REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Postoperative
visual
loss
due
to
conversion
disorder
after
spine
surgery:
a
case
report
Dailson
Mamede
Bezerra
a,b,c,∗,
Eglantine
Mamede
Bezerra
d,
Antonio
Jorge
Silva
Junior
d,
Marco
Aurélio
Soares
Amorim
a,
Denismar
Borges
de
Miranda
e,faCentrodeEnsinoeTreinamentoDr.JoséQuinan,Goiânia,GO,Brazil
bDefesaProfissionaldaSociedadedeAnestesiologiadoEstadodeGoiás(2015/2016),Goiânia,GO,Brazil
cUniversidadeEstadualPaulistaJúliodeMesquitaFilho(FMB/Unesp),FaculdadedeMedicina,Botucatu,SP,Brazil
dHospitalAdventistadeBelém,Servic¸odeAnestesiologia,Belém,Pará,Brazil ePontifíciaUniversidadeCatólicadeGoiás(PUC/GO),Goiânia,GO,Brazil
fUniversidadeFederaldeGoiás(UFG),Goiânia,GO,Brazil
Received1February2015;accepted3March2015 Availableonline15September2016
KEYWORDS
Generalanesthesia; Blindness;
Conversiondisorder; Laminectomy; Decubitusventral
Abstract
Backgroundandobjective: Patients undergoing spinal surgeries may develop postoperative visualloss.Wepresentacaseoftotalbilateralvisuallossinapatientwho,despitehaving clini-calandsurgicalriskfactorsfororganiclesion,evolvedwithvisualdisturbanceduetoconversion disorder.
Casereport: A malepatient,39yearsold, 71kg, 1.72m, ASAI,admittedtoundergofusion anddiscectomyatL4---L5andL5---S1.Venoclysis,cardioscopy,oximetry,NIBP;inductionwith remifentanil,propofolandrocuronium;intubationwithETT(8.0mm)followedbycapnography andurinarycatheterization fordiuresis.Maintenancewithfulltarget-controlledintravenous anesthesia.Duringfixationandlaminectomy,thepatientdevelopedseverebleedingand hypo-volemicshock.After30min,hemostasisandhemodynamicstabilitywasachievedwithinfusion ofnorepinephrine,volumeexpansion,andbloodproducts.IntheICU,thepatientdeveloped mentalconfusion,weaknessinthelimbs,andbilateralvisualloss.Itwasnotpossibleto iden-tifyclinical,laboratoryorimagefindingsoforganiclesion.Heevolvedwithepisodesofanxiety, emotionallability,andlanguageimpairment;thehypothesisofconversionsyndromewithvisual component was raised afterpsychiatric evaluation.The patient hadcompleteresolution of symptomsaftervisualeducation andintroductionoflowdosesofantipsychotic, antidepres-sant,andbenzodiazepine.Othersymptomsalsoregressed,andthepatientwasdischarged12 daysaftersurgery.After60days,thepatienthadnomoresymptoms.
∗Correspondingauthor.
E-mail:dailsonbezerra@yahoo.com.br(D.M.Bezerra). https://doi.org/10.1016/j.bjane.2015.03.005
Conclusions:Conversiondisordersmayhavedifferentsignsandsymptomsofnon-organicorigin, includingvisualcomponent.Itisnoteworthythattheoccurrenceofthistypeofvisual dysfunc-tioninthepostoperativeperiodofspinalsurgeryisarareeventandshouldberememberedas adifferentialdiagnosis.
©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Anestesiageral; Cegueira; Transtorno conversivo; Laminectomia; Decúbitoventral
Perdavisualconversivaempós-operatóriodecirurgiadecoluna:relatodecaso
Resumo
Justificativaeobjetivo:Pacientes submetidos a procedimentos cirúrgicos espinhais podem evoluircomperdavisualpós-operatória.Apresentamosquadrodeperdavisualbilateraltotal empacienteque,apesardeapresentarfatoresderiscoclínicosecirúrgicosparalesãoorgânica, evoluiucomdistúrbiovisualconversivo.
