we report on a 63-year - old , average frame , caucasian male found to have clinical stage t1c adenocarcinoma of the prostate who , after discussion of all options , elected to undergo laparoscopic radical prostatectomy ( larp )
. a routine preoperative course then followed , including a medical history and physical examination , normal chest x - ray , electrocardiogram , basic metabolic panel and complete blood count .
the procedure was performed with an operative time of 276  min and was without incident .
blood loss was approximately 200  ml , and the patient was hemodynamically stable throughout the entire procedure .
after reversal of anesthesia and extubation , he was reported to be able to move all extremities upon arrival to the post anesthesia care unit ( pacu ) .
a few moments later he was unable to demonstrate any movement of all four extremities .
the anesthesia personnel were asked to first exclude drug reaction or persistent neuromuscular blockade from muscle relaxants ; neurology and spinal surgery consultation followed within the hour , and his sensation and muscle tone was found to be intact .
deep tendon reflexes were grade ii throughout all extremities a non - contrast computed tomography ( ct ) scan of the brain was negative for acute hemorrhage . magnetic resonance imaging ( mri ) of the brain , thoracic and cervical spine proved to be negative for spinal cord compression or injury , and a magnetic resonance arteriogram ( mra ) of the brain showed no aneurysm or other lesion .
neurology and spinal surgery neurological findings were consistent with pure motor quadriplegia with a differential diagnosis including an anterior spinal cord infarct or ischemia not evidenced by the mri .
spinal cord injury protocol was initiated including bolus dose steroids followed by continuous steroid infusion . at 12 and 24 
h post - surgery the patient still demonstrated complete motor quadriplegia . with the diagnosis of spinal injury becoming
less favored , a trial of hyperbaric oxygen therapy to treat a presumptive diagnosis of gas air embolism ( gae ) was requested .
the first hyperbaric oxygen therapy was started approximately 26  h postoperatively and led to an immediate ability to move his upper extremities and some minimal movement of his lower extremities .
twelve hours later the second hyperbaric oxygen treatment appeared to further increase his motor function .
an aggressive physical therapy regimen followed and over the course of the next 14  days a slow but steady recovery was appreciated .
he is now more than 8  weeks postoperative and is fully recovered and functional in the community .
laparoscopic radical prostatectomy is rapidly becoming the procedure of choice for surgical treatment of clinically localized prostate cancer .
current recommended guidelines for positioning were followed and include having the patient in steep trendelenberg position , the legs placed in stirrups , and the knees flexed and lowered .
all pressure points are padded with foam pads to prevent injury and the neck remains aligned and supported in a neutral position .
postoperatively our patient reported a remote history of minor hyperextension cervical spine injury that required no surgery and left him with no deficits .
there was no evidence of congenital abnormality or injury on any of our imaging studies .
reversible motor paralysis is not a known complication of larp or other laparoscopic surgery that could be found in the current literature .
however , there have been reports of specific deficits including paralysis in the literature that were attributed to gae by other authors [ 35 ] .
the lack of significant response to steroids in our case led us to doubt spinal cord injury as the explanation for these deficits .
negative mri findings agreed with this conclusion , and a repeat mri was performed 1  week postoperatively that showed no delayed findings consistent with injury .
our first discussion of a diagnosis of gae or anterior spinal cord ischemia was entertained early on postoperative day one . with no current diagnostic modality to confirm this suspicion , a trial of hyperbaric oxygen therapy was suggested and with excellent response .
most of the literature on gae and treatment modalities with hyperbaric oxygen therapy is based on decompression sickness and scuba diving injuries [ 68 ] .
.   demonstrated venous outflow obstruction as the cause of paralysis following induced decompression sickness in dogs .
the dogs were treated with dextran 70 with various outcomes prior to euthanization and autopsy .
there was significant white matter destruction showing  extensive spongy degeneration and  focal zones of demyelination with sparing of the gray matter .
these findings were felt to be consistent with venous occlusion from gas embolism leading to the paralysis .
gae has been shown to produce similar spinal cord syndromes in other reports and typically has responded well to hyperbaric oxygen therapy .
the pneumoperitoneum used in larp could have resulted in venous entry of gas embolus eventually traveling to the inferior vena cava ( ivc ) . upon removal of the steep trendelenberg position
, the gae could travel to the more proximal vena cava and cause obstruction of the lumbar veins and subsequently venous congestion compromising the spinal cord .
this might explain the delay between the end of the procedure and the onset of motor paralysis .
although the diagnosis of gae with spinal cord involvement was suspected , there is no typical presentation or firm method of diagnosis available . with a significant index of suspicion for a gae and a rapid recovery with hyperbaric oxygen therapy
although no immediate response was recognized , steroid administration could have been responsible for the eventual recovery as well .
regardless of the accurate etiology of the paralysis , we want to stress here the importance of early ( i.e. < 8  h ) multidisciplinary evaluation and treatment .
treatment including steroid administration to cover spinal cord injury and hyperbaric oxygen therapy if gae is a consideration could be critical in this rare event .
 laparoscopic radical prostatectomy ( larp ) has been accepted as first line therapy for clinically localized prostate cancer . 
 complications have been low and outcomes are comparable to that of open surgery with potential benefits including shorter hospital stay , less pain and quicker return to normal activity . 
 unexplained paralysis following larp is a rare entity with no reported cases in the current literature . 
 we report a case of complete motor paralysis following larp . 
 an extensive multidisciplinary evaluation did not definitively establish a diagnosis . 
 aggressive multimodality treatment led to a complete recovery . 
 our understanding of this phenomena with the possible etiology and treatment is discussed . 
Case presentation
Discussion