The physiologic effects of neuraxial blocks may be
misinterpreted as complications Serious neurologic complications
are rare The true incidence of most neurologic injury is
unknown
Slide 5
The frequency 0.1 per 10,000 the mechanism: 1. direct needle
trauma to the spinal cord 2. the injection of a foreign substance
into the CSF 3. Contamination by the descaling liquid used to
cleanse the procedure 4. the chloroprocaine neurotoxicity 5.
Adhesive arachnoiditis, cauda equina syndrome to be related to a
combination of low pH and the antioxidant sodium bisulfite
preservative 6. Profound hypotension or ischemia of the spinal cord
7. Anterior spinal artery syndromepainless loss of motor and
sensory function with sparing of proprioceptionby the posterior
column The anterior cord vulnerable to ischemic single and tenuous
source of arterial blood supply (Adamkiewicz) Ischemia caused
profound hypotension,mechanical obstruction, vasculopathy, or
hemorrhageirreversible anterior cord damage
Slide 6
The rate 0.1 per 10,000 The lumbosacral roots vulnerable to
direct exposure of large doses of LA: a single injection of highly
concentrated LA (5% lidocaine) prolonged exposure to a LA through a
continuous catheter spinal catheters smaller than 24 G( headache) :
1- to pooling of LA around the lumbosacral nerve roots 2- slow
injectate flow through the fine-bore catheter: exposing them to
high concentrations of LA
Slide 7
the rates 0.06/10,000 after SA after EA tenfold higher
Slide 8
risk factors including : 1. Difficult or traumatic needle or
catheter insertion 2. coagulopathy 3. elderly age 4. female gender
commonly features: Radicular back pain,prolonged blockade longer
and bladder or bowel dysfunction should prompt MRI on an urgent
basis
Slide 9
rate of radiculopathy or paresthesia or peripheral neuropathy
EA CSE SA in adults for the purposes of perioperative anesthesia or
analgesia in the obstetric, pediatric, and chronic pain settings
difficult to determine because investigation, diagnosis, causation,
outcomes are highly variable. SA-EA (0.1 per 10,000) CSEs (0.2 per
10,000), mostly in young, healthy patients.
Slide 10
A relatively common complication to result from puncture of the
dura membrane: neuraxial anesthesia after myelography diagnostic
lumbar puncture 1. First, the loss of CSF through the dura traction
on pain-sensitive intracranial structures 2. Alternatively, the
loss of CSF compensatory painful intracerebral vasodilation to
offset the reduction in intracranial pressure
Slide 11
The characteristic feature: a frontal or occipital headache
that worsens with the upright or seated posture and is relieved by
lying supine Associated symptoms : nausea, vomiting, neck pain,
dizziness, tinnitus, diplopia, hearing loss, cortical blindness,
cranial nerve palsies, and even seizures. In more than 90% of
cases, the onset of characteristic symptoms within 3days of the
procedure, 66% start within the first 48h Spontaneous resolution
usually within 7 days in the majority (72%) of cases, whereas 87%
of cases resolve by 6 months
Slide 12
Factors That Can Increase the Incidence of Headache After
Spinal Puncture 1. Age: Younger, more frequent 2. Sex: Females >
males 3. Needle size: Larger > smaller 4. Needle bevel: Less
when the needle bevel is placed in the long axis of the neuraxis
noncutting needle cutting 5. Pregnancy: More when pregnant 6. Dural
punctures: More with multiple punctures Factors That Do Not
Increase the Incidence of Headache After Spinal Puncture 1.
Insertion and use of catheters for continuous spinal anesthesia 2.
Timing of ambulation
Slide 13
Conservative management : 1. supine positioning 2. hydration 3.
caffeine 4. and oral analgesics. 5. Sumatriptan has also been used
with varying effect but is not without side effects
Slide 14
Epidural blood patch definitive therapy its safety and efficacy
well-documented a single epidural blood patch 90% initial
improvement rate persistent resolution 61% to 75% of cases
Slide 15
ideally performed 24 hours after dural puncture and after the
development of classic symptoms prophylactic epidural blood
patching??? the direction of spread was preferentially cephalad A
recent multinational, multicenter, randomized, blinded trial
suggested that 20 mL of blood is a reasonable starting target
volume blood will spread over a mean distance of nine spinal
segments A second patch may be performed 24 to 48 hours after the
first in the case of ineffective or incomplete relief of
symptoms
Slide 16
after intrathecal administration of every LA
(Traditionally,lidocaine) SA is usually characterized: 1. bilateral
or unilateral pain in the buttocks legs or, less commonly, isolated
buttock or leg pain. 2. Symptoms occur within 24 hours of the
resolution of SA 3. not associated with any neurologic deficits or
laboratory abnormalities 4. mild to severe pain and typically
resolves spontaneously in 1 week or less highest after intrathecal
lidocaine and mepivacaine and is far less frequent with bupivacaine
The type of needle reduced by a double-orifice needlesingle-
orifice injecting anesthetic caudally in the thecal sac not
commonly with epidural procedures(occurred with lidocaine) commonly
the lithotomy position NSAID the first line of treatment,but pain
severe even require opioids.
Slide 17
in SA hypotension (defined as SBP30%) is associated with:
chronic alcohol consumption,history of hypertension, BMI, and the
urgency of surgery. TREATMENT: 1. prevention of hypotension caused
by vasodilatation by a prophylactic (preloading) 2. infusion of
colloid or crystalloid during the performance of the neuraxial
block (coloading) 3. this is no longer recommended as a routine
practice.
Slide 18
blockade of the thoracic sympathetic fibers (preganglionic
cardiac accelerator fibers at T1-T5) reflexive slowing of the HR as
vasodilation reduces the venous return to the RA stretch receptors
exaggerated bradycardia(40 to 50) : 1. baselineHR 60 2. age 37
years 3. male gender 4. nonemergency status 5. -adrenergic blockade
6. prolonged case duration Severe bradycardia (