Relatodecaso:Masculino,39anos;71kg;1,72m;ASAI,admitidopararealizac¸ãodeartrodese ediscectomiaemL4-L5eL5-S1.Venóclise,cardioscopia,oximetria,PANI;induc¸ãocom remifen-tanil,propofolerocurônio;intubac¸ãocomTOT8,0mmseguidaporcapnografiaediuresepor sondagemvesical.Manutenc¸ãoemanestesiavenosatotalalvo-controlada.Durantefixac¸ãoe laminectomia,evoluiucomimportantesangramentoechoquehipovolêmico.Após30minutos obteve-sehemostasiaeestabilidadehemodinâmicacominfusãodenoradrenalina,expansão volêmicae hemoderivados.Na UTI,evoluiu comconfusãomental,fraqueza em membrose perdavisualbilateral.Nãofoipossívelidentificarachadosclínicos,laboratoriaisoudeimagem paralesãoorgânica.Evoluiucomepisódiosdeansiedade,labilidadeemocionaledistúrbiode lin-guagem;foiaventadahipótesedesíndromeconversivacomcomponentevisualapósavaliac¸ão psiquiátrica. Apresentou melhoria total desintomas visuais apóseducac¸ão eintroduc¸ão de baixasdosesdeantipsicótico,antidepressivoebenzodiazepínico.Houveregressãodosdemais sintomascomaltanodécimosegundodiapós-operatório.Encontrava-seassintomáticoapós60 dias.
Conclusões:Distúrbiosconversivospodemapresentardiversossinaisesintomasdeorigemnão orgânica,incluindocomponentevisual.Destaca-sequeaocorrênciadessetipodedisfunc¸ão visualnopós-operatóriodecirurgiasespinhaiséeventoraroedeveserlembradocomo diag-nósticodiferencial.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Patientsundergoing spinal surgery may rarely experience postoperativevisualloss.1Theetiologicalfactorsrelatedto theselesionshave beendescribed mostlyasorganic,with objectiveidentificationofinjurythroughclinical examina-tionandimagingtests.2---6
However, there are situations in which the identifi-cation of an organic cause for the visual loss is not possible.7 In these situations, the deficit is described as being ‘‘functional’’. This term is intended to combine thefollowingconditions:conversiondisorder(somatoform), factitious and simulation disorder.7,8 Compared with fac-titious and simulation disorders, the conversion disorder symptoms are unintentional. However, often this distinc-tionisdifficult,requiringtheexperiencedpsychiatricstaff expertise.
This report aims todraw attention to the inclusion of visual loss from conversion disorder as rare differential
diagnosisincasesofpostoperativevisualloss.Insuchcases, thepresenceofahighlevelofsuspicioninadditionto neuro-ophthalmologicalexaminationabletoexcludethepresence ofpositivesignsfororgandamageiscriticalforearly diag-nosisandtreatment.
Case
report
Malepatient,39years,71kg, 1.72m,presenting with his-toryofradiculopathyandpersistentmotordeficitintheleft lowerlimb,wasadmittedforfusionanddiscectomyatboth levelsL4---L5andL5---S1.
Inthepre-anestheticevaluation, hehadno comorbidi-ties, allergies or previous surgeries. The patient denied continueduseofmedication,andlaboratorytestswere nor-mal. Magnetic resonance imaging (MRI) showed extrusive foraminalherniationtotheleftatL4---L5andL5---S1.
neuromuscularblockingmonitor,andnoninvasivepressure, induction of anesthesia was performed with remifentanil (0.5mcg.kg−1.min−1), lidocaine 2% without
vasoconstric-tor(2mL),propofol(4mcg.mL−1),androcuronium(50mg).
Endotrachealintubationbydirectlaryngoscopywith8.0mm uncuffed tube. Maintained in total intravenous anesthe-sia with target controlled propofol (2---2.5mcg.mL−1) and
remifentanil (0.05---0.5mcg.kg−1.min−1). Additional
mon-itoring included capnography and catheterization after anesthesiainduction.
ThepatientwasplacedinthepronepositiononWilson’s supportwithfacerestingonmopwithoutdirectcompression of theocular globes, withperiodic review ofthe position throughoutthesurgery.
Duringpedicle fixation andlaminectomy,a large quan-tityofbleedingwasseen.Fluidreplacementwasinitiated withcrystalloids associated withinfusion of aminocaproic acid(5gfor1hfollowedby1g.h−1)untiltheendofsurgery.
Thepatientprogressedwithhemorrhagichypovolemicshock (heart rate 150bpm and blood pressure 60×40mmHg).
