Saturday, February 09, 2013

Child Paralyzed after Tonsils Removed

In an upcoming article in the journal, Anaesthesia, a case study was reported in which a 7-year old boy in India developed quadriplegia after an elective surgery to remove his tonsils and adenoids. Quadriplegia is a loss of the ability to move and/or feel both arms, both legs, and the parts of the body below the area of injury to the spinal cord. The tonsils are a pair of oval masses at the back of the throat.

The adenoid is a mass of tissue behind the nasal cavity, where the nose blends into the throat. The tonsils and adenoid are often surgically removed in children if they become large enough to obstruct airflow.

During the surgery of the 7-year-old child, he was treated with two types of powerful anesthesia known as fentanyl and thiopental. This was maintained with two forms of inhaled anesthesia known as isoflurane and nitrous oxide. The muscles were relaxed with another medication (atracurium). The surgery lasted 40-minutes. After surgery, he was drowsy and not breathing spontaneously. Medication was administered to try and reverse the muscle relaxing effects of anesthesia, but the breathing problems continued, and she became agitated and weak in all four limbs.

Although residual effects of anesthesia are sometimes the cause of these problems, the authors of the case report noted that a more serious cause should be explored the longer they persist. Initially, no obvious cause could be found. To investigate the situation further, the boy was sent for an x-ray and MRI (magnetic resonance imaging) of the spine. MRI scans produce extremely detailed pictures of the inside of the body by using very powerful magnets and computer technology. The results revealed a previously undetected condition known as atlanto-axial instability (AAI), which is increased flexibility between the first and second bones of the neck. He underwent surgery to fixate these bones and had  a slow but complete recovery of motor power over 7-months. He still needs some slight supplemental oxygen support.

As it turns out, the child has been evaluated before surgery for what were signs and symptoms of AAI, but the doctor falsely attributed them to failure to thrive due to tonsil disease despite a neurological exam showing weakness in the arms and legs, muscle wasting, and abnormal reflexes. The signs and symptoms included tiredness, poor weight and height gain, difficulty climbing stairs, and mild neck pain,

Because AAI was not recognized, when the head and neck were moved around during the surgery, the authors stated that the head hyperextended which resulted in a subluxation (signification structural displacement ). This, in turn, caused compression of the cervical spine. This compression causes impairment of the nerve signals that normally travel through this area of the spinal cord. It resulted in quadriplegia in this case because the compression was in the cervical (neck) region below which impulses regarding sensation and movement travel to and from the arms and legs.

The authors noted that the most common warning sign of AAI (85% of cases) is neck pain and headaches in the back of the head that radiate to towards the top of the head.  However, because signs and symptoms of AAI may be misinterpreted and because some patients may have no signs and symptoms, the only definitive way to detect it is with diagnostic imaging. Although the authors did not suggest performing x-rays or other imagine scans on patients before surgical procedures, it would be the only way to know for sure. However, exposure to radiation from x-rays and high financial causes of more advanced scans are likely barriers to this happening.  

Suggested reading: Walk, Don't Run: One Woman's Battle with Quadriplegia, A Memoir of Hope and Healing
Reference: Agarwal J, Tandon MS, Singh D, Ganjoo P. (2013, in press). Quadriplegia in a child following adenotonsillectomy. Anaesthesia.

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