e flacid p a r a p l e g i a w i t h sensory l e v e l probably in T2. S e v e r e b i l a t e r a l p a p i l l e d e m a w i t h n u m e r o u s , large, h e m o r r h a g i c foci.

A v e n t r i c u l o - p e r i t o n e a l s h u n t w a s u r g e n t l y placed, t h e s a m e day, w i t h m e d i u m pressure R a i m o n d i c a t h e t e r coupled t o a P o r t n o y v e n t r i c u l a r c a t h e t e r .

F r o m n e x t d a y s h e h a d n o m o r e h e a d a c h e and w a s in perfect s t a t e of c o n s -c i o u s n e s s . P a p i l l e d e m a disappeared d u r i n g n e x t t w o w e e k s . In J a n u a r y 28, o -c u l a r m o v e m e n t s and pupils w e r e normal, a n d s h e w a s able to feel pinprick d o w n to L2 and t o l o c a l i z e t a c t i l e s t i m u l i in both l e g s and feet. I n F e b r u a r y 2 3 s h e had flexion and e x t e n s i o n of both feet and toes, but p r o x i m a l m u s c l e s of l o w e r limbs w e r e still paralysed. In April 20, p o w e r w a s s l i g h t l y reduced in f l e x i o n a n d e x t e n s i o n of b o t h feet, and m o d e r a t e l y reduced in flexion a n d e x t e n s i o n of both l e g s . S e n s a t i o n w a s normal. I n Sept. 13, p a t i e n t w a l k s alone, w i t h o u t canes.

C o m m e n t : a c u t e aseptic m e n i n g i t i s i m m e d i a t e l y f o l l o w i n g "epidural a n e s t h e s i a " . T r e a t m e n t w i t h r e p e a t e d l u m b a r p u n c t u r e s a n d i n t r a - t h e c a l i n j e c t i o n s of Me-t h y l - p r e d n i s o l o n e a c e Me-t a Me-t e u n Me-t i l n o r m a l fluid o b Me-t a i n e d . I n c r e a s e d i n Me-t r a c r a n i a l pressu-re, o n e m o n t h later, n o r m a l i z e d a f t e r a second series of l u m b a r p u n c t u r e s a n d i n t r a - t h e c a l Methyl-prednisolone. A c u t e increased i n t r a c r a n i a l pressure, o c u l o m o t o r d i s t u r b a n c e s a n d c o m p l e t e p a r a p l e g i a in T 2 one m o n t h later. Complete n o r m a lization of i n t r a c r a n i a l p r e s s u r e a n d partial r e c o v e r y of p a r a p l e g i a after v e n -t r i c u l o - p e r i -t o n e a l s h u n -t .

DISCUSSION

I n probably t h r e e of o u r p a t i e n t s ( c a s e s 2, 3 4) t h e h i g h l e v e l of a n e s t h e s i a obtained is indicative of spinal (subarachnoid) a n e s t h e s i a2

. T h e rapid o n s e t of n e u r o m u s c u l a r w e a k n e s s and s e n s o r y l e v e l to a v e r y h i g h d e r m a t o m e could be i n t e r p r e t e d a s possible m i s p l a c e m e n t of t h e a n e s t h e t i c s o l u t i o n into t h e subdural s p a c e2 6

. T h i s could not be e x c l u d e d a s no fluid w a s obtained in t h e s e i n s t a n c e s , b u t w o u l d be hard to d e m o n s t r a t e .

T h e i m m e d i a t e n e u r o l o g i c deficit in c a s e 1 is s u g g e s t i v e of radicular — c a u d a equina — lesion, b u t t h e p r e s e n c e of unequivocal e x t e n s o r p l a n t a r responses m a d e it c l e a r t h a t a cord lesion w a s also present, in L3.

