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Bilateral lower limb hypoesthesia after radical prostatectomy in the hyperlordotic position under general anesthesia

[Hypoesthésie bilatérale des membres inférieurs après prostatectomie radicale sous anesthésie générale en position d’hyperlordose]

Hélène Beloeil, MD^*, Pierre Albaladejo, MD^*, Sophie Hoen, MD^*, Pascal Eschwege, MD and Dan Benhamou, MD^*

^* From the Departments of Anesthesiology,
Urology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France.

Address correspondence to: Pr Dan Benhamou, Department of Anesthesiology, Hôpital de Bicêtre, 94275 Le Kremlin Bicêtre Cedex, France. Phone: 33-1-45213447; Fax: 33-1-45212875; E-mail: dan.benhamou{at}bct.ap-hop-paris.fr

Purpose: To report a case of postoperative bilateral lower limb hypoesthesia occurring after surgery under general anesthesia in the hyperlordotic position for radical prostatectomy. The possible pathophysiologic mechanisms are discussed.

Clinical features: This 52-yr-old patient was slightly overweight and was on fenofibrate for hypercholesterolemia. He had no history of cardiovascular disease. Arterial blood pressure was overall well maintained except for a very transient hypotension at surgical incision. Blood loss was moderate and did not require transfusion. Soon after recovery, the patient complained of paresthesia in both legs and neurological examination revealed bilateral lower limb hypoesthesia, compatible with an incomplete medullar syndrome at the level of T12–L1. On postoperative day one, a plain magnetic resonance imaging scan demonstrated a hyperintense signal in the spinal cord from T8 to T9 on T2-weighted images consistent with ischemia of the spinal cord whereas the heterogeneous aspect of the spinal cord was due to an unusually high fat content of the epidural space. Neurological signs improved progressively and one week later the patient had recovered normal sensory functions of both lower limbs.

Conclusion: Although arterial ischemia is the most common cause of postoperative spinal cord injury, other mechanisms may be invoked. We raise the possibility that a combination of intraoperative risk factors (hypotension, excessive postural changes) with anatomic predispositions (increased epidural venous pressure or fat content, previous bone disease) can produce arterial and/or venous ischemia of the spinal cord.

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