Reactions 1007 - 26 Jun 2004

★ SBupivacaine/clonidine

First report of spinal cord disorder: case reportA 45-year-old man developed a spinal cord lesion after long-

term continuous intrathecal infusion of bupivacaine andclonidine for refractory pain in his right leg.

The man initially received a single intrathecal bupivacaine2mg injection at the L3–L4 level, which significantly reducedhis pain; a programmable pump was subsequently implantedto deliver a continuous intrathecal infusion of 4% bupivacaine.His bupivacaine dose was quickly increased, and maintainedbetween 24 and 26.6 mg/day. After 13 months, clonidine200 µg/day was added due to decreasing efficacy and episodesof orthostatic hypotension associated with the bupivacaineinfusion. He received bupivacaine 20 mg/day and clonidine200 µg/day over the next 600 days, with good pain relief.Approximately 3 years after pump implantation, the manpresented with lower back pain with anterior belt-likeirradiation, paraesthesia and weakness in his left leg, andurinary and faecal retention. An examination revealed gaitataxia with impaired proprioception in his left leg, abolishedvibration sensation up to his left knee, and a left foot drop.Three days later he lost proprioception up to the level of Th11bilaterally, and developed left leg hyper-reflexia, extensor leftplantar reflex and bilateral hypoaesthesia of all sacralsegments. A spinal MRI revealed a round 3mm cavity withinthe spinal cord at the level of Th9–11, and oedema extendingfrom the level of Th5 to the conus medullaris.

The intrathecal pump was stopped, with the catheter left inplace, and the man was treated with oral prednisolone. Overthe next 3 months his symptoms improved, but hisproprioception was only partially recovered and mild gaitataxia persisted. MRIs 1 and 3 months later showed a hyper-intense posterolateral lesion at the Th10–11 level on the leftside, a centromedullary lesion at Th9, and resolution of theoedema.

Author comment: "Although the precise cause of thelesion remains unknown, we have considered the possibilityof a direct trauma as well as a drug related neurotoxic effect.Direct injury cannot be excluded."Perren F, et al. Spinal cord lesion after long-term intrathecal clonidine andbupivacaine treatment for the management of intractable pain. Pain 109: 189-194,No. 1-2, May 2004 - Switzerland 800977374

» Editorial comment: A search of AdisBase and Medline didnot reveal any previous case reports of spinal cord disorderassociated with bupivacaine or clonidine. The WHO AdverseDrug Reactions database contained one report of spinal cordcompression, but no reports of spinal cord injury associatedwith clonidine, and no reports of spinal cord compression orinjury associated with bupivacaine.

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Reactions 26 Jun 2004 No. 10070114-9954/10/1007-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved