Spinal Cord Infarction Secondary to Hypotension After Administration of Epidural Anesthesia for Vaginal Delivery: A Case Report

Case Diagnosis: Spinal cord infarction

Case Description or Program Description: A 20-year-old nulliparous female with preeclampsia presented for labor induction due to concerning fetal heart rates. Oxytocin was used for induction, and she was treated with nifedipine for preeclampsia with severe features. After a successful test dose at the L3-4 level, she received epidural analgesia with ropivacaine. Two hours later, she experienced symptomatic hypotension, requiring intravenous fluids and pressors. She delivered without further complications but reported pain at the epidural site radiating to the lower limbs, along with lower limb weakness and sensory loss after epidural removal.

Setting: Acute Inpatient Rehabilitation (IPR)

Assessment/Results: The patient underwent computed tomography (CT) scans of her brain and lumbar spine which showed no acute abnormalities. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine were limited by motion artifact but did not show signs of ischemia within the limitations of the study. She underwent an electrodiagnostic study of the lower limbs 10 days post-injury which showed spontaneous activity only in the proximal muscles. Admission to acute inpatient rehabilitation was recommended.

Discussion (relevance): Spinal cord infarction is a rare complication following epidural anesthesia. In this case, the development of spinal cord ischemia was likely multifactorial, with prolonged hypotension post-epidural administration serving as the primary contributing factor. Imaging studies were inconclusive and not repeated, as it would not have changed management. The clinical presentation of acute lower limb weakness, sensory deficits, and electrodiagnostic findings strongly support a diagnosis of spinal cord ischemia. In IPR, the exam was consistent with T10 motor incomplete injury which indicated a fair prognosis for recovery.

Conclusions: Spinal cord infarction due to hypotension is a known risk associated with certain cardiovascular surgeries. However, cases of spinal cord infarction following vaginal delivery are rare. Patients experiencing this condition can benefit from intensive inpatient rehabilitation in specialized spinal cord injury units to promote functional recovery.