CASE REPORT SPINE Volume 37, Number 3, pp E195–E198 ©2012, Lippincott Williams & Wilkins Spine www.spinejournal.com E195 Adhesive Arachnoiditis With Extensive Syringomyelia and Giant Arachnoid Cyst After Spinal and Epidural Anesthesia A Case Report Takashi Hirai, MD, Tsuyoshi Kato, MD, PhD , Shigenori Kawabata, MD, PhD, Mitsuhiro Enomoto, MD, PhD, Shoji Tomizawa, MD, PhD, Toshitaka Yoshii, MD, PhD, Kyohei Sakaki, MD, Kenichi Shinomiya, MD, PhD , and Atsushi Okawa, MD, PhD Study Design. A case report of a patient with adhesive arachnoiditis after combined spinal and epidural anesthesia. Objective. To report an extremely rare case of paraplegia due to adhesive arachnoiditis with extensive syringomyelia (ES) and a giant anterior arachnoid spinal cyst (AASC) after spinal and epidural anesthesia for obstetric surgery. Summary of Background Data. Progressive inflammation of the arachnoid mater due to trauma, infection, or hydrocortisone was reported as early as the 1970s. However, coexistence of ES and a giant AASC after spinal and epidural anesthesia is extremely rare. Methods. A 29-year-old woman suffered from sudden anuresis 5 months after spinal and epidural anesthesia for a cesarean section and subsequently experienced paraplegia and numbness below the chest. Magnetic resonance imaging showed an AASC compressing the spinal cord at T1–T6 and an adhesive lesion at T7. Posterior laminectomy at T6–T7 and adhesiolysis for arachnoid adhesion at T7 were performed. Although there was slight recovery of locomotive function postoperatively, it gradually worsened until 3 years after surgery. Magnetic resonance imaging at that time demonstrated a giant AASC and ES at the lower-thoracic cord. The cord compressed by the AASC became thinner sagittally. Secondary surgery involving posterior laminectomy at T5–T6 and insertion of a cyst-peritoneal shunt into the AASC was performed. Results. The patient could walk without a cane 3 years after the shunt operation, although numbness and motor weakness of the T he etiology of adhesive arachnoiditis (AA) has been described by many authors. 1 ,2 In the 19th century, it was thought to be caused by blood in the cerebrospinal fluid (CSF) or infections such as syphilis, gonorrhea, or tuberculo- sis. More recently, contrast media, 3 trauma, 4 ,5 preservatives, 6 epidural steroids, 7 ,8 vasoconstrictors, 9 and local anesthesia 10 ,11 have all been implicated in the cause of AA. In most cases, however, the cause remains unknown. With regard to a link between AA and epidural anesthesia, no more than 30 cases have been reported in the English literature. 6 ,9 ,10 ,12 –14 Of these 30 cases, there have been no reports of the coexistence of a giant anterior arachnoid spinal cyst (AASC) and extensive syringomyelia (ES). Although spinal and epidural procedure is widely used for anesthesia in orthopedic surgery, it rarely causes delayed persistent neurologic complications. 6 ,9 CASE REPORT A 29-year-old woman underwent combined anesthesia with epidural (insertion of a microtube at L1/L2 using ropiva- caine hydrochloride hydrate 0.2%, morphine hydrochloride 4%, and droleptan) and spinal injection (puncture at L3/L4 using 2.4 mL isobaric bupivacaine 0.5%) when undergoing a cesarean section in another hospital. During the operation, anesthesia was kept below the T5 level. Before this event, she had no history of a lumbar spine disorder. Preoperative magnetic resonance imaging (MRI) (Figure 1A) was taken because all patients who would receive epidural and/or spinal From the Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan. Acknowledgment date: April 5, 2011. Acceptance date: June 20, 2011. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint request to Takashi Hirai, MD, Depart- ment of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; E-mail: hirai.orth@tmd.ac.jp lower extremities remained. Magnetic resonance imaging 3 years after the shunt operation showed a reduction of the AASC and decompression of the cord despite no improvement in ES. Conclusion. This is the first report of a patient with a giant AASC and ES caused by spinal and epidural anesthesia. Although the optimal surgical treatment for these conditions remains unclear, shunting of the cyst effectively prevented the progression of symptoms. Key words: adhesive arachnoiditis, arachnoid cyst, syringomy- elia, paraplegia, spinal and epidural anesthesia. Spine 2012;37: E195–E198 DOI: 10.1097/BRS.0b013e31822ba817 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.