Acute bleeding after spinal anaesthesia due to puncture of unsuspected lumbar myxopependimoma

Editor, A 33-year-old male patient, with the American Society of Anesthesiologists (ASA) status 1, nonsmoker, height 1.70 m and weight 80 kg, was admitted to the hospital with a fractured right tibia bone following a motor bike accident. Surgery was programmed for the next day. After a local infiltration with lidocaine 2%, spinal anaesthesia was performed with the patient in a sitting position. A 27 G sprotte needle was inserted into the lumbar interspace L3\L4. Entrance into the subarachnoid space was confirmed by free and clean flow of cerebrospinal fluid (CSF). After gentle aspiration to check the needle tip location, local anaesthetic (isobaric marcaine 0.5%, 20 mg) was slowly injected. No paresthesia or bone contact occurred. A sensory block to T8 level was reached. Motor and sensory recovery occurred regularly after 8 h. Subcutaneous morphine (10 mg) was given immediately after spinal block, and 10 mg after 8 h management. The postoperative course was uneventful and the patient was discharged from the hospital after 2 days. On the third day, the patient started to complain of pain and paresthesias in the lower extremities. Symptoms exacerbated over the next 12 h. The patient decided to go back to hospital only on the evening of the fourth day. On admittance, clinical examination showed cauda equina syndrome with urinary retention. Visual Analogue Score (VAS) was 6\7. Routine blood tests and vital parameters were all normal. MRI (magnetic resonance imaging) scan demonstrated a neuraxial haematoma. The MRI localisation was either subdural or epidural, and as only partial uptake of the radiocontrast material occurred, this suggested the presence of a concomitant intradural pathological process (Figs 1 and 2).Fig. 1Fig. 2Urgent L3-L4 laminectomy was performed. Opening of the dura revealed the haematoma intermingled with a greyish, elongated, thinly encapsulated tumour covered by adherent cauda equina nerve roots. Using blunt and sharp microinstruments, the mass was gradually mobilised and then gently removed after section of the filum terminale. A small tumour fragment had to be left in place in order to avoid injury to a nerve root tightly adherent to the lesion. The surgical procedure lasted 4 h. Nascis II (30 mg kg−1 intravenous bolus and 5.4 mg kg−1 h−1 during the next 24 h) was started during surgery. After surgery, the patient was admitted to the ICU for postoperative monitoring. Neurological condition markedly improved. After 24 h, there was no motor or sensitive impairment. The patient was discharged 2 days later. Histological examinations revealed a myxopapillar ependymoma (WHO 1) with a haematoma in its context and the absence of any malignant degeneration. Discussion The safety of neuraxial blocks has been well established and acknowledged over a series of studies and trials.1–3 Spinal anaesthesia has enjoyed a long history of success and has celebrated a centennial anniversary.2 According to the ASA Closed Claims Project, a structured evaluation of adverse anaesthetic outcomes collected from the closed anaesthesia malpractice insurance claim files, of more than 35 professional liability American companies, haematoma is accounted for 43% of the 84 complications of the neuraxis in regional anaesthesia claims from 1980 to 1999 and resulted in permanent neurologic deficit in 89% of these cases.3 From the ASA claim project database, haematoma was also the most common cause of neuraxial injuries, and the majority (72%) of these cases were associated with either intrinsic or iatrogenic coagulopathy. These results were consistent with the review of the literature by Vanderemeulen et al.,4 in which the authors found that 42 of 61 neuraxial haematomas (68%) were associated with impaired coagulation. Intraspinal haematoma, though rare, is an established complication of lumbar puncture; spinal localisation is extremely uncommon. The commonest site of bleeding is the epidural space. Small-sized needles with pencil-point tip are known to produce the lowest incidence and severity of postspinal headache.5 Even ependymomas are quite rare; in the central nervous system, they account for 3.9% of all neuroepithelial tumours. Ependymomas are well delineated moderately cellular gliomas. Myxopapillar ependymoma (WHO grade I) occurs almost exclusively in the conus cauda phylum terminale, with a generally favourable prognosis. In adults, 60% of ependymomas are tumours of the spinal cord and 40% are intracranial. Spinal ependymomas are found most frequently in patients with neurofibromatosis type 2 and also in persons of the same family, which points to a genetical inheritance of susceptibility to this type of tumour. From the SEER (Surveillance, Epidemiology, and End Results) database, 1402 patients were identified. The incidence rate per 100 000 person-years was significantly higher in male than in female patients (men 0.227 ± 0.029, women 0.166 ± 0.03).6 Clinical manifestations are localisation dependent.7 Various signs and symptoms can develop, especially as a tumour grows and impinges on the spinal cord or on the nerve roots, blood vessels or bones of the spine. Signs and symptoms may include the following: Back pain, often radiating to other parts of the body, usually worse at night. Loss of sensation or muscle weakness, most commonly of the legs. Difficulty in walking, often leading to falls. Loss of bowel or bladder function. Paralysis that may occur in varying degrees and in different parts of the body, depending on nerve compression. Scoliosis or other spinal deformities resulting from large but benign tumours. Back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumours. The pain may be worse at night or on awakening. It may also spread beyond the spine to the hips, legs, feet or arms and may become more severe over time, in spite of treatment. Spinal tumours progress at different rates. In general, malignant tumours grow faster than benign ones. Benign tumours may develop very slowly, sometimes existing for years or even decades before producing any symptoms. The patient in this case report, when was interviewed by the anaesthetist the day before surgery, neither mentioned any underlying neurological symptoms, nor was he specifically questioned on that point by the anaesthetist. Even the questionnaire routinely filled up preoperatively by patients made no reference to possible preexisting neurological complaints. On the day of surgery, the patient opted for a spinal anaesthesia. During recovery in ICU after emergency decompression of the dural haematoma, the patient disclosed for the first time that for the past 2 months he had been suffering from pain in his lower limbs. The pain was exacerbated when driving his car. This case report highlights the importance of an attentive preoperative clinical evaluation of patients undergoing spinal anaesthesia. Specific questions regarding any neurological signs or symptoms should be routinely asked to the patient who is often unaware that they could be of any importance or have any relationship to the surgery he will be undergoing. The preoperative interview, especially of young patients, often tends to be hurried and superficial, all the more so when the disorder concerned is considered ‘minor’. This overconfidence on the part of the anaesthetist can lead to serious intraoperative and postoperative complications. Furthermore, we strongly recommend close clinical surveillance post-anaesthesia, especially when postoperative lumbar radicular symptoms occur.8–11