Withtheadministrationofcrystalloids(8500mL),twounits of packed red blood cells, and infusion of noradrenaline (0.1---0.3mcg.kg−1.min−1)therewasresolutionofsymptoms
after 30min. Surgical procedure of 6h duration and total blood loss estimated at 2000mL. Satisfactory hemostasis wasobtained attheendofsurgery.Central venousaccess andinvasivebloodpressureweremadeonlyafterthe pro-cedureduetothepronepositionduringtheintraoperative period.
The patient was taken to the intensive care unit (ICU) intubated and receiving norepinephrine (0.1mcg.kg−1.min−1). In the immediate postoperative
period, he required additional fluid replacement with crystalloids (1000mL), one packed red blood cells, and maintenanceoflow-dosenorepinephrine.Laboratorytests revealedhypokalemiaandhypocalcemia,whichwere prop-erly corrected. At theend of the firstpostoperative day, the patient was stable, without vasoactive drug support, andwassuccessfullyextubated.Aspartofthestrategyfor multimodalanalgesia,oralpregabalin(75mg12/12h) and intravenousmorphine(10mg4/4h)wereinitiated.
Onthesecondpostoperativeday,heshowedaslight men-tal confusion and loss of strength in the upper and left lowerlimbs.Weorderedneurologicalmonitoringandabrain MRI,whichshowednoanatomicalchangesthatcouldjustify thesymptoms. Weoptedfor the suspensionof pregabalin andmorphineforpossibleassociationwithcognitive impair-ment.
Onthethirddayaftersurgeryhehadpersistentmental confusion,motorweaknessandmildanterogradeamnesia, complaining of complete visual impairment. Ophthalmo-logical examination denied perception of visual stimuli in both eyes, with ectoscopy, duction, convergence, and retinalmappingunchanged;pupilswithphotomotor reflec-tionunchanged.Brainmagneticresonanceangiographyand carotidDopplershowednochangessuggestiveoforgan dam-age.Monitoringandphysicaltherapy werestartedtohelp motorrecovery.
The patient was discharged from the ICU at the end ofthethird postoperativedaywithlaboratory parameters within normal limits and without significant pain com-plaints (1---2 in the visual numericalscale). On the fourth
postoperative day he evolved with insomnia, agitation, emotionallability(tearfulandanxious),hospitaldischarge desire, language disorder (‘‘humming’’ and ‘‘infantile’’ speech),motordeficitsmaintenance,andpersistencetotal visualdeficit.
Behavioralinconsistencieswereobserved,suchas inabil-ity to resistthe passive movement of limbs, but able to standand walk withassistance, follow people witheyes, andidentifycolorsofobjects.Subjectedtopsychiatric eval-uation,whichsuggestedthehypothesis ofvisualloss from conversion disorder, he started taken haloperidol (0.5mg 12/12h) and escitalopram (5mg.day−1) after family and
patientcounseling,whodidnotadheretothepsychotherapy indicatedbytheteamaspartofmultimodaltreatment.
Thenextday,heachievedfullrecoveryofvisualacuity, maintainingintermittentepisodesofanxietyand psychomo-toragitation (specially at night)along the fifth andsixth postoperativeday;so,diazepam(5mgatnight)wasadded. Heremainedhospitalizeduntilthetwelfthpostoperative day,withgradualrecovery ofother conversionsymptoms. Atdischarge,thesymptomswererestrictedtoonlyamild motordeficitandparesthesiaofleftlowerlimbrestrictedto L4---S1dermatomes,symptomsreportedpreoperatively.The patientunderwent outpatientmonitoring withpsychiatry, physiotherapy andsurgical team. He remainedon contin-uous use of escitalopram (5mg.day−1). After 60 days of
outpatientfollow-up,hehadnovisual,cognitiveormotor deficit.
