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Alternating bilateral Horner’s syndrome during continuous thoracic epidural analgesia

Alternating bilateral Horner’s syndrome during continuous thoracic epidural analgesia Continuous thoracic epidural analgesia is frequently used for abdominal and thoracic surgical procedures. High epidural blockade due to cephalad spread of local anaesthetic is a rare complication, with a reported incidence of 1.4% [1]. Clinical presentation is variable, and can include bradycardia, hypotension, brachial plexus paresis and phrenic nerve blockade. Due to sympathetic blockade at the C8–T1 spinal levels, Horner’s syndrome characterised by unilateral miosis, enophthalmos, palpebral ptosis, anhidrosis and, occasionally, ipsilateral facial flushing can develop [2].A 30‐year‐old man developed Horner’s syndrome following T8–T9 epidural placement for extensive abdominal surgery. On postoperative day 1, he developed right‐sided Horner’s syndrome (Fig. 1a) with ipsilateral upper extremity paraesthesia and uneven sensory block. Following recognition, the epidural infusion rate was decreased, patient‐controlled bolus locked and the catheter pulled back. On postoperative day 3, he developed Horner’s syndrome on the left, with full resolution contralaterally (Fig. 1b). Apart from transient right upper extremity paraesthesia occurring with epidural blousing, he did not experience other symptoms related to high epidural blockade. Of note, the patient wore an abdominal binder, which, in theory, could increase epidural pressure promoting rostral local anaesthetic spread. A similar mechanism has been suggested in labouring obstetric patients with lumbar epidurals [3].1Figure(a) Postoperative day 1; http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Anaesthesia Reports Wiley

Alternating bilateral Horner’s syndrome during continuous thoracic epidural analgesia

Holck, G.; Quaye, A. N.
Anaesthesia Reports , Volume 10 (1) – Jan 1, 2022
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Wiley
Copyright
2022 © Association of Anaesthetists
eISSN
2637-3726
DOI
10.1002/anr3.12147
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Abstract

Continuous thoracic epidural analgesia is frequently used for abdominal and thoracic surgical procedures. High epidural blockade due to cephalad spread of local anaesthetic is a rare complication, with a reported incidence of 1.4% [1]. Clinical presentation is variable, and can include bradycardia, hypotension, brachial plexus paresis and phrenic nerve blockade. Due to sympathetic blockade at the C8–T1 spinal levels, Horner’s syndrome characterised by unilateral miosis, enophthalmos, palpebral ptosis, anhidrosis and, occasionally, ipsilateral facial flushing can develop [2].A 30‐year‐old man developed Horner’s syndrome following T8–T9 epidural placement for extensive abdominal surgery. On postoperative day 1, he developed right‐sided Horner’s syndrome (Fig. 1a) with ipsilateral upper extremity paraesthesia and uneven sensory block. Following recognition, the epidural infusion rate was decreased, patient‐controlled bolus locked and the catheter pulled back. On postoperative day 3, he developed Horner’s syndrome on the left, with full resolution contralaterally (Fig. 1b). Apart from transient right upper extremity paraesthesia occurring with epidural blousing, he did not experience other symptoms related to high epidural blockade. Of note, the patient wore an abdominal binder, which, in theory, could increase epidural pressure promoting rostral local anaesthetic spread. A similar mechanism has been suggested in labouring obstetric patients with lumbar epidurals [3].1Figure(a) Postoperative day 1;

Journal

Anaesthesia Reports – Wiley

Published: Jan 1, 2022

Keywords: epidural analgesia: complications; parasympathetic nervous system: ganglia; regional anaesthesia: mechanism of injury

References

  • Transient Horner's syndrome following thoracic epidural anesthesia for mastectomy: a prospective observational study
    Park, SY; Chun, HR; Kim, MG
  • Horner syndrome: a clinical review
    Martin, TJ
  • Horner's syndrome following obstetric neuraxial blockade ‐ a systematic review of the literature
    Chambers, DJ; Bhatia, K