I s c h a e m i c lesions of t h e cord are a l i k e l y cause of s o m e of t h e n e u r o l o g i c problems occurring a f t e r epidural a n e s t h e s i a . I n s o m e c a s e s 5

.28

-ted t h a t t h e combined vasoconstrictive effect of the adrenaline and the

hypotension produced by the epidural blockade, by occluding the radicular

vessels to the spinal cord, are sufficient to deprive the cord of an adequate

blood supply. Cord ischaemia is certainly involved in m a n y other cases and

possibly in m o s t cases of m y e l o p a t h y secondary to spinal (subarachnoid)

anesthesia. V a s c u l a r changes in radicular and anterior spinal artery w e r e

present in m o s t cases whose pathologic material w a s reported

. Intrathecal

adrenaline w a s demonstrated to cause paraplegia in dogs, but in doses

corres-ponding t o 2,5 m g per k g

. I t is possible that the immediate m y e l o p a t h y

observed in case 1 w a s caused by cord ischaemia. A vascular — anterior

spinal artery — syndrome, w a s also present in our case 2.

C S F c y t o l o g y w a s normal in the case reported by U r q u h a r t - H a y

and

not reported in the patients of Davies and S o l o m o n

, B r a h a m and S a i a

and Bonica e t a l .

. C S F examination in our cases 1 and 4 (the t w o w h o

w e r e e x a m i n e d in the first 24 hours after epidural anesthesia) are

cha-racteristic of an a c u t e inflammatory reaction, a chemical meningitis.

M a n y of the reported cases of arachnoiditis post spinal (subarachnoid)

a n e s t h e s i a are atributed to the presence of contaminants in the spinal

anes-thetics

-

>

. Contaminants w e r e p r o v e d

to be able to cause severe

arachnoiditis in experimental m o n k e y s and the lesions and conditions of a n e s

-thesia w e r e v e r y similar to those in h u m a n cases pathologically studied.

A m o n g the contaminants possibly responsible for such reactions, there

are s o m e detergents c o m m o n l y used in m a n y Hospitals for cleaning of surgical

and a n e s t h e t i c material. A s long ago as in 1954, Paddison and A l p e r s

emphasized t h a t caution should be exercised in the use of detergent cleaned

apparatus for intrathecal injections and that detergent materials should not

be employed in t h e preparation of t h o s e i t e m s used in m i x i n g and injecting

spinal a n e s t h e t i c a g e n t s . In t w o of our patients (cases 2 and 3) detergents

w e r e certainly used in preparation of the peridural tray. T h e y w e r e probably

not used in case 1. If detergents were the responsible a g e n t of chemical

meningitis and arachnoiditis after spinal anesthesia, t h e y would certainly be

able to cause the s a m e reactions after introduction of a larger amount, even

in epidural space. Much of the a n e s t h e t i c material is diffused, through

the arachnoid villi, to the subarachnoid s p a c e

. In fact, there is not an

experimental s t u d y to demonstrate diffusion of detergents through arachnoid

villi. Actually, a t these times, detergents should never be used for

prepa-ration of a n e s t h e t i c trays and disposable syringes and needles should be

used w h e n e v e r possible.

I n our case 4 w e are sure t h a t no detergent or any other possible

contaminant w a s used in the preparation of the anesthetic material.

Bonica et a l .

of solution w a s injected. In one patient in w h o m m a s s i v e subarachnoid

block occurred, serious neurologic sequelae developed; soon after the injection,

the patient b e g a n to complain of severe lancinating pain.

Tissue reactions h a v e been observed for the usual local anesthetics in

concentrations only s o m e w h a t higher t h a n those recommended for a n e s t h e

-s i a

.

. Experimentally, paraplegia w a s provoked in animals by increased

concentrations of a n e s t h e t i c a g e n t s

.

.

T h e r e would be s t r o n g evidence that increased amount of anesthetic in

the subarachnoid space is the c a u s e of cord lesion in our case 4. E v e n if w e

cannot rule o u t the action of detergents in cases 2 and 3, the similarity

of our four cases s u g g e s t s t h a t t h e y w e r e possibly caused by the

intra-thecal (subarachnoid or subdural) injection of large a m o u n t s of Lidocaine.