Discussion
Visual losshas been described asa postoperative compli-cationof varioussurgicalprocedures,usuallywithlimited recovery.9,10However,itsoccurrenceisrare,withreported incidenceofupto0.2%afterspinalsurgery.8
Probably due to the incomplete knowledge of its eti-ology, is not always possible to unequivocally identify a causativefactor.11,12However,themain organicconditions involvedin itspathogenesis are:retinal ischemia,2,3 ante-riorandposteriorischemicopticneuropathy,4,5andcortical blindness.6 Visual deficit may be unilateral or bilateral, havevaryingdegreesofseverity,andaffectindiscriminately bothsexes.The main riskfactorsidentifiedareprolonged surgeries, anemia, hypotension, hypoxia, atherosclerosis, fluid overload, and direct ocular compression.13,14 Some medicationsused perioperatively, such as anticonvulsants andopioids, maylead tovisualdisturbances. However,in suchcases,improvement tends tooccurwith thesedrugs discontinuation.15
Theconversionsyndromeischaracterizedbyneurological symptomswithnocorrelationwithneurologicaldisease,but itcausesdiscomfortorfunctionaldamagetothepatient.16 Patientswhoareyoung,female,andwithlowsocioeconomic statusarethemostsusceptible;theestimatedincidencein thegeneralpopulationisbetween4---12/100,000.17 Depres-sion,anxiety,andinterpersonalconflictsfrequentlyworsen the symptoms, which may include non-epileptic seizures, weakness,paralysis, movement disorders, language disor-ders,cognitiveandsensorysymptoms.18
Amongthesensorysymptoms,visuallossfromconversion disorderisrelativelycommonandmayincludevisual blur-ring,diplopia,nystagmus,visualfielddefects,andcomplete visual loss.8,18,19 The diagnosis of visual loss from conver-sion disorder must be corroborated by ophthalmological examinationthatdemonstratesunequivocallynormalvisual function,inadditiontopsychiatricevaluationtodiscardthe presenceoffactitiousorsimulationdisorderforsecondary gains,8asoccurredinthiscase.
Postoperative conversion disorder is an unusualevent, buthasagoodprognosiswhendiagnosedandtreated prop-erly.Ithasbeendescribedafterawidevarietyofsurgical procedures,bothinadultsandchildren.20,21 Althoughmost oftenrelatedtogeneralanesthesia,itmayalsooccurafter regionalanesthesia.22 Inthis patient,itwasan important differentialdiagnosis,becauseimprovementonlyoccurred withspecifictreatmentforconversionsyndrome.
Thediagnosisrequiresahighlevelofsuspicion.Several simpletestscanbeappliedtoaidinthedifferentiationof visuallossduetoorganicorconversioncauses.18,22However, inthispatient,the applicationof theseclinical trialswas waivedby the psychiatry,asthe historyand overall clini-calpicture of thepatient stronglyindicated symptoms of conversiondisorder.
Observationalstudiessuggestasafirst-linetreatmentof conversiondisorders thepatient’s educationregarding his diagnosis,always seekingtocreate atherapeutic alliance andadding amultidisciplinary team.18,23 In addition, cog-nitivebehavioral therapy andmotor physical therapy,the latterin thepresenceof motordeficit, canbringbenefits suchassecond-linetreatmentwhen patient’sclarification isinsufficient.24,25 However,it isnot unusualthatthereis resistancetotheseconservativemeasuresinseverecases; in thissituation, it is suggested asa third-line treatment theuseofpharmacologicalagents.Antidepressantsaremost commonlyused,althoughtherearereports26onthe effec-tiveuse of other classes ofdrugs, such asantipsychotics, anticonvulsants,andsedatives.27---29
Due to the severity of visual symptoms and refusal to adheretocognitivebehavioraltherapy,inthiscasewechose theimmediatestartofdrugcombinationwithantipsychotic andantidepressantinlowdosesforimmediateeffect,and maintenance of antidepressant as mid-term therapy.26---29 The total recovery of this patient is consistent with the majorityofreportsinwhichtherewasspecificdiagnosisand treatmentforconversionsyndrome.
Postoperativevisuallossfromconversiondisorderafter spinalsurgeryisaclinicalcasenotyetreported.Thiscase reportintendedtoalertprofessionalsinvolvedinthe peri-operativeperiodofthistypeofsurgeryforthepossibilityof sucharareoccurrence.Highlevelofsuspicionand involve-mentofamultidisciplinaryteam(anesthesiology,neurology,
ophthalmology, psychiatry, psychology,physiotherapy, and nursing)arekeytoearlydiagnosisandeffectivetreatment ofthistypeofdisease,whichgenerallyhaveagood progno-sis.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Katz DA, Karlin LI. Visual field defect after posterior spine fusion.Spine.2005;30:E83---5.
2.BlauthCI,ArnoldJV,SchulenbergWE,etal.Cerebral microem-bolismduring cardiopulmonary bypass:retinal microvascular studiesinvivowithfluoresceinangiography.JThoracCardiovasc Surg.1988;95:668---76.
