Postop deficit

[gasdoc77]

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On postop follow up a patient has loss of temperature and pinprick from right (unilateral) nipple line down to toes. It extends from midline in front to midline in back (complete). Motor/strength intact. Initial t-spine MRI w/wo contrast negative. Anyone seen such a thing? Any suggestions? Case was ENT and position was neutral, no sig blood loss, etc. Is this pathognomonic for any particular lesion/process? Much thanks from the anesthesia side.

 

[Thama]

That's not plausibly a peripheral pattern. Sounds like a lateral cord insult of some sort. Depending on etiology, MR may not be useful in picking it up (such as if it's a very small infarct).

 

[Postictal Raiden]

Sounds a contralateral spinothalamic lesion. I’d say a lesion affect the left ateriolateral spinothalamic fibers at ~T2-3. As mentioned above, this is a very small region.

 

[Algor]

Could be a spinal stroke, but I would consider MRI brain because it can be thalamic stroke that only partially affects sensory fibers. Finally, if the patient had underlying cervical spinal stenosis, then neck manipulations during intubation could damage the cord as well, so I would image C-spine. There is also no neurological exam described, so hard to tell.

 

[deathmerchant]

On postop follow up a patient has loss of temperature and pinprick from right (unilateral) nipple line down to toes. It extends from midline in front to midline in back (complete). Motor/strength intact. Initial t-spine MRI w/wo contrast negative. Anyone seen such a thing? Any suggestions? Case was ENT and position was neutral, no sig blood loss, etc. Is this pathognomonic for any particular lesion/process? Much thanks from the anesthesia side.

The possible differentials include an ischemic lesion in the thoracic or even cervical cord, a thalamic lesion or Functional/Psychogenic.

An Ischemic lesion in the spinal cord is hard to see on MRI, esp since they don't usually do a Diffusion sequence. and a Flair can sometimes be negative in the first 12-24 hours. Also a small stroke in the cord could be hard to see. If you don't have a neurologist who can examine and localize further, I would consider repeating MRI brain, C and T spine With Diffusion weighted images.

That being said, If the patient has only sensory symptoms with no motor problems, other neuro exam is normal and the patient is not a high risk patient (DM, HTN, Smoking etc), Functional/Psychogenic etiology is more likely. There are examination techniques to elicit that.

Finally, even if it is a small stroke in thalamus or spinal cord with no weakness, there is not much to do. He should improve pretty fast. Send him home on aspirin and statin with a close neuro f/u.

 

[gasdoc77]

Thank you all for the suggestions. Neuro is on board but I just hoped you might offer a few zebras to consider.
Pretty sure the patient is reliable (young healthy cross fitter who is visibly VERY concerned).
If a small stroke (or anything else for that matter) what might be a reasonable expectation for a full, partial, or no recovery? Obviously we are far outside the thrombolytic window.
Can a virus or MS that manifests due to perioperative stress (shingles etc) localize like this (very distinct)?

 

[deathmerchant]

Thank you all for the suggestions. Neuro is on board but I just hoped you might offer a few zebras to consider.
Pretty sure the patient is reliable (young healthy cross fitter who is visibly VERY concerned).
If a small stroke (or anything else for that matter) what might be a reasonable expectation for a full, partial, or no recovery? Obviously we are far outside the thrombolytic window.
Can a virus or MS that manifests due to perioperative stress (shingles etc) localize like this (very distinct)?

Spinal cord ischemia seems less likely, An ant spinal artery ischemia would affect one of the descending tracts as well and hence cause weakness. Also the patient seems young and healthy. In the extremely unlikely chance that it is a very small ischemia, i expect complete resolution in few days to a week.
MS or NMO lesions should show up on MRI, they are usually bigger. Also, they are rarely unilateral as they don't follow vascular territories. Same for viral. It is also weird to develop MS or Viral infection right after surgery.

I Vote Functional on this one, esp with an sensory cut off, no symptoms on other side, no motor symptoms and seemingly a midline split. Seems like a Type A person, who are more prone.

Either way, there is nothing to do other than reassurance, may be an aspirin for the meantime and a repeat MRI in few days to week. I expect complete resolution.

Let us know what happens.

 

[gasdoc77]

Spinal cord ischemia seems less likely, An ant spinal artery ischemia would affect one of the descending tracts as well and hence cause weakness. Also the patient seems young and healthy. In the extremely unlikely chance that it is a very small ischemia, i expect complete resolution in few days to a week.
MS or NMO lesions should show up on MRI, they are usually bigger. Also, they are rarely unilateral as they don't follow vascular territories. Same for viral. It is also weird to develop MS or Viral infection right after surgery.

I Vote Functional on this one, esp with an sensory cut off, no symptoms on other side, no motor symptoms and seemingly a midline split. Seems like a Type A person, who are more prone.

Either way, there is nothing to do other than reassurance, may be an aspirin for the meantime and a repeat MRI in few days to week. I expect complete resolution.

Let us know what happens.

Thank you for your input. Will keep you posted.

 

[Merely]

Neurologists are so damn smart I love watching them work

 

[gasdoc77]

Ok. So apparently further imaging included MRI of c-spine showing a lesion around C4. Working diagnosis currently transverse myelitis (etiology unknown). Seems higher than expected based upon symptoms. Input appreciated.

 

[neglect]

Ok. So apparently further imaging included MRI of c-spine showing a lesion around C4. Working diagnosis currently transverse myelitis (etiology unknown). Seems higher than expected based upon symptoms. Input appreciated.

Due to the spinothalamics ascending a few levels before decussating to join fibers from lower segments, the deficit is always dropped off by a few levels.

Timing is really weird.

Agree with everything above, and interesting to see different styles play out. Now I think it is clear: look for other areas of demyelination and if present, discuss MS DMT. The question is if the patient had demyelination symptoms as the basis for the initial surgery.

 

[Telamir]

That looks...a bit too bright for TM? Normally you get some T2 enhancement but that has almost the same intensity as CSF in the middle. Might be just how the image looks but has an LP been done? Is the CSF inflammatory? Does it take up contrast?

 

[deathmerchant]

Ok. So apparently further imaging included MRI of c-spine showing a lesion around C4. Working diagnosis currently transverse myelitis (etiology unknown). Seems higher than expected based upon symptoms. Input appreciated.

Interesting! Thanks for the update.
Localization is not always fool proof. As mentioned above, few level drop is expected!
It shouldn't be that hard from now, there are decent guidelines for management of a lesion like that. Good luck.

 

[Yarr]

Interesting case! Would also be interesting to see what the axial T2, and contrast uptake of that section looked like which could help with the differential. Just looking at that one image, the differential is broad. Sometimes when the body's reserve is compromised (possibly post op), latent neuro symptoms can manifest.

 

[Algor]

This is just another illustration how everything is important in neurology. History, exam are crucial and we are trying to guess here based on very limited information, e.g. one line of history and sag. T2 MRI image. What it could be? Pretty much anything. MS is definitely most common, but you need to put everything together and even after that keep your mind open.