D u r a l perforation is not so rare on epidural anesthesia, and this would

still leave the possibility for an hiperergic reaction to Lidocaine in the

patients w h e r e the reaction occurs. All four anesthesias w e r e done by

res-pectful, experienced anesthesiologists, and in no case w a s C S F obtained before

injection of t h e anesthetic.

E v e n if the t e s t dose is injected, the possibility of neurologic

compli-cations to develop still remains, and its early detection would be desirable

if therapeutic m e a s u r e s w e r e able to change t h e course of the disease.

All four patients had very intense pains, t h a t m u s t be interpreted as

radicular, in the first 8 to 10 hours after anesthesia, and t h e s e ceased w i t h

analgesics, not to return. In both patients — c a s e s 1 and 4 — w h o had a

lumbar puncture performed during the first 24 hours, C S F w a s typical of an

aseptic meningitis. I t could be supposed t h a t the radicular syndrome of the

other t w o patients w a s also the expression of an aseptic meningitis.

In at least one patient (case 4) and, w i t h all probability, also in cases

2 and 3, the disease run a three s t a g e s c o u r s e : aseptic meningitis, followed

by an a s y m p t o m a t i c period, and then the adhesive, fibrous, thickening of

the arachnoid, causing obstruction to C S F flow and compression of cord

vessels.

Intracranial subarachnoid obstruction occurred in t w o of our cases. It

is v e r y m u c h rarer than the spinal lesions. Thickening of the leptomeninges

of t h e base of the brain w a s demonstrated in s o m e cases

>

>

H o w l a n d a t a t .

studied the effect of intrathecal corticosteroids in

preventing the development of paraplegia and arachnoiditis after

experi-m e n t a l injection of P a n t o p a q u e and blood in subarachnoid space. E v e n if

the s t u d y w a s m a d e w i t h a limited number of animals, neurologic sequellae

w e r e less conspicuouis in t h e treated group. D a v i s e t a l .

s u g g e s t e d the

addition of methyl-prednisolone to t h e contrast m e d i u m Conray ( m e g l u m i n e

i o t h a l a m a t e ) to minimize the risk of arachnoiditis. Positive evidence of the

benefit of this procedure is still l a c k i n g .

. Intrathecal methyl-prednisolone

w a s demonstrated by Lehrer et a l .

to achieve m a r k e d l y increased

con-centrations of the steroid in nervous s t r u c t u r e s close to the injection w h e n

compared to administration by s y s t e m i c route. T h e y propose t h a t more

effec-tive local soluble steroid levels w i t h i n the central nervous s y s t e m can be

obtained w i t h intrathecal than w i t h s y s t e m i c administration.

Intrathecal injections of Depo-Medrol w e r e administered to cases 2, 3

and 4. I n case 2 their effect cannot be judged because t h e y w e r e m a d e

after parapleglia w a s complete. B o t h in cases 3 and 4 a remarkable

impro-v e m e n t of the intracranial hypertension w a s obserimpro-ved after s o m e Depo-Medrol

injections. I m p r o v e m e n t lasted for three and four w e e k s , respectively, and

w a s very brief a f t e r a second injection in case 3.

Nicholson and E v e r s o l e

advised irrigation of the subarachoid space

w i t h isotonic saline solution w h e n a cauda equina syndrome w a s observed

after spinal anesthesia. R e m o v a l of large a m o u n t s of C S F w a s m a d e in

several consecutive days in our case 4 and this proved to be unsatisfactory.

I t m a y still be possible that energic w a s h i n g of subarachnoid space or

con-tinuous drainage of C S F , coupled or not w i t h more intensive intrathecal

corticosteroid therapy would be effective in preventing the ulterior

deve-lopment of arachnoiditis w h e n the initial meningo-radicular syndrome is

present and disclosed. Lumbar puncture should be performed w h e n e v e r

radicular pains are v e r y severe after peridural anesthesia.

