Rev. Bras. Anestesiol. vol.67 número2

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Neuraxial

anesthesia

after

local

anesthesia

for

management

of

percutaneous

vertebroplasty

complication

during

vertebroplasty

Hüseyin

Balkarlı

_,

_Mesut

_Kılıc

_¸

_{, ˙Ibrahim}

_Öztürk

a_{AkdenizUniversityFacultyofMedicine,OrthopaedicsandTraumatology,Antalya,Turkey} b_{OndokuzmayısUniversityFacultyofMedicine,OrthopaedicsandTraumatology,Samsun,Turkey}

c_{Dıs¸kapıYıldırımBeyazıtEducationandResearchHospital,AnesthesiologyandReanimation,Ankara,Turkey}

Received9June2014;accepted16July2014 Availableonline27October2014

KEYWORDS

Neuraxialanesthesia; Percutaneous vertebroplasty; Vertebra; Fracture

Abstract Percutaneousvertebroplastyisarelativelysafe,simpleandcommonlyperformed interventional procedurefor themanagementofvertebral compressionfractures. However, seriouscomplicationsarerarely reportedintheprocedure.Thosearepulmonaryembolism, severeinfection,paraplegiaandanoccurrenceofanewfractureinanadjacentvertebraafter vertebroplasty.Acutecomplicationsaregenerallyassociatedwiththeprocedure.Wepresent thecaseofneuraxialanesthesia,developedafterlocalanesthesiawith8mLof2%prilocaine, in a68-year-old woman who underwent percutaneous vertebroplastyafter anosteoporotic collapsedfractureintheL1vertebraduetotrauma.Toourknowledge,thisisthefirstcasein

theliterature.

©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE Bloqueioneuraxial; Vertebroplastia percutânea; Vértebra; Fratura

Bloqueioneuroaxialapósanestesialocalparamanejodecomplicac¸ão

devertebroplastiapercutâneadurantevertebroplastia

Resumo Vertebroplastia percutânea é um procedimento intervencionista relativamente seguro, simples e comumente realizado para tratar fraturas por compressão vertebral. No entanto, as complicac¸ões graves relacionadas ao procedimento são raramente relatadas, incluindoembolia pulmonar,infecc¸ãograve,paraplegiaeaocorrênciadeuma novafratura emvértebraadjacenteapósavertebroplastia.Complicac¸õesagudassãogeralmenteassociadas aoprocedimento.Apresentamosocasodebloqueioneuroaxial,realizadoapósanestesialocal

∗_{Correspondingauthor.}

E-mail:drozturk28@gmail.com(˙I.Öztürk).

http://dx.doi.org/10.1016/j.bjane.2014.07.007

0104-0014/©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC

206 H.Balkarlıetal.

com8mLdeprilocaínaa2%,emumamulherde68anosdeidade,submetidaàvertebroplastia percutâneaapósfraturaosteoporóticanavértebraL1devidoatrauma.Deacordocomnossa

pesquisa,esteéoprimeirocasonaliteratura.

©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Percutaneous vertebroplasty (PV) is a relatively safe, simple,and commonly performedprocedure for the man-agement of vertebral compression fractures, but serious complications have been reported, including pulmonary embolism,1 _{severe infection,}2 _paraplegia3 _{and an}

occur-rence of a new fracture in an adjacent vertebra after vertebroplasty.4_{Acutecomplicationsaremostlyrelatedto}

surgicalprocedures,whichincludeleakageofbonecement, infection,andfracturealongthepathofthevertebroplasty cannula.5,6

We present a rare case of neuraxial anesthesia corre-latedwith localanesthesiaduring a surgical PV usingthe transpedicularapproach.

Case

report

A68-year-oldand75kgweighingfemalepatientwas admit-ted to the Emergency Department of Tavas Community Hospitalwithbackpainduetotraumafollowingfallingdown athome.Thepatienthadanosteoporoticcollapsedfracture intheL1 vertebra,which wastreated conservativelywith

bedrest,corsetandanalgesicmedications.Atthe3rdweek follow-up examination, pain had not reduced and onthe directradiographmorethan50%ofthefracturedL1

verte-brawasobservedtohavecollapsedcomparedtotheupper adjacent vertebra(Fig. 1). PV was recommended for the patient.

