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JAIN MUKUL ET AL : SPINAL CORD COMPRESSION FOLLOWING ECT
Aggravated Spinal Cord Compression following Electroconvulsive Therapy Dear Sir A 20 year old female weighing 50kg diagnosed as paranoid schizophrenia with inability to control bladder/ bowel for last 15 days and suicidal attempt was scheduled for emergency modified ECT (MECT). Routine clinical examination revealed no neurological abnormality suggestive of spinal fracture. During preanesthetic checkup, routine physical examination did not reveal any abnormality and routine investigations were within normal limits except X Ray chest which was suggestive of pulmonary Koch's. Sputum was negative for acid fast bacilli. Standard anaesthetic technique was applied during MECT. After giving Inj. Glycopyrrolate 0.2 mg, induction was done with 100mg thiopentone and 35mg succinylcholine and vitals (Pulse rate, B.P., SPO2, ECG, Seizure monitoring) were monitored. Patient showed improvement in psychiatric illness after third MECT. Later on she complained leg pain and inability to pass urine along with increasing difficulty in walking. Neurological examination at that time revealed spinal deformity at dorso-lumbar region along with exaggerated lower limb reflexes and extensor planters. MRI revealed L1 vertebral body fracture with anterior compression of cord along with intensity changes in the cord. She got relief after decompression and fixation of the pedicle. Reported complications of MECT are mainly cardiovascular. Although fracture of vertebrae following MECT is rare, it may occur in a compromised patient during direct ECT. Though x ray of spine was indicated prior to ECT especially in elderly because of degenerative changes in spine1, as our patient or her attendants did not give any significant history except urinary incontinence, the possibility of any fracture or compression of vertebrae was missed during PAC. It was only diagnosed when features of spinal cord compression became obvious after third ECT. Considering the history of fall from 20 feet height and pain at back after 3rd MECT, it was assumed that patient already had a compression/ fracture in the vertebrae, which was missed at the time of PAC for MECT. Patients with schizophrenia are reported to have diminished pain sensitivity2 and probably it was the reason that patient was not aware of pain in back. It has been reported that chronic schizophrenic patients have an increased threshold of Cfiber function.3 A dysregulation of N-methyl-d-aspartate
Figure 1 MRI film showing the fractured L1 vertebra with indentation of spinal cord
(NMDA) receptor transmission in schizophrenic patients may account for pain insensitivity. 4 Pain insensitivity in schizophrenic patients may also be a result of antipsychotics, as most antipsychotics have analgesic effects. 5 Pain insensitivity may have life threatening consequences because pain insensitivity can delay the diagnosis and treatment of illness. REFERENCES 1. Abram R. Electroconvulsive therapy in the medically completed patient. Psychiatry Clin North America Am 1991; 14: 871. 2. Virit O, Savas H A, Altindag A. Lack of pain in schizophrenia: A patient whose arm was burnt and amputed. General Hospital Psychiatry 2008; 30: P 384385 3. Kudoh A, Ishihara H, Matsuki A. Current perception thresholds and postoperative pain in schizophrenic patients. Reg Anesth Pain Med 2000; 25:475-9. 4. Javitt DC, Zukin SR. Recent advances in the phencyclidine model of schizophrenia. Am J Psychiatry 1991; 148: 1301- 8. 5. Patt RB, Proper G, Reddy S. The neuroleptics as adjuvant analgesics. J Pain Sympt Manag 1994; 9: 446 -53. Mukul Jain, Arvind Arya, Deepak K Jha, Sourabh Mehrotra, Utpal Sarma, Amit Mehra
Dept. of Neuroanesthesiology, Dept. of Neurosurgery and Dept. of Psychiatry, IHBAS, New Delhi, India Correspondence : Dr. Mukul Jain E-mail :
[email protected]
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