A Case of Fournier’s Gangrene Contraindicating Spinal Anesthesia

To the Editor:—

Fournier’s gangrene is a necrotizing fascilitis of the genitalia and perineum that may extend to the neighboring soft tissues such as the anterior abdominal wall, buttocks, or lower extremities. 1–3Treatment of this syndrome requires adequate drainage and debridement as promptly as possible. We report a case of Fournier’s gangrene for which spinal anesthesia was considered to be contraindicated.

A 64-yr-old woman suffered from painful swelling in the perineal region. Her body temperature was 38°C for 1 week. She had a medical history of insulin for diabetes mellitus. On admission, the cellulitic activity extended to the anal and perineal regions and bilateral thigh walls with prominent subcutaneous crepitation. Her white blood cell count and blood sugar and C-reactive protein levels were 8,660/μl, 425 mg/dl, and 39.0 mg/dl, respectively. A surgeon requested spinal anesthesia for drainage because on physical examination, her back appeared normal. However, we found the existence of some gas in her back, including the paravertebral area on computed tomography, suggesting subcutaneous and paravertebral dissection of the infection (fig. 1 

). Therefore, we chose to use general anesthesia instead of spinal anesthesia.

In Fournier’s gangrene, emphysema in the subcutaneous and paravertebral area of the lower back have not been reported to date. Therefore, in most reports, either local or spinal anesthesia was selected for surgical debridement. In our hospital, we have recently treated two patients with Fournier’s gangrene by surgical debridement. Local anesthesia was selected in one patient, and the other was administered spinal anesthesia; roentgenogram examination was not performed. These two operations were performed without any complication. Anesthesiologists generally know that spinal anesthesia should not be performed through infected tissues. However, sometimes infections are not clear on inspection or palpation. In this case, the extensive spread of the infection to the subcutaneous and paravertebral area was only visible with an imaging study. Therefore, computed tomography should be carefully checked to clarify the existence of gas in a patient’s back. Otherwise, general anesthesia should be selected in the drainage for Fournier’s gangrene to prevent intraspinal canal infections.