Sir,
We report a case of a 2-year-old female child who presented to the emergency with
a history of high-grade fever for 25 days, progressive neck extension for 15 days
and poor oral intake since 5 days. All developmental milestones were achieved as per
her peers, and there was no history of seizures, weakness of limbs or difficulty in
swallowing or breathing. On admission, the child was afebrile, weighed 8 kg, head
circumference 46 cm, pulse rate 140/min, respiratory rate 30/min, Glasgow Coma Scale
(GCS) 15/15, normal reactive pupils and moving all four limbs spontaneously. The overall
physical examination was unremarkable except for the presence of ophisthotonic posture
[Figure 1]. Non-contrast computed tomography head revealed temporo-parietal mass with effacement
of the ipsilateral temporal horn of lateral ventricle suggestive of hydrocephalus.
External ventricular drainage (EVD) was planned in the Neurointensive Care Unit and
for which child was intubated. Difficult intubation cart was prepared, and the child
was properly positioned using sheets and pillow to support her back and head to avoid
position related neurological injuries and facilitate tracheal intubation. She was
given intravenous propofol 20 mg with fentanyl 20 mcg. Under sedation, child was intubated
with 3.5 mm microcuffed endotracheal tube using McIntosh blade (Cormack-Lehane Grade
I). After confirmation of bilateral equal air entry, she was put on pressure control
ventilation. Later 1 mg vecuronium to facilitate the procedure that lasted for 20
min and was uneventful.
Figure 1: Posture of child on admission
Five hours post-procedure child developed flaccid quadriplegia with fall in GCS (E3VTM1). Thirty ml of cerebrospinal fluid was drained by EVD during this time. For sudden
inexplicable drop in GCS and motor power in an ophisthotonic child, magnetic resonance
imaging (MRI) of the brain and spinal cord was obtained. MRI revealed an interventricular
tumour with extensive leptomeningeal spread and compression at the foramen magnum.
There was oedema at the level of upper cord along with ascending tentorial herniation
[Figure 2].
Figure 2: Magnetic resonance imaging of head and spinal cord showing extensive leptomeningeal
spread, compression at foramen magnum, oedema at the level of upper cord along with
transtentorial herniation
The risk of neurological injury during airway manoeuvring, especially endotracheal
intubation is defined but rarely encountered. The literature has few case reports
regarding occurrence of cervical spine fractures during intubation in elderly patients
with ankylosing spondylitis or severe osteoporosis.[1] However, the condition is rarely described in children.[2] We found child moving limbs following intubation but became quadriplegic after administration
of muscle relaxant. We presume that quadriplegia was due to leptomeningeal spread
along with compression at the level of the foramen magnum. Catastrophic ascending
tentorial herniation due to cerebrospinal fluid drainage via EVD is another possibility.
We recommend that such patients should be dealt with utmost care not only during airway
manoeuvring but also subsequent positioning. Post-intubation quadriplegia is a rare
entity especially in undiseased spine and cord in paediatric population so structural
neurological disease should always be considered in the differential diagnosis for
so-called post-intubation neurological deficits. We suggest screening for subtle neurological
deficits, adequate precautions during airway manipulations and pre- and post-procedure
documentation of muscle power in patients with least suspicion of neurological deficit
or abnormal posture like ophisthotonus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
