Eye Problem Following Foot Surgery -- Abducens Palsy as a Complication of Spinal Anesthesia

Kamil Cagri Kose, MD; Oguz Cebesoy, MD; Engin Karadeniz, MD; Sinan Bilgin, MD

Disclosures

October 17, 2005

Discussion

Post-LP complaints may also be called the syndrome of intracranial hypotension, which encompasses a triad of headache, ear problems, and ocular symptoms.[6]

Differential diagnosis of sixth nerve palsy includes neoplasms, infiltrative and inflammatory lesions, infection, and vascular lesions.[6] Late onset of the palsy associated with nausea and headache suggests overdrainage of the CSF with consequent traction on the nerve.[9]

Large series indicate that the incidence of PLPH and other central nervous system-related side effects of LP depend on age, sex, and the diameter and shape of needle. Smaller needles produce PLPH less often than larger needles of the same shape.[1,3,8] In our patient we had to use a Quincke type spinal needle because relatively atraumatic Sprott or Whitacre needles or smaller Quincke needles (like 25G) were not available in our institution.

Multiple insertions of the needle into the subarachnoid space may also be a possible cause of PLPH and abducens palsy.[7] Younger age and female gender are definite risk factors.[8]

Risk of abducens palsy after LP is not definite. A study of Thomke and colleagues report the risk to be 1 in 5800,[3] and Follens and colleagues report an incidence of 1 in 400.[6] The incidence of abducens palsy after myelography is 1 in 500 cases.[4] Abducens palsy after LP can be unilateral or bilateral.[1,6] It usually occurs 4-14 days after LP and resolves completely after 4 weeks to 4 months.[1,3,4,5,6,7,9] Our case was the first, among 12.785 spinal anesthesias performed in the past 6 years (.0078%). It is also unique in its duration, which was about 6 months. To our knowledge, this is the longest duration in the English literature.

Treatments for PLPH once it has occurred include oral or IV caffeine, epidural saline, and epidural blood patches.[2,8] An epidural blood patch, although effective in treating PLPH, is ineffective in preventing the occurrence of abducens nerve palsy when performed at the onset of double vision.[4,10] MRI can be used both to determine the site of CSF leakage and for accurate placement of the blood patch.[2]

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