All the signs and neuromuscular symptoms that appear several years after the healing of acute poliomyelitis.

Reminder: polio is almost eradicated worldwide thanks to routine vaccination of infants. Nevertheless, outbreaks can  appear in some underdeveloped countries (Africa, Asia, refugees) and communities who refuse vaccination are at risk.

The causative virus is an enterovirus of the picornavirus family. There are 3 different serotypes. The poliovirus infection is asymptomatic in 95% of cases.

But produces:

-        in 4-8% of cases, a flu-like syndrome

-        in 1-2% of cases, an aseptic meningitis

-        in 1-2% of cases, an asymmetrical flaccid paralysis due to infection of neurons in the anterior horn of the spinal cord. Total or partial recovery within a few weeks;

Different forms:

1)   spinal polio (79%): paralysis of the limbs, generally asymmetric

2)   bulbar poliomyelitis (2%): respiratory involvement

3)   bulbospinal polio (18%): association of 1) and 2)

Post-polio syndrome is not a relapse of the disease (the patient is not contagious) and does not correspond to the final sequelae of infection (muscular contractures, amyotrophy, for example). It could be due to degeneration (by senescence or overuse) of axonal fibers of motor neurons that have proliferated during the healing phase to colonize motor units of neurons that have been destroyed (and thus create "giant" motor units) and enabled the patient to recover all or part of his motor functions.

The post-polio syndrome responds to the following 5 criteria:

*        history of polio paralysis (with loss of motor neurons)

*        notion of total or partial recovery after the bout of paralysis followed by a period of stability of the neurological functions of at least 15 years

*        gradual emergence of new signs of muscle weakness and/or abnormal central and muscular fatigue; other signs: swallowing disorders, chronic pain (muscle, periarticular, osteoarthritis), dyspnea (obstructive or central apneas during sleep), urinary problems ...

*        symptoms for at least 1 year

*        exclusion of other medical causes which could explain the patient disorders

Multidisciplinary treatment of maintenance of the motor skills of the patient.

Anesthetic implications:

evaluate muscle strength; possible presence of neuropathic pain; chronic pain treatment; theoretically: increased sensitivity to inhaled anesthetics and morphine but this does not seem to be confirmed by clinical response to inhaled anesthetics and morphine; breathing problems during sleep; increased risk of aspiration pneumonitis; monitoring of curarization (try to get a basal response before the paralyzing): in one case, the duration of action of succinylcholine (0.8 mg/kg) lasted 35 minutes but did not result in hyperkalemia. Some cases of decreased adrenocortical stress response have been described; intolerance to cold; fragile joints (positioning).

The use of a regional anesthesia is a matter of controversy: there is no scientific evidence of a risk of toxicity of local anesthetics used by intrathecal or neuraxial route on motoneurons which survived the polio episode. To be evaluated on a case by case basis.

informations : www.post-polio.org

References:

-         Lambert DA, Giannouli E, Schmidt BJ. 
Postpolio syndrome and anesthesia. 
Anesthesiology 2005; 103: 638-44.

-         Werner A, Bourgeois B, Merckx P, Paugam-Burtz C, Mantz J. 
Successful use of succinylcholine for cesarean delivery in a patient with postpolio syndrome.
Anesthesiology 2007; 107: 680-1.

-         Higashizawa T, Sugiura J, Takasugi Y. 
Spinal anesthesia in a patient with hemiparesis after poliomyelitis. 
Masui 2003; 52: 1335-7.

-         Schwartz A, Bosch LM. 
Anesthetic implications of postpolio syndrome : new concerns for a old disease. 
AANA Journal 2012; 80 : 356-61.

-        Van Alstine LW, Gunn PW, Schroeder DR, Hanson AC, Sorenson EJ, Martin DP. 
Anesthesia and poliomyelitis: a matched cohort study. 
Anesth Analg 2016; 122:1894-1900

-        Tseng W-C, Zhi-Fu W, Liaw W-J, Hwa S-Y et al.
A patient with postpolio syndrome developed cauda equina syndrome after neuraxial anesthesia : a case report.
J Clin Anesth 2017 ; 37 :49-51

Updated: February 2017