Surgical liberation of arachnoid adhesions is a difficult task and usually

unefective, a l t h o u g h rare reports of good results in chronic arachnoiditis

justify a trial in more localized l e s i o n s

.

. N e u r o l o g i c deficit, however, is

some t i m e s relieved only temporarily and then, subsequently, progress to

complete paraglegia

.

T h e time relation of development of paraplegia and unexpected recovery

after p l a c e m e n t of ventriculo-peritoneal shunt, in cases 3 and 4, s u g g e s t a

causal relation. R e c o v e r y would not be atributed to intra-thecal

Depo-Me-drol, for neurologic deterioration continued after the injections and no other

therapeutic m e a s u r e w a s used a t this time.

N e l s o n e t al.

increase in protein w a s the only significant change noted in spinal fluid in

their cases. C S F protein decreased in s u c c e s s i v e e x a m i n a t i o n s in our cases,

transiently during and after methyl-prednisolone injections.

SUMMARY

F o u r p a t i e n t s w h o r e c e i v e d e p i d u r a l a n e s t h e s i a p r e s e n t e d s u s t a i n e d m y e

-l o p a t h y ; t h r e e of t h e m h a d c o m p -l e t e p a r a p -l e g i a a n d o n e a -l u m b o - s a c r a -l

m y e l o p a t h y w i t h u r i n a r y r e t e n t i o n . All f o u r p a t i e n t s c o m p l a i n e d of v e r y

i n t e n s e r a d i c u l a r p a i n s i m m e d i a t e l y a f t e r t h e a n a l g e s i c effect of L i d o c a i n e w a s

over. T w o p a t i e n t s in w h o m l u m b a r p u n c t u r e w a s d o n e in t h e f i r s t 24 h o u r s

p r e s e n t e d a n a s e p t i c m e n i n g i t i c r e a c t i o n in C S F . P a r a p l e g i a c o m p l e t e d in t w o

t o t e n m o n t h s in t h r e e p a t i e n t s a n d in t w o of t h e m s e v e r e i n t r a c r a n i a l

h y p e r t e n s i o n d e v e l o p p e d a t t h i s t i m e . I t is p r o p o s e d t h a t t h e d i s e a s e r u n s

a t w o s t a g e s c o u r s e , a t l e a s t in s o m e c a s e s , c h a r a c t e r i z e d b y a n a s e p t i c m e

-n i -n g i t i s , followed, a f t e r a s i l e -n t p e r i o d of s o m e m o -n t h s , b y sig-ns of a d h e s i v e

s p i n a l a n d i n t r a c r a n i a l a r a c h n o i d i t i s . I n t r a c r a n i a l h y p e r t e n s i o n w a s

con-t r o l l e d b y v e n con-t r i c u l o - p e r i con-t o n e a l s h u n con-t ; in con-t w o p a con-t i e n con-t s a con-t r a n s i con-t o r y effeccon-t of

i n t r a t h e c a l i n j e c t i o n s of m e t h y l p r e d n i s o l o n e a c e t a t e w a s o b s e r v e d . T w o p a

-t i e n -t s r e c o v e r e d a l m o s -t c o m p l e -t e l y f r o m p a r a p l e g i a .

RESUMO

Paraplegia e hipertensão craniana após anestesia epidural.

Relato de 4 casos.

