Abstract
Purpose
We describe a complication of epiduroscopy with encephalopathy and rhabdomyolysis associated with the contrast medium iotrolan.
Clinical features
A 76-yr-old man with failed back surgery syndrome underwent epiduroscopy. Sufficient lysis could not be achieved in the epidural space above the level of L4 due to dense adhesions and scar tissue. After epidural injections of iotrolan and mepivacaine, he developed motor weakness and hypoesthesia in both legs, which lasted for three hours. He also became confused, agitated, disoriented, and developed neck stiffness and tremors involving the head and legs. Computed tomography revealed diffuse contrast enhancement within the intracranial cerebrospinal fluid (CSF) spaces, indicating an intraoperative dural tear. Marked increases in serum creatinine phosphokinase and myoglobin indicated subsequent acute rhabdomyolysis. Crystalloid infusion and semi-recumbent positioning facilitated iotrolan absorption from the CSF, and the patient recovered uneventfully.
Conclusions
Dural tear during epiduroscopy may allow access of contrast media into the CSF. Neurotoxicity secondary to iotrolan within the CSF was a likely contributing factor to the encephalopathy and subsequent rhabdomyolysis. This is an instructive example of the importance of diagnosing inadvertent dural tear during epiduroscopy under iotrolan, for avoidance of adverse events such as encephalopathy and rhabdomyolysis.
Résumé
Objectif
Nous décrivons une complication survenue lors d’une épiduroscopie avec le produit de contraste iotrolan consistant en une encéphalopathie et une rhabdomyolyse.
Eléments cliniques
Un homme de 76 ans présentant des séquelles d’un échec d’une chirurgie aux rachis a subi une épiduroscopie. Une lyse suffisante n’a pas pu être obtenue dans l’espace péridural au-dessus de L4 à cause d’adhésions denses et de tissus cicatriciels. Suite à des injections péridurales d’iotrolan et de mépivacaïne, il a développé une parésie ainsi qu’une hypoesthésie au niveau des membres inférieurs qui durèrent trois heures. Il est également devenu confus, agité, désorienté, et a développé une raideur du cou et des tremblements de la tête et des jambes. La tomodensitométrie a révélé un rehaussement diffus du produit de contraste dans les espaces intracrâniens du liquide céphalo-rachidien (LCR), indiquant une déchirure péropératoire de la dure-mère. Des augmentations significatives de la créatinine-phosphokinase sérique et de la myoglobine signalant une rhabdomyolyse aiguë ultérieure ont été observées. Une perfusion de cristalloïde ainsi qu’un positionnement semi-allongé ont facilité l’absorption de l’iotrolan du LCR, et le patient s’est rétabli sans problème.
Conclusions
La déchirure de la dure-mère durant l’épiduroscopie peuvent permettre l’injection de produit de contraste dans le LCR. Une neurotoxicité due à l’iotrolan dans le LCR est un facteur qui a possiblement contribué à l’encéphalopathie et à la rhabdomyolyse subséquente. Ceci est un exemple instructif de l’importance du diagnostic de la déchirure de la dure-mère commises par inadvertence durant l’épiduroscopie sous iotrolan, afin d’éviter des complications telles que l’encéphalopathie et la rhabdomyolyse.
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Mizuno, J., Gauss, T., Suzuki, M. et al. Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy. Can J Anesth 54, 49–53 (2007). https://doi.org/10.1007/BF03021899
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DOI: https://doi.org/10.1007/BF03021899