1 case of neurological symptoms of analgesics occurring in the post-epidural delivery of anilal pain in pregnant women with epidural vascular malformation

1Patient informationpatient, female, 32 years old, height 162 cm, body mass 68 kg, body mass index (BMI) 25.91 kg/m2, due to "pregnancy 39 weeks pregnant 1 birth 0, maternity" admitted to the hospitalHospital temperature (T) 36.5 degrees C, heart rate (HR) 92 times / min, respiratory rate (RR) 19 times / min, blood pressure (BP) 122/76mmHg, physical fitness, no back and back limb pain and abnormal medical history, electrocardiogram, blood, urine routine, liver and kidney, electrolyte, blood clotting function, etcare free of abnormal, uterine opening to 3 cm of maternal painpre-analgesia visual simulation score (VAS) score 6 points, left lycing down by L2-3 epidural cavity puncture tube are smooth, to 1.5% Lidocain (containing 1:2000 000 epinephrine) 3mL test volume of no chiropractic symptoms followed by electronic analgesic pump (recipe: salt: salt The first infusion dose is set at 10mL, the continuous background infusion speed is 6mL/h, the patient's self-controlled analgesia (PCA) 2mL/time, the locking time is 15minAnalgesics began 5min after VAS score 4 points, analgesia began 30min, the patient gets out of bed activities, walking freely, no lower limb numbness, weakness symptoms;the whole analgesic process BP, HR, T and other vital signs no significant change, analgesic effect is satisfied, analgesic pump fluid dosage of 43.2mL, patients do not do PCA independentlyAfter delivery 3h patients complain ediphy of both lower limbs numbness, weakness, chest back pain, check the body to see the T6 plane below the feeling of decreasing, double lower limb muscle strength level 2, pathological signs did not drawGiven oxygen absorption, nutritional nerves, dehydration and other treatment, after 2h symptoms relief, 5h symptoms disappearedIt is recommended that the patient have an MRI examination to clarify theof the diagnosis, which the patient refusesafter the delivery of the 2nd day, the 4th day after the patient's change of position of the double lower limb numbness, pain symptoms, after sitting flat about 1h are self-relievingPostpartum 32d patients again with "double lower limb numbness, pain January, sexual aggravation" admitted to the hospital, vertebral MRI examination results show: T2-3 level vertebral tube outside the endofal membrane has a size of about 0.5 cm x 2.3 cm swelling T1 is an isometric signal (Figure 1), T2 is a high signal (Figure 2), the swelling is connected to the epidural broad substrate, the spinal cord is pressured, the enhanced scanning swelling is unevenly reinforced, suggesting intrauterine bleeding, consider: spinal tumorEmergency full-line to take the subduction position, surgical removal of T2, T3 ratchetand and vertebral plate, removal of local yellow ligaments, revealed vertebral tube see about 3 cm x 2 cm x 2 cm solidified hematoma, peeling hematoma after the epidural malformation vascular , with the epidural and nerve root adhesion is not obvious, surgical complete removal of tumor tissue Under the postoperative medical examination microscope, a large number of only single-layer endothelial cells and collagen fiberth walls vascular , lack of muscle layer and elastic layer Pathological indication: spongiform hemangioma (Figure 3) After surgery, the patient's condition gradually improved, the double lower limb numbness, weakness, chest and back pain and other symptoms gradually reduced, after the operation 16d discharged from the hospital, after February to return to the above symptoms no more attacks figure 1 T2-3 level see a size 0.5 cm x 2.3 cm shuttle occupied lesions, T1WI presents such as signal 2 T2WI high signal, it sees mixed signal shadow Figure 3 under the microscope can see a large number of only single-layer endothelial cells and collagen fibers Thin-walled blood vessels, lack of muscle layer and elastic layer (HE staining, x 200) 2 Discussion spinal spongiform hemangioma is one of the hidden spinal vascular malformations, accounting for 5% to 12% of spinal vascular diseases, can occur in any section of the spine, to the chest waist section is most common According to the growth site can be divided into myelin type, epidural inner myelin shape, epidural shape, which is the most seen in myelin type, simple epidural external type is rare, only 4% of all epidural tumors Its origin and mechanism are the same as intracranial spongiform hemangioma, which is abnormal in the vascular and non-hemangioma development of the spinal cord The mirror is shown as sparse, thin wall, inner membrane is linear-like spongy blood vessel sinus, the inner wall of the blood vessels has no smooth muscle and elastic fiber layer, only by a single layer of epithelial composition Imaging examination is of great value to evaluate the relationship between lesions and surrounding anatomy, and MRI can better display different types of vascular lesions in the vertebral tube, and can accurately locate them, at the same time, it can show the degree and scope of spinal degeneration, which is beneficial to the diagnosis and treatment of lesions and to judge the prognosis intra-spinal spongiform hemangioma in the vertebral tube with the symptoms of sensory movement disorders such as limb numbness, pain and weakness below the affected plane as the main clinical The disease can also develop acute symptoms related to hemorrhage and hematoma formation Is there a causal relationship between paraplegics caused by intravertebral lesions and analgesic operation sorraters in the vertebral tube? Jiang Xuecheng consults the literature on limb paralysis after nearly 20 years of intravertebral anaesthetic, and believes that when patients have vertebral tube memory in tumors and other preoccupied lesions, the capacity and pressure changes produced by intravertebral punctures and injections may compress the tumor and spinal cord, resulting in symptoms and physical signs of neurological abnormalities some scholars believe that due to the lack of venous valves in the outer vein sular membrane of the spinal cord can not resist pressure, changes in intravertebral pressure induced blood vessel rupture bleeding, patients thus appear in the spinal cord and nerve root pressure acute symptoms According to this, the case is caused by the puncture injection of the content of the vertebral tube and pressure changes, induced hemangioma in the body bleeding, and then pressure the spinal cord, the corresponding plane of nerve pressure symptoms, the tumor body bleeding stopped, compression reduced, nerve symptoms disappeared; Hematoma next to the tumor seen during the operation confirms speculation this case of pregnant women, epidural analgesia before no vertebral pre-dominant history, symptoms and signs, epidural delivery analgesia after 3h after the emergence of double lower limb numbness, weakness, chest back pain, because the patient appears limb paralysis symptoms early rejection of imaging examination, although conservative treatment symptoms relief, but failed to clearly diagnosis miss the early surgery The patient's medical history and necessary neurological examination, including limb movement, warm pain, touch, etc., must be detailed before the operation of intravertebral delivery analgesia, and the perfect postoperative follow-up system is an important measure to detect abnormal conditions early, and the extension of nerve blocking effect after analgesics is high Vigilance, if necessary, with patients and family members to fully communicate for imaging tests to clearly diagnose, once clear lysing in the vertebral tube, should immediately stop the analgesia, close observation, please consult the relevant departments, early tumor excision, can obtain good results to reduce the patient's neurological after-effects