FRACS Orthopaedic Exams
A sixty-eight-year-old man who had been diagnosed with severe osteoarthritis of the left knee presented for a total knee replacement.
An epidural catheter was inserted prior to the operation to provide anesthesia during surgery and analgesia postoperatively. According to the medical record, the catheter was inserted without difficulty, the operation was completed uneventfully, and the patient was then transferred to a ward.
The epidural catheter was removed on the third postoperative day, twelve hours after administration of the anticoagulant injection, and the patient was allowed to have oral analgesics as needed. The next day (four days postoperatively), the patient reported muscle weakness and low-back pain. Neurologic evaluation revealed muscle weakness in all muscle groups of the lower extremities. An urgent magnetic resonance imaging scan was ordered, but the scanner was not available. In the afternoon, a clinical evaluation revealed increased muscle weakness in all muscle groups of the lower extremities. The muscle strength was rated as 3 in all muscle groups. The next morning, the patient demonstrated further weakening in the lower extremities, and muscle strength in all muscle groups was rated as 2 (iliopsoas, quadriceps, and hamstrings muscles) or 3 (anterior tibial and posterior tibial muscles). The patient had also lost control of bowel and bladder sphincters.
1. What is the diagnosis?
2. What is your plan of management in this man?
3. What is his prognosis after appropriate treatment?