Ratikorn Boonchai¹, Sarayuth Boonchai²

Background: Total spinal anesthesia (TSA) following epidural analgesia is rare but potentially life-threatening, particularly during major abdominal surgeries such as pancreaticoduodenectomy. Degenerative spinal disease may increase the risk of rapid cephalad spread of local anesthetic, thereby predisposing patients to immediate TSA even with technically correct catheter placement.

Case Report: A 60-year-old woman scheduled for elective pancreaticoduodenectomy developed immediate TSA following a thoracic epidural test dose of 3 mL 2% lidocaine with adrenaline (1:200,000). Despite a negative cerebrospinal fluid (CSF) aspiration test, she experienced rapid-onset neurological impairment and respiratory arrest. Emergency management included airway support, tracheal intubation, mechanical ventilation, invasive monitoring, and spinal imaging. Magnetic resonance imaging (MRI) revealed multilevel degenerative spinal changes that may have contributed to the intrathecal spread of local anesthetic. The surgery was postponed, and the patient fully recovered neurologically without residual deficits.

Conclusion: The present case highlights the need for thorough pre-procedural spinal evaluation in patients with suspected degenerative changes. A negative CSF aspiration does not rule out the risk of intrathecal migration. Clinicians should consider alternative regional techniques such as erector spinae or paravertebral blocks in high-risk patients. Multidisciplinary coordination and vigilant intraoperative monitoring are essential to improving patient safety and perioperative outcomes.

Received 4 June 2025 | Revised 18 September 2025 | Accepted 25 September 2025

DOI: 10.35755/jmedassocthai.2025.10.845-850-03121