Q u a t r o p a c i e n t e s q u e r e c e b e r a m a n e s t e s i a e p i d u r a l a p r e s e n t a r a m m i e l o p a ¬

t i a d e l o n g a e v o l u ç ã o ; e m t r ê s o c o r r e u p a r a p l e g i a c o m p l e t a e u m a p r e s e n

-t o u u m a s í n d r o m e m e d u l a r l o m b o - s a c r a c o m r e -t e n ç ã o u r i n a r i a . T o d o s os

p a c i e n t e s s e q u e i x a r a m de i n t e n s a s d o r e s r a d i c u l a r e s i m e d i a t a m e n t e a p ó s a

c e s s a ç ã o do efeito a n a l g é s i c o d a l i d o c a í n a . Dois p a c i e n t e s a p r e s e n t a r a m u m a

r e a ç ã o m e n i n g í t i c a a s s é p t i c a no líquido c e f a l o r r a q u e a n o n a s p r i m e i r a s 24

h o r a s . A p a r a p l e g i a t o r n o u - s e c o m p l e t a e m 2 a 10 m e s e s a p ó s a a n e s t e s i a ;

dois p a c i e n t e s t i v e r a m h i p e r t e n s ã o c r a n i a n a s e v e r a . E m a l g u n s casos, s e n ã o

e m todos, e s t a a f e c ç ã o a p r e s e n t a u m a e v o l u ç ã o e m d u a s e t a p a s , c a r a c t e r i z a d a s

p o r m e n i n g i t e a s s é p t i c a i m e d i a t a , s e g u i d a , depois de u m p e r í o d o silencioso d e

p o u c o s m e s e s , d e s i n a i s d e a r a c n o i d i t e a d e s i v a e s p i n a l e i n t r a c r a n i a n a . A

h i p e r t e n s ã o i n t r a c r a n i a n a foi c o n t r o l a d a p o r d e r i v a ç ã o v e n t r i c u l o - p e r i t o n e a l ;

e m 2 p a c i e n t e s h o u v e m e l h o r a t r a n s i t ó r i a p e l a a d m i n i s t r a ç ã o d e m e t i l - p r e d n i ¬

s o l o n a i n t r a t e c a l . E m dois p a c i e n t e s h o u v e r e c u p e r a ç ã o q u a s e c o m p l e t a d a

p a r a p l e g i a .

R E F E R E N C E S

2 . B O N I C A , J. J.; B A C K U P , P . H.; A N D E R S O N , C. E.; H A D F I E L D , D . ; C R E P P S , W. F . & M O N K , B. F . — P e r i d u r a l b l o c k : a n a l y s i s of 3.637 c a s e s a n d a r e v i e w . A n e s t h e s i o l o g y 1 8 : 7 2 3 , 1957.

3 . B R A H A M , M. C. & SAIA, A. — N e u r o l o g i c a l c o m p l i c a t i o n s of e p i d u r a l a n e s -t h e s i a . B r i -t i s h Med. J., Sep-t. 13:657, 1958.

4 . C A T T E R B E R G , J. & I N S A U S T I , T. — P a r a p l e g i a s c o n s e c u t i v a s a a n e s t e s i a p e r i d u r a l ( E s t u d o c l í n i c o y e x p e r i m e n t a l ) . R e v . A s o c i a c i ó n M é d i c a A r g e n t i n a 7 8 : 1 , 1984.

5 . D A V I E S , A.; S O L O M O N , B. & L E V E N E , A. — P a r a p l e g i a f o l l o w i n g e p i d u r a l a n e s t h e s i a . B r i t i s h Med. J. 2:654, 1958.

6 . D A V I S , F . M.: L L L E W E L L I N , R. C. & K I R G I S , H. D. — W a t e r s o l u b l e c o n t r a s t m y e l o g r a p h y u s i n g m e g l u m i n e i o t h a l a m a t e ( C o n r a y ) w i t h m e t h y l - p r e d ¬ nisole a c e t a t e ( D e p o - M e d r o l ) . R a d i o l o g y 9 0 : 7 9 0 5 , 1968.

7 . D R I P P S , R. D. & V A N D A M , L. D. - - L o n g - t e r m f o l l o w - u p of p a t i e n t s w h o r e c e i v e d 10.098 s p i n a l a n e s t h e t i c s . J.A.M.A. 156:1486, 1954.

