Hypoesthesia of the Lower Limb
Short summary
Male patient had twist injury of his knee with tear of the ACL and was operated. After the surgery he suffered acute lumbalgia. Twelve days later he was re-admitted for knee effusion and elevated body temperature, and arthrolysis and joint washing were performed. Following the procedure he complained of hypoesthesia of the proximal lower left limb and knee. EMG reveled L4 and S1 root damage, and MRI showed reduced lumbar lordosis and different disc lesions. In case of compression neuropathy (tourniquet), the expert recommends symptomatic only treatment.
Medical Background
The patient had twist injury of his Lt. knee with tear of the ACL. He was operated on 11.07. The operation was done under G.A. (after 3 attempt to administer spinal anesthesia). He was discharged from hospital on the 4th post operative day with prophylactic clexan treatment. At that point the patient suffered "acute lumbalgia" and on discharge there were probably no pathological neurological complaints and findings. Twelve days later he was re-admitted for knee effusion and elevated body temperature. Arthrolysis and joint washing were performed under spinal anesthesia. Following the procedure the patient complained of hypoesthesia of the "proximal lower left limb" with slight hypoesthesia of the knee. Tendon reflexes are reported to be "normal and symmetric". EMG reveled L4 and also S1 root damage on the left. MRI was undertaken, showing reduced lumbar lordosis and different disc lesions. Among those are Rt. L5-S1 and L3-4 disc herniation that doesn't look responsible for the patient's symptoms. Remaining disc lesions are diffuse bulge, a little more to the left on L2-3 and L4-5 discs.
Medical opinion
I have no information about late events in the patient's condition and I must assume his complaints have not been changed.
1. I am not sure that the spinal anesthesia is directly responsible for the patient's problem. As mentioned, back pain existed prior to the neurological complaints. The most traumatic event associated with the spinal anesthesia was on 11.07 but following this surgery there is no report of neurological deficit. On the contrary, the second surgery (with no data about any anesthetic difficulties) ended with some neurological deficit. This may be due to disc lesion (probably L4-5 level), compression neuropathy (tourniquet) or less likely, damage directly attributed to the spinal anesthesia procedure. Disc lesion may become worse following forceful flexion of the lumbar spine as in the administration of spinal anesthesia. In my experience as a spinal surgeon, complications related to spinal anesthesia are rare.
2. I can't accept classifying the current symptoms as "chronic". Symptoms are of 3 months time and according to my opinion, it's too early to be classified as chronic condition. However, the MRI shows multiple level discopathy and this (with long standing back pain) may represent a chronic state.
3. In case of disc lesion or compression neuropathy there is good chance for spontaneous recovery.
4. In case of compression neuropathy (tourniquet), the compression does no longer exist and the only treatment is symptomatic, physiotherapy and even acupuncture therapy may be found beneficial. In case disc lesion is responsible, I don't see any indication for surgery but I can offer to perform nucleotomy (coblation), a minimal invasive procedure for the L4-5 disc. This is an ambulatory procedure performed under local anesthesia (sometime with sedation). The success rate is about 70% and complications are very rare.
