Pathomechanisms and treatment of paraplegia after epidural anesthesia

Paraplegia rarely occurs after epidural anesthesia, and has been believed to result from spinal compression by extradural hematoma from venous plexus. In this review, we introduce new findings and possible pathomechanism of spinal ischemic change after the injury of major spinal arteries. Sequelae of such arterial injury could be the most serious when Adamkiewicz artery, which mainly derives from left side of Th8-12 vertebral levels in the Japanese, was injured. Posterior spinal decompression would be effective for extradural hematoma, if spinal cord infarction does not coexist. When the spinal cord is highly compressed by hematoma from major arteries, urgent surgical decompression is required. On the other hand, when major spinal arteries like Adamkiewicz is injured, severe spinal ischemic change could happen and the effect of surgical decompression would be limited. To avoid such arterial injuries during epidural anesthesia, the puncture should be performed to appropriate direction and depth with minimum trials by using a median approach.