8 . D R O G U E T , M. P. & D J I N D J I A N , R. — A p r o p s d ' u n m a l a d e a t t e i n t d'a¬ r a c h n o i d i t e s p i n a l e , o p é r é et c o n s i d é r a b l e m e n t a m é l i o r é . R e v . N e u r o l . ( P a r i s ) 1 0 2 : 2 9 5 , 1960.

9 . G R E E N F I E L D , J . G.; R I C K A R D S , A. G. & M A N N I N G , G. B . — T h e p a t h o l o g y of p a r a p l e g i a o c c u r r i n g a s a d e l a y e d s e q u e l a of s p i n a l a n e s t h e s i a , w i t h s p e c i a l r e f e r e n c e t o t h e v a s c u l a r c h a n g e s . J. P a t h . B a c t . 119:107, 1955.

1 0 . H E L L M A N N , K. — E p i d u r a l a n a e s t h e s i a in O b s t e t r i c s : a second look a t 26.127 c a s e s . C a n . A n a e s t h . Soe. J. 12:398, 1965.

1 1 . H O W L A N D , W. J . & CURRY, J. L. — E x p e r i m e n t a l s t u d i e s of P a n t o p a q u e a r a c h n o i d i t i s . R a d i o l o g y 8 7 : 2 5 3 , 1966.

1 2 . J O S E P H , S. I. & D E N S O N , J. S. — S p i n a l a n e s t h e s i a , a r a c h n o i d i t i s a n d p a -r a p l e g i a . J.A.M.A. 168:1330, 1958

1 3 . K E N N E D Y , F . ; S O M B E R G , H . M. & G O L D B E R G , B. R. — A r a c h n o i d i t i s a n d p a r a l y s i s f o l l o w i n g s p i n a l a n e s t h e s i a . J.A.M.A. 129:664, 1945.

1 4 . L E H R E R , G. M.; M A K E R , H. S. & W E I S S B A R T H , S. — B r a i n u p t a k e of Cortisol a n d c o r t i s o n e f r o m t h e C S F a n d s y s t e m i c s i t e s . N e u r o l o g y ( M i n n e a p o l i s ) 2 3 : 63, 1973.

1 5 . L O F S T R O M , B . — C l i n i c a l e v a l u a t i o n of local a n e s t h e t i c s . In B O N I C A , J. J. — R e g i o n a l A n e s t h e s i a . F . A. D a v i s Co., P h i l a d e l p h i a , 1969, p á g . 20-43. 1 6 . L U N D Y , J. S.; E S S E X , H . E. & K E R N O H A N , J . W. — E x p e r i m e n t s w i t h a n e s

t h e t i c s : l e s i o n s p r o d u c e d in s p i n a l c o r d of d o g s b y d o s e of p r o c a i n e h y d r o c h l o r i -d e s u f f i c i e n t t o c a u s e p e r m a n e n t a n -d f a t a l p a r a l y s i s . J.A.M.A. 101:1546, 1933. 1 7 . MCDONALD, A. D. & W A T K I N S . K. H. — A n e x p e r i m e n t a l i n v e s t i g a t i o n i n t o

t h e c a u s e of p a r a l y s i s f o l l o w i n g s p i n a l a n a e s t h e s i a . B r i t i s h J. S u r g . 2 5 : 8 9 7 , 1938.

1 8 . M E Y E R , A. — I n t o x i c a t i o n s . In B L A C K W O O D , W.; M A c M E N E M E Y , H . W.; M E Y E R , A.; N O R M A N , R. M. & R U S S E L L , D. S. — G r e e n f i e l d s N e u r o p a t h o l o g y . 2 n d ed. E d w a r d A r n o l d P u b l i s h e r s , L o n d o n , 1963, p á g . 249-251.

