Cord and cauda equina injury complicating elective orthopedic surgery

Presented is a case series of 3 patients, all of whom developed neurologic deficits due to cord or cauda equina compression during elective extremity surgery.

To identify characteristics of presentation that may differentiate cord or cauda equina injury from peripheral nerve palsy following extremity surgery and to establish the value of early decompression in patients with intraoperative injury.

Intraoperative neural injury has been described in association with epidural and spinal anesthesia, with cervical or spinal manipulation in the face of instability, and with ischemic injury suffered during extensive vascular repair. However, it has not been described after uncomplicated elective extremity surgery.

Retrospective review of a case series.

In 1 patient, intraoperative paraplegia occurred after routine shoulder arthroscopy. A second patient underwent elective bilateral total hip replacement and awoke with neurologic deficits in both lower extremities, then went on to develop an acute cauda equina syndrome. The third patient developed a central cord syndrome following an otherwise uncomplicated total hip replacement. Two patients were initially misdiagnosed as peripheral nerve palsies. All 3 patients had preexisting spinal stenosis at the level of neural injury. All underwent routine positioning and anesthetic care but were recognized as having a neural injury early in the recovery period. In only 1 case was the diagnosis of a cord level injury made immediately. All 3 patients were treated with urgent surgical decompression once diagnosed. Following surgery, neurologic symptoms improved in each of the 3 patients allowing early mobilization.

Spontaneous neural injury is rare but can occur to the anesthetized patient. Neurologic examination should be routinely performed in the recovery room; and if significant neurologic deficits are seen, investigative workup should not be delayed. If an intraspinal lesion is identified, immediate decompression may offer favorable results. Neurologic deficits should not be dismissed as peripheral palsies without careful evaluation.