Paraplegia following epidural analgesia: a potentially avoidable cause?

Neurological deficit is an uncommon but catastrophic complication of epidural anesthesia. Epidural hematomas and abscesses are the most common causes of such neurological deficit. We report the case of a patient with renal cell carcinoma with lumbar vertebral metastasis who developed paraplegia after receiving thoracic epidural anesthesia for a nephrectomy. Subsequently, on histo-pathological examination of the laminectomy specimen, the patient was found to have previously undiagnosed thoracic vertebral metastases which led to a thoracic epidural hematoma. In addition, delayed reporting of symptoms of neurological deficit by the patient may have impacted his outcome. Careful pre-operative investigation, consideration to using alternative modalities of analgesia, detailed patient counseling and stringent monitoring of patients receiving central neuraxial blockade is essential to prevent such complications.

The varying shape of the coronoid process of the mandible.

The coronoid process (meaning crow) is a flattened triangular bony process of the ramus of the mandible. It is usually directed upwards and slightly forwards in the living subject. The coronoid process is of clinical significance to the maxillofacial surgeon for reconstructive purposes. Several authors have described the varying shapes of the process. In the present study, the variable shape and surface area of the coronoid process were observed in a collection of 154 south Indian mandibles. Using the criterion proposed by Isaac and Holla (2001), the coronoid process of each side was inspected for the shape and direction, and surface area of the ramus and the coronoid process was also calculated. The shape of the coronoid process was bilaterally triangular in 16.2%, hook-shaped in 45.5%, rounded in 18.2% rounded and hook-shaped in 4.5%, and unilaterally triangular in 12.3%, hook-shaped in 11.7%, and rounded in 7.1% of the mandibles. The coronoid processes faced directly upward in 55.4%, forward in 40.7% and backward in 3.8% of the mandible.