At the preoperative evaluation of patient, laboratory tests, electrocardiogram and X-ray of lung were normal. Therewasnochronicsystemicdisease.Andherphysical sta-tuswasevaluatedaslevel1accordingtoAmericanSociety ofAnesthesiologist’sscale.Thepreoperativevisualanalogue painscalescore(VAS)was8.Afterobtaininginformed con-sent, patient’s fracture line waslocated with fluoroscopy inpronepositionandthenunderfluoroscopiccontrol,local anesthesiaof 8mL of 2% prilocaine wasapplied fromthe pedicleentranceasfarasthesubcutaneoustissue.No neu-rologicaldeficitwasdeterminedfollowinglocalanesthesia. Afterlocationofthepedicleentranceofthefractured ver-tebraunderfluoroscopy, an11G needlewasentered from thepedicle.Whentheneedlereached2/3anteriorofthe vertebralcorpusonthelateralview,theanterior---posterior viewwasregarded and thatthe tipof the needle wasat thesamelevelasthespinousprocess.Theneedleposition wascheckedbyfluoroscopy.Atthisstage,theneurological examinationofthepatientwasnormal.Afterconfirmation

oftheneedletiplocation,8mLofcementwasinjectedinto thefractureline(Fig.2).

During and following the cementing, the neurological examinationofthepatientwasnormal.Aftersettingofthe cement,thepatientwasplacedinasupineposition. Imme-diatelyafterthepatientwaspositionedsupine,abilateral lowerextremitylossofstrength(2/5)andsensationdeficit occurred.Itwasnoticedbytheoperatorduringneurological examination.Bloodpressurewasmeasuredas90/50mmHg and500mLof0.9%NaClwasadministered.Asthesensation loss,atT10levelatfirstexamination,reacheduptoT5.The

patientwasmovedintothebeach-chairpositiontoprevent furtherdevelopmentofneuraxialblock.

The patient was again evaluated neurologically, and bilateral loss of strength (0/5) in the lower extremities and anesthesia were observed. 6mg betamethasone was administered intramuscularly. The patient was evaluated with direct radiographs at operating theater and cement wasnotobserved incanal (Fig.3). 30min aftertheonset of the sensation deficit, blood pressure was measured as 110/90mmHgandthedeficithadreturnedtothelevelofthe umbilicus.

On evaluation of patient by computer tomography, no cement was observed in canal (Fig. 4). At the 4th hour of follow-up sensation and motor deficit was completely resolved. The patient wasmobilized. We didnot observe hypotension or bradycardia and no inotropic drug was needed.

Discussion

Vertebroplastyhasbeenwidelyusedtotreatvertebralbody compression fractures (VCFs) caused by varied patholo-gies includinghemangioma, multiple myeloma, osteolytic metastases,and primaryorsecondary osteoporosis.7_VCFs

arethemostcommontypeofosteoporoticfractures, result-ingin severeback pain,spinaldeformity,muscleatrophy, prolonged hospitalization, and potential risk of increased mortality.8

Inmeta-analysisofPV,lowcomplicationrateof0.4---3.8% hasbeenreported.9_{OverallcomplicationratesduetoPVare}

Figure1 (A)AcuteL1fracture.(B)After3weeksconservativetreatment.

Inliterature,nopatienthasbeenreportedwith neurax-ialanesthesiadevelopmentassociatedwithlocalanesthesia during PV. The significance of this is that a neurological injuryassociatedwiththeguideusedduringtheprocedure maybeconfusedwithneurologicalinjurywhichmayoccur after leakage of the cement into thecanal and a second operationsuchasopensurgeryisrequired.Differential diag-nosisshouldcertainlybemadefortheseabove-mentioned

complications which may arise following PV and other neurologicalinjurieswhichoccurduringPV.Ifthereare neu-rologicaldeficits which occur during PV and this event is consideredtobeassociatedwithlocalanesthetic,thelevel ofneuraxialanesthesiamaybeincreasedandcomplications associatedwiththeincreasedlevelshouldbekeptinmind, thepatientshouldbecloselymonitored,andanesthesia spe-cialistmustcertainlyconsultthepatient.

208 H.Balkarlıetal.

Figure3 (A)PostoperativeX-ray(AP).(B)PostoperativeX-ray(lateral).

Figure4 (AandB)PostoperativeCT.

Conclusion

Inourknowledge,thisisthefirstneuraxialanesthesiacase duetolocalanesthesiaafterPV intheliterature.Ifthere isnocementintothecanal,neuraxialanesthesiashouldbe keptinmind.Atthispoint,radiopaqueagentmaybeuseful beforeinjectionoflocalanestheticdrugforconfirmingthe placeof needle’stip,topreventan inadvertentneuraxial anesthesia.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

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6.Tanigawa N,KariyaS,KomemushiA, etal.Cement leakagein percutaneousvertebroplastyforosteoporoticcompression frac-tureswithorwithoutintravertebralclefts.AJRAmJRoentgenol. 2009;193:W442---5.

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