Review of Incidents

Following vascular surgery under spinal-epidural anaesthetic, there was no return of any sensation or motor function in the lower limbs (Bromage score 3) within 4 hours. The block was not monitored in recovery and although ward staff raised concerns, there was a delay in review and a significant delay in undertaking a MR scan (more than 10 hours). The MR scan confirmed a suspected hematomyelia (haemorrhage occurring within the spinal cord) and the patient suffered permanent neurological sequelae.

Commentary:

This case highlights the need for careful monitoring of patients for block regression following spinal epidural anaesthesia, as recommended by the Association of Anaesthetists¹ Units should have an SOP for providing access to rapid MRI 24/7 to prevent delays in diagnosis, with its attendant risks for patient safety.

References:

1. Association of Anaesthetists. Safety Guideline: Safety guideline: neurological monitoring associated with obstetric neuraxial block. , 2020.