Postoperative hemiparesis due to conversion disorder after m
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Perioperative conversion disorder that manifests as postoperative muscle weakness is an uncommon diagnosis made through exclusion of neurological, metabolic or iatrogenic aetiologies. Conversion disorder, is a functional neurological deficit that is a diagnosis of exclusion without any attributable medical cause or malingering, typically affecting motor and/or sensory function or even causing transient loss of consciousness.

A 39‐year‐old woman presented for a right breast mass excision and biopsy. Her past medical history was significant for migraine headaches and her past psychiatric history significant for childhood trauma, right upper extremity burns and domestic abuse as an adult.

For this operation, her anaesthetic consisted of moderate‐to‐deep sedation, composed of midazolam 2 mg, propofol infusion between 60 – 90 μg.kg−1.min−1, fentanyl 75 μg and no neuromuscular blocking drug. Twenty millilitres of bupivacaine 0.25% was injected around the incision by the surgeon. The patient tolerated the 35‐min procedure well. Of note, she was alert and oriented to person, place and time, and conversant immediately postoperatively.

One hour postoperatively, she was noted to have right upper and lower extremity paresis without discernible temperature sensation and no withdrawal to noxious stimuli. She continued to be conversant, alert and oriented. Her vital signs were within normal limits. Her cranial nerve examination was unremarkable. No hypertonia, hyperreflexia or posturing was observed and proprioception remained normal. Routine bloodwork showed normal electrolyte levels, renal function and blood counts.

Based on neurology recommendations, a magnetic resonance image of the brain, head and cervical neck was performed and ruled‐out stroke, haemorrhage, mass or any structural cause for paresis. It was significant only for mild congenital stenosis and a slight disc bulge seen at C5‐C6 with no myelopathy.

On day three of her admission, with continued right‐side hemiparesis, multidisciplinary team believed that there was enough evidence to investigate psychosomatic diagnoses and psychiatrists were consulted. The psychiatry team diagnosed the patient with a postoperative conversion disorder based on continued functional neurological symptoms with a low suspicion of malingering or secondary gain. She was evaluated by physical medicine for rehabilitation and eventually transferred to their care. The care team was instructed to avoid any unnecessary diagnostic testing and rather focus on affirming the patient's symptoms as being ‘organic’ and ‘functional’ as opposed to ‘psychogenic.’ After 28 days of inpatient rehabilitation focusing on upper and lower extremity strength‐building exercises, cognitive behavioural therapy and continued affirmation of her symptoms in a low acuity setting, the patient eventually regained her baseline motor function and was discharged home.

Finally, this case highlights the importance of assessing a patient's social and trauma history during the peri‐operative period and the need to carefully manage conversion disorders with the appropriate team of specialists in order to facilitate the supportive care necessary for recovery from a functional standpoint. This patient's hemiparesis likely represented an unconscious manifestation of stress resulting in the somatisation of her psychological state. This may explain the lateralisation of her symptoms to her right, given her right‐sided upper extremity burns as a child and the concern for a right‐side breast lesion.

Source : https://onlinelibrary.wiley.com/doi/full/10.1002/anr3.12035
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