Introduction: Paraplegia due to spinal cord infarction is a rare and devastating perioperative event. Its occurrence in the setting of an epidural technique is even rarer.1 There are various causes, some potentially treatable, however an early diagnosis and intervention is required. Nevertheless, the primary etiology will often remain unknown.
Case report: Male, 61 years old, ASA III, presented for an elective repair of a voluminous abdominal hernia. Hypertension, diabetes mellitus type II, obesity and past history of rectum cancer with preoperative CRT. The patient was operated under general anesthesia combined with a lumbar continuous epidural infusion without any noteworthy occurrence. In the postoperative period the epidural infusion was continued with ropivacaine (0,2%) and morfine (0,005%) at a rate of 6mL/ h. The patient was discharged from the post-anesthesia care unit with effective analgesia and without any noticeable motor deficits.
In the next morning the patient was able to walk assisted to the bathroom for self-care hygiene. Later during that morning the patient complained of sudden intense motor weakness in lower limbs. The infusion was stopped and the patient was urgently referred to examination by a neurologist who observed the occurrence of an anterior spinal artery syndrome (paraplegia of lower limbs, hypoesthesia, areflexia, sphincter dysfunction and spared proprioception. An MRI was emergently done but there were no findings suggestible of any compressive causes, but only a signal alteration compatible with ischemia of conus medullaris.
Discussion: The spinal cord infarction is a very rare condition in the perioperative setting, even more in the context of a running epidural technique. A case review found only 13 publicated cases between 1969 and 2007.2 The ethiopathogenesis is multifactorial and complex. Among the possible perioperative causes we can hypothesize hypoperfusion state, embolism, thrombus, haematoma, infection and also complications directly attributed to the epidural technique. In this particular case we accounted several risk factors: cardiovascular risk factors, prothrombotic state (surgery and malignancy), post-radiation vasculitis. The continuous infusion of epidural local anesthetics assumes high importance in these circumstances because it can have a contributing role (increased epidural pressures) and it can also masquerade signs and symptoms leading to a late diagnosis. Since the patient was able to walk next morning while running the epidural and to the sudden onset of paralysis we can arguably exclude the epidural technique as the principal cause of the neurologic deficits.
Learning points: The rarity of this complication justifies the publication of the case because it draws the attention for the possible occurrence of neurologic impairment in patients undergoing neuraxial techniques while not being directly causative.

Paraplegia in a patient with epidural cateter