Yorozu Tomoko, Matsumoto Midori, Hayashi Satoru, Yamada Tatsuya, Nakaohji Takako, Nakatsuka Itsuo
Department of Anesthesiology, Federation of National Public Service Personnel Mutual Aid Associations, Tachikawa Hospital, Tachikawa 190-8531.
Masui. 2002 Oct;51(10):1151-4.
A 64-year-old man was scheduled for transure thral resection of the prostate. The patient's medical history showed borderline diabetic state and two uncomplicated surgeries under spinal anesthesia. Spinal anesthesia was performed at the L 3/4 interspace using hyperbaric 0.24% dibucaine 2.2 ml, which was followed by general anesthesia because the anesthesia level had spread only to the lower left side of the body. On the next day, he complained of difficulty of defecation and urination combined with hypesthesia around the anus, which was diagnosed as cauda equina syndrome. The symptoms had not changed for three weeks. Then, there was a gradual recovery but slight hypesthesia remained even four months after the surgery. Speculation of this clinical etiology suggests that high concentration of dibucaine, having maldistributed inside the intrathecal space, affected cauda equina, which resulted in irreversible nerve damage. There were other risk factors for cauda equina syndrome in this patient such as lithotomy position, history of frequent spinal anesthesia, diabetes and advanced age. None of these are contraindication for spinal anesthesia. Many elderly patients particularly undergoing urological surgeries are likely to have such risk factors. Therefore at least dibucaine should be avoided for spinal anesthesia because of its high neurotoxicity compared with other local anesthetics.
一名64岁男性计划接受经尿道前列腺切除术。患者的病史显示为临界糖尿病状态，曾在蛛网膜下腔麻醉下进行过两次无并发症的手术。在L 3/4椎间隙使用2.2毫升0.24%的高压丁卡因进行蛛网膜下腔麻醉，随后因麻醉平面仅扩散到身体左下侧而追加全身麻醉。术后第二天，他出现排便和排尿困难，并伴有肛门周围感觉减退，被诊断为马尾综合征。症状持续三周未变。随后逐渐恢复，但术后四个月仍有轻微感觉减退。推测该临床病因是高浓度丁卡因在鞘内空间分布不均，影响了马尾神经，导致不可逆的神经损伤。该患者还存在其他马尾综合征的危险因素，如截石位、频繁蛛网膜下腔麻醉史、糖尿病和高龄。这些都不是蛛网膜下腔麻醉的禁忌证。许多老年患者，尤其是接受泌尿外科手术的患者，可能有此类危险因素。因此，由于丁卡因与其他局部麻醉药相比具有较高的神经毒性，蛛网膜下腔麻醉至少应避免使用丁卡因。
