Anesthesiologist’s Poor Epidural Placement Results in Neurological Injury

This case involves a twenty-four- year-old woman who underwent a caesarian section. The patient was given an epidural for pain prior to delivery and experienced a crushing sound and excruciating pain immediately following the injection. The patient also had a notable drop in blood pressure shortly after the epidural had been administered. Upon ambulation, the patient reported left leg “dragging” and significant pain up until the time of discharge from the hospital. The patient had complained of loss of sensation in the nipple area as well that seemed to be overlooked by the staff. On postoperative day two, the patient was still complaining of worsening lower extremity leg pain. Anesthesia was consulted and determined that the pain was likely due to an inflammatory process at which point they started the patient on Medrol Dosepak and a neurology consult recommended a round of Gabapentin. The medications failed to resolve the pain and the patient was discharged with instructions to follow up in a neurology clinic in two to three weeks. Upon further investigation and MRI studies, it was discovered that the patient suffered from a distal cord injury that was most likely due to the epidural needle being inserted above the L1 vertebrae.

Question(s) For Expert Witness

1. What are the accepted complications of epidural nerve blocks and does the level of insertion change the possible complications?

Expert Witness Response

Minor adverse effects and complications of epidural nerve block include pain at the injection site, unintentional dural puncture, and vasovagal syncope. Major complications include damage to neural structures, epidural hematoma, and epidural abscess. These major complications are rare but can be life-threatening when they occur. With the exception of the decreased incidence of inadvertent dural puncture, the complications of the caudal approach to the epidural space mirror those of the lumbar approach. Because of the proximity of the rectum, conscientious attention to sterile technique must be observed to avoid infection, which can easily spread to the epidural space via the Batson plexus. Because of the vascular nature of the caudal epidural space, the potential for local anesthetic toxicity remains ever present.