Description:

A 27-year-old, G1P1 female with no neurologic history presents to clinic one month post-partum after experiencing transient neurologic changes during epidural placement. The first placement at L2-L3 resulted in immediate upper and lower right facial weakness. The second placement at L3-L4 resulted in a recurrence of the right facial palsy along with right arm weakness, right truncal sensory loss, and clinical signs of Horner’s Syndrome (ptosis and miosis). In both instances, all deficits resolved completely and instantaneously upon catheter removal. The third epidural attempt resulted in adequate pain relief without complication, and labor progressed normally. Postpartum neurological examination was normal with exception of mildly diminished reflexes globally. MRI of the neuroaxis (with gadolinium for brain and lumbar spine studies) was unrevealing for causative pathology. 

Data regarding incidence of cranial nerve palsy associated with epidural anesthesia is limited. The implicated structures involved in the transient events (cranial nerve, sympathetic chain, and sensory roots) raised suspicion for structural intraspinal pathology, increasing susceptibility to developing these deficits. However, MRI demonstrated no evidence for mass lesion, syringomyelia, or predisposing structural anomaly. This, as well as immediate resolution of symptoms after catheter removal, suggested a mechanical process. We have several theories as to etiology to these symptoms: transient mechanical traction or pressure phenomenon [1] on neural structures, transient intracranial hypotension [2] associated with epidural catheter, or cephalad spread of anesthetic agents to affect sympathetic preganglionic fibers at C8 and T1 [3].