52letý muž (89 kg, index tělesné hmotnosti 30,1 kg/m2) s nádorem žaludku byl naplánován na laparoskopickou gastrektomii. Jeho zdravotní anamnéza zahrnovala hypertenzi, diabetes mellitus, hyperlipidemii a kouření. V operačním sále byla po umístění standardních monitorů zavedena Tuohyho jehla do epidurálního prostoru na úrovni Th8–9, zatímco pacient byl v pravé laterální poloze. Jehla byla zavedena do pozice na základě orientace úkosu jejího céfalu. Do epidurálního prostoru byla zavedena epidurální jehla 5 cm. Z katetru nebyla odebrána žádná krev nebo mozkomíšní tekutina (CSF). Poté bylo do katetru vstříknuto 3 ml 1% mepivacainu bez motorického bloku. Celková anestezie byla navozena 110 mg propofolem a remifentanilem a tracheální intubace byla provedena pomocí 50 mg rokuronia. Celková anestezie byla udržována směsí kyslíku a vzduchu a 1,5–2% sevofluranu. Šest mililitrů 1% mepivacainu bylo zavedeno do epidurálního prostoru 10 minut před operací a kontinuální infuze 140 ml 0,25% levobupivacainu, 0,5 mg fentanilu a 50 ml fyziologického roztoku do epidurálního prostoru byla zahájena rychlostí 4 ml/h. Vitální funkce pacienta zůstaly po celou dobu operace stabilní a pacient netrpěl závažnou hypotenzí. Ztráta krve byla minimální. Po skončení operace byl pacient extubován a potvrdili jsme, že se neobjevily žádné známky slabosti svalů dolních končetin. Dosaženo dobré analgezie a pacient netrpěl žádnými pooperačními komplikacemi spojenými s epidurální anestezií. V 1. pooperačním dni (přibližně 24 hodin po operaci), kdy pacient byl schopen chodit a močit bez potíží, byl močový katétr odstraněn. Po 30 hodinách po operaci se však pacient náhle začal potýkat s bolestmi zad a anurií a nemohl hýbat dolními končetinami. Dotek pacienta byl tupý pod bradavkami. Ačkoli z katétru nebyl odebrán žádný mozkomíšní mok, předpokládali jsme, že se epidurální katétr přesunul do subarachnoidálního prostoru a zastavil epidurální infuzi. O dvě hodiny později byl pacient schopen pohybovat oběma kotníky a cítil, že se mu zlepšil dotek. Po 2. pooperačním dni však pacient stále nemohl pohybovat koleny, a proto jsme odstranili epidurální katétr a provedli magnetickou rezonanci (MRI) jeho míchy. T2-vážené obrazy MRI ukázaly abnormální signál v míše od úrovně Th3 do Th8, který byl v souladu s poraněním míchy (Obr. ), ale nebyl nalezen žádný hematom nebo absces (který by mohl míchu stlačit). Objevila se zejména „sova“ v axiálním pohledu (Obr. b), která je specifická pro infarkt předního rohu []. Difúzně vážené zobrazování (DWI) také ukázalo hyperintenzitu, která odpovídala T2-váženým obrazům, a zjevný difúzní koeficient (ADC) byl snížen (údaje nejsou uvedeny). Plánovali jsme provést angiografii, abychom zjistili přesnou příčinu infarktu, ale pacient s tím nesouhlasil. Na základě MRI nálezů pacienta a doporučení ortopedů a neurochirurgů bylo pacientovi intravenózně podáno 300 mg hydrokortisonu a Edaravone®, antioxidant, ale neprovedli jsme antikoagulační léčbu kvůli strachu z pooperačního krvácení. Bohužel se paraplegie a problémy s citlivostí pacienta příliš nezlepšily. V 23. pooperačním dni byl pacient převezen do jiné nemocnice, aby podstoupil rehabilitaci. Etiologie po epidurální anestezii SCI zahrnují přímý tlak na míchu způsobený hematomem nebo abscesem a ischemii míchy způsobenou hypotenzí, spasmem, embolismem, arteriální disekcí nebo traumatem postihujícím důležité tepny, které zásobují míchu.[] V tomto případě nebyl nalezen žádný tlak na míchu způsobený hematomem a nedošlo k žádné abnormální perioperační hypotenzi. Zdá se, že nejpravděpodobnější příčinou SCI v tomto případě je ucpání důležitých tepen, které zásobují míchu, konkrétně přední míšní tepny (ASA). Páteř je prokrvována jedinou přední a dvěma zadními míšními tepnami. Míšní tepnami prochází cévní svazek, který zásobuje přední dvě třetiny míchy. Vzhledem k tomu, že je vertikální propojení míšních tepen špatné, jsou oblasti míchy zásobované míšními tepnami náchylné k ischemii. Oklušení míšních tepen způsobuje klinický stav známý jako syndrom míšních tepen. Jeho klinické projevy zahrnují motorickou paralýzu, areflexii a ztrátu funkce střevního a močového měchýře a změny smyslových funkcí zahrnují absenci bolesti a teplotního vnímání, zatímco propriocepce a schopnost vnímat vibrace nejsou narušeny kvůli ušetření zadních sloupců. Příznaky a projevy pozorované v našem případě dobře odpovídají všem těmto klinickým projevům syndromu míšních tepen. MRI je spolehlivým a citlivým prostředkem pro hodnocení poranění míchy, který vytváří abnormální T2 hyperintenzitu a zesílení na takovém skenu [] Tumory, myelitida a demyelinizace také vytvářejí abnormální T2 hyperintenzitu, ale v tomto případě jsme byli schopni vyloučit tyto příznaky kvůli klinickému průběhu stavů pacienta a „očnímu“ vzhledu axiálního skenu T2-vážené zobrazování. Difuzní vážené zobrazování (DWI) je uznávaným a citlivým nástrojem pro detekci akutního poranění míchy, který vytváří abnormální T2 hyperintenzitu a zesílení na takovém skenu [] Tumory, myelitida a demyelinizace také vytvářejí abnormální T2 hyperintenzitu, ale v tomto případě jsme byli schopni vyloučit tyto příznaky kvůli klinickému průběhu stavů pacienta a „očnímu“ vzhledu axiálního skenu T2-vážené zobrazování. Difuzní vážené zobrazování (DWI) je uznávaným a citlivým nástrojem pro detekci akutního poranění míchy, který vytváří abnormální T2 hyperintenzitu a zesílení na takovém skenu [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] 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nebylo možné určit jedinou příčinu syndromu ASA, který byl v tomto případě zaznamenán. Pokud si však pacient stěžuje na slabost svalů dolních končetin a/nebo abnormální pocity, je důležité provést co nejdříve vyšetření MRI a léčbu, aby se předešlo trvalé paraplegii, zejména po epidurální analgezii.