Tetzlaff J E, Dilger J, Yap E, Smith M P, Schoenwald P K
Department of General Anesthesiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Can J Anaesth. 1998 Jul;45(7):667-9. doi: 10.1007/BF03012099.
Spinal anaesthesia is selected for many lower extremity surgical procedures each year in the United States with a high degree of safety and efficacy. Even when adverse neurological outcomes have occurred, anatomical abnormality or coagulopathy have been implicated in the majority of cases. Epinephrine is used in high concentrations in many of these anaesthetics to increase the duration and intensity of the block. Although epinephrine is known to decrease spinal cord blood flow, its use in normal patients has not caused complications. We report a case where spinal anaesthesia with bupivacaine and epinephrine resulted in anterior spinal artery compromise and the development of a cauda equina syndrome postoperatively.
A 57-yr-old man with severe coronary artery and peripheral vascular disease was scheduled for incision and drain of an abscess of the left thigh. He received an atraumatic dural puncture and injection of 12.5 mg bupivacaine with 0.2 ml 1:1000 epinephrine. During onset, he experienced a severe, painful sensation of the thighs which resolved with development of the block. Postoperatively, he was noted to have exacerbation of proximal muscle weakness and decreased perineal sensation and rectal tone. Subsequent EMG studies demonstrated proximal neuron loss consistent with cauda equina syndrome, presumed to be related to insufficiency of the anterior spinal artery.
Routine use of epinephrine in spinal anaesthesia for patients with multi-organ vascular disease should be considered carefully because of the possibility of vascular insufficiency of the spinal cord which would be exaggerated by the vasoconstrictive effect of epinephrine.
在美国，每年有许多下肢外科手术选择脊髓麻醉，其具有高度的安全性和有效性。即使出现了不良神经学后果，大多数情况下也与解剖异常或凝血功能障碍有关。在许多这类麻醉剂中使用高浓度肾上腺素以延长阻滞时间并增强阻滞强度。虽然已知肾上腺素会减少脊髓血流，但在正常患者中使用它并未引起并发症。我们报告了一例布比卡因和肾上腺素脊髓麻醉导致脊髓前动脉受损并术后出现马尾综合征的病例。
一名57岁患有严重冠状动脉和外周血管疾病的男性计划进行左大腿脓肿切开引流术。他接受了无创伤性硬膜穿刺，并注射了12.5毫克布比卡因和0.2毫升1:1000肾上腺素。在起效过程中，他感到大腿剧烈疼痛，随着阻滞的发展疼痛缓解。术后，发现他近端肌肉无力加重，会阴感觉和直肠张力降低。随后的肌电图研究显示近端神经元丧失，符合马尾综合征，推测与脊髓前动脉供血不足有关。
对于患有多器官血管疾病的患者，脊髓麻醉中常规使用肾上腺素应谨慎考虑，因为存在脊髓血管供血不足的可能性，而肾上腺素的血管收缩作用会加剧这种情况。
