NEUROLOGICAL COMPLICATION FOLLOWING TOTAL HIP-ARTHROPLASTY UNDER CATHETER EPIDURAL-ANESTHESIA

This case report describes paralysis of the plantar flexors and extens ors after a total hip replacement in a 33-year-old woman performed und er epidural anaesthesia (PDA), Six years previously, the patient had u ndergone a bone marrow transplantation for chronic myeloid leukaemia. She had developed a deep vein thrombosis, a pulmonary embolus, and a s evere graft-versus-host reaction of the skin, leading to markedly redu ced mouth opening. The hip operation was performed using PDA following antithrombotic prophylaxis with low-molecular-weight heparin, Blood c ould initially be aspirated after advancing the PDA catheter, and a se cond puncture of the epidural space 1 segment higher enabled correct p lacement of the catheter. The patient received 500 ml Dextran 60 perio peratively and the operation was completed without any further problem s. The PDA catheter was removed 2 h after the operation following the return of movement of both thighs. Fourteen hours after the completion of surgery it was noticed that the dressing over the epidural punctur e site was blood-stained, the patient was incontinent, and complete lo ss of movement of the operated leg was present, An epidural haematoma was the suspected cause, but could not be definitely confirmed by a CT scan. Nevertheless, a laminectomy was undertaken to evacuate the susp ected haematoma. As expected, tracheal intubation was only possible br onchoscopically. Intraoperatively, some low-grade epidural oozing at t he level of the initial puncture site was observed, and a hemilaminect omy of 5 was performed. For the first time postoperatively, the bleedi ng time was measured and was markedly prolonged to 20 min (as describe d by Mielke, normal value up to 8 min). A coagulopathy was suggested, with the differential diagnosis of impaired platelet function. The par alysis of the plantar flexors and extensors and some sensory loss were still present 6 months after the operation, It remains uncertain whet her the PDA in a patient receiving low-molecular-weight heparin result ing in a the suspected epidural haematoma was the cause of the neurolo gical sequelae and in agreement with the consultant neurologist, we be lieve that a direct traumatic lesion of the L5/S1 segment or damage to the sciatic nerve are also likely causes of the symptoms, Undoubtedly , the lack of adequate postoperative neurological monitoring and the i ntraoperative administration of dextran despite the known epidural vas cular lesion deserve criticism, This case report demonstrates the ofte n complex development of neurological complications after nerve blocks , where a definite cause can frequently not be determined.