1 9 . M O O R E , D. C. & B R I D E N B A U G H , L. D . -— S p i n a l ( s u b a r a c h n o i d ) b l o c k : a r e v i e w of 11.574 c a s e s . J.A.M.A. 1 9 5 : 9 0 7 , 1966.

2 0 . N E L S O N , D.; V A T E S JR., T. & T H O M A S JR., R. — C o m p l i c a t i o n s from i n t r a -t h e c a l s -t e r o i d -t h e r a p y in p a -t i e n -t s w i -t h m u l -t i p l e s c l e r o s i s . A c -t a N e u r o l . S c a n d . 49:176, 1973.

2 1 . N I C H O L S O N , M. J. & E V E R S O L E , V. H . — N e u r o l o g i c c o m p l i c a t i o n s of s p i n a l a n e s t h e s i a . J . A . M . A . 1 3 2 : 6 7 9 , 1964.

2 2 . P A D D I S O N , R. M. & A L P E R S , B . J. — R o l e of i n t r a - t h e c a l d e t e r g e n t s in p a t h o g e n e s i s of a d h e s i v e a r a c h n o i d i t i s . A r c h . N e u r o l . P s y c h i a t . ( C h i c a g o ) 7 1 : 87, 1954.

2 4 . R I T C H I E , J. M.; C O H E N , P. J. & D R I P P S , R. D . — L o c a l A n e s t h e t i c s . In GOODMAN, L. S. & G I L M A N , A. — T h e P h a r m a c o l o g i c a l B a s i s of T h e r a p e u t i c s . 4 t h Ed. T h e M a c M i l l a n Co., N e w York, 1970, p á g . 371-401.

2 5 . S C H W A R T Z , G. A. & B E V I L A C Q U A , J . E. — P a r a p l e g i a f o l l o w i n g s p i n a l a n e s t h e s i a . A r c h . N e u r o l . ( C h i c a g o ) 10:308, 1964.

2 6 . S H A N T H A , T. R. & E V A N S , J. A. — T h e r e l a t i o n s h i p of e p i d u r a l a n e s t h e s i a to n e u r a l m e m b r a n e s a n d a r a c h n o i d vili. A n e s t h e s i o l o g y 3 7 : 5 4 3 , 1972. 2 7 . T S U K A G O S H I , H . ; M O R I , H.; E N O M O T O , A.; N A K A O , K. & F U K U S H I M A , N .

— S e n s o r y p o l y r a d i c u l o n e u r o p a t h y f o l l o w i n g s p i n a l a n e s t h e s i a . N e u r o l o g y ( M i n -n e a p o l i s ) 20:266, 1970.

2 8 . U R Q U H A R T - H A Y , D. — P a r a p l e g i a f o l l o w i n g e p i d u r a l a n a l g e s i a . A n e s t h e s i a 2 4 : 4 6 1 , 1969.

2 9 . W E I S S , R. M.; S W E E N E Y , L. & D R E Y F U S S , M. — C i r c u n s c r i b e d a d h e s i v e s p i n a l a r a c h n o i d i t i s . J. N e u r o s u r g . 1 0 : 4 3 5 , 1962.

3 0 . W I N K E L M A N , N . W. — N e u r o l o g i c s y m p t o m s f o l l o w i n g a c c i d e n t a l i n t r a s p i n a l d e t e r g e n t i n j e c t i o n . N e u r o l o g y ( M i n n e a p o l i s ) 2 : 2 8 4 , 1952.

3 1 . W I S E , B . L. & S M I T H , M. — S p i n a l a r a c h n o i d i t i s o s s i f i c a n s . A r c h . N e u r o l . ( C h i c a g o ) 1 3 : 3 9 1 , 1965.

3 2 . Y A S K I N , H . A. & A L P E R S , B . J . — N e u r o p s y c h i a t r y c o m p l i c a t i o n s f o l l o w i n g s p i n a l a n e s t h e s i a . A n n . I n t . Med. 23:184, 1 9 4 5 .