3.OzcanMS,PraetelC,BhattiT,etal.Theeffectofbody inclina-tionduringpronepositioningonintraocularpressureinawake volunteers:acomparisonoftwooperatingtables.AnesthAnalg. 2004;99:1152---8.
4.JohnsonLJ,ArnoldAC.Incidenceofnonarteriticandarteritic anteriorischemicopticneuropathy:apopulation-basedstudy inthestateofMissouriand LosAngelesCounty,California.J ClinNeuroophthalmol.1994;14:38---44.
5.SchobelGA,SchmidbauerM,MillesiW,etal.Posteriorischemic opticneuropathyfollowingbilateralradicalneckdissection.Int JOralMaxillofacSurg.1995;24:283---7.
6.Newman MF, Mathew JP, Grocott HP, et al. Central ner-vous system injury associated with cardiac surgery. Lancet. 2006;368:694---703.
7.Bruce BB, Newman NJ. Functional visual loss. Neurol Clin. 2010;28:789---802.
8.BergKT,HarrisonAR,LeeMS.Perioperativevisuallossinocular andnonocularsurgery.ClinOphthalmol.2010;4:531---46. 9.RothS,ThistedRA,EricksonJP, etal.Eyeinjuries afternon
ocularsurgery;astudyof60,965anestheticsfrom1988to1992. Anesthesiology.1996;85:1020---7.
10.ShmygalevS,HellerAR.Perioperativevisuallossafternonocular surgery.Anaesthesist.2011;60:683---94.
11.Kawaguchi M, Hayashi H, Kurita N, et al. Postopera-tivevisual disturbances afternonophthalmic surgery. Masui. 2009;58:952---61.
12.GroverV,JangraK.Perioperativevisionloss:acomplicationto watchout.JAnaesthesiolClinPharmacol.2012;28:11---6. 13.LeeL,RothS,ToddM,etal.Riskfactorassociatedwithischemic
optic neuropathyafter spinal fusion surgery. Anesthesiology. 2012;116:15---24.
14.Apfelbaum JL, Roth S, Connis RT, et al. Practice advisory for perioperative visual loss associated with spine surgery: anupdated reportbythe AmericanSociety of Anesthesiolo-gistsTaskForceon PerioperativeVisual Loss.Anesthesiology. 2012;116:274---85.
15.TothC.Pregabalin:latestsafetyevidenceandclinical implica-tionsforthemanagementofneuropathicpain.TherAdvDrug Saf.2014;5:38---56.
16.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;2013.
17.Carson A, Stone J, Hibberd C, et al. Disability, distress, and unemployment in neurology outpatients with symptoms ‘‘unexplainedbyorganicdisease’’.JNeurolNeurosurg Psychi-atry.2011;82:810---3.
19.Sharpe M, WalkerJ, Williams C,et al. Guidedself-help for functional(psychogenic) symptoms: arandomized controlled efficacytrial.Neurology.2011;77:564---72.
20.MaddockH,CarleyS,McCluskeyA.Anunusualcaseofhysterical postoperativecoma.Anesthesia.1999;54:717---8.
21.Judge A, Spielman F.Postoperative conversion disorder ina pediatricpatient.PaediatrAnaesth.2010;20:1052---4. 22.Chen CS, Lee AW, Karagiannis A, et al. Practical
clini-cal approaches to functional visual loss. J Clin Neurosci. 2007;14:1---7.
23.AybekS,HubschmidM,MossingerC,etal.Earlyintervention forconversiondisorder:neurologistsandpsychiatristsworking together.ActaNeuropsychiatr.2013;25:52---6.
24.Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilotRCT.Neurology.2010;74:1986---94.
25.Czarnecki K, Thompson JM, Seime R, et al. Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol. Parkinsonism Relat Disord. 2012;18:247---51.
26.Voon V, Lang AE. Antidepressant treatment outcomes of psychogenic movement disorder. J Clin Psychiatry. 2005;66:1529---34.
27.OulisP,KokrasN,PapadimitriouGN,etal.Adjunctivelow-dose amisulprideinmotorconversiondisorder.ClinNeuropharmacol. 2009;32:342---3.
28.MessinaA,FoglianiAM.Valproateinconversiondisorder:acase report.CaseRepMed.2010;2010:1---3.
