Spinal anesthesia symptoms

Transient neurological symptoms have been observed in patients after spinal anesthesia (Hampl et al. 1995). Activity and tolerability of new local anesthetics after intrathecal injection were studied in various animal species in order to predict both parameters for spinal (subarachnoid) anesthesia in patients. 

Hampl KF, Schneider MC, Ummenhofer W, Drews J (1995) Transient neurological symptoms after spinal anesthesia. Anesth Analg 81 1148-1153... 

A 37-year-old man who had abused metamfetamine, paint thinner, psychotomimetic drugs, and alcohol for 20 years was given chlorpromazine, haloperidol, and fluni-trazepam just before surgery. After spinal anesthesia he was given propofol 5 mg/kg/hour intravenously. However, euphoria and excitement occurred 10 minutes after the start of the infusion and he had excitement, hallucinations, and delirium. His symptoms were suppressed by intravenous haloperidol 5 mg. 

Lambert DH. Transient neurologic symptoms when phenylephrine is added to tetracaine spinal anesthesia—an alternative. Anesthesiology 1998 89(1) 273. 

A 68-year-old man developed total spinal anesthesia after the administration of 20 ml of ropivacaine 1% without a prior test dose via an epidural catheter, which was inadvertently placed intrathecally (83). Initial aspiration of both the Touhy needle and the catheter failed to identify the intrathecal position of the catheter. The patient noted weakness in his right leg immediately after the end of the injection. This was followed by weakness in his right arm, asystole, apnea, and loss of consciousness. Ventricular escape beats were noted and sinus rhythm returned after mask ventilation with 100% oxygen and the administration of atropine 1 mg and ephedrine 50 mg. He was able to open his eyes, but remained apneic and was therefore intubated and ventilated. Cardiovascular stabihty was maintained with incremental boluses of ephedrine to a total of 60 mg. He regained consciousness and was successfully extubated 145 minutes later. AH sensory and motor deficits had resolved within 8 hours and no neurological deficit or transient neurological symptoms were detected 5 days later. 

A receding spinal block to level Ll-2 gave rise to acute bradycardia (34-40/minute) and transient loss of consciousness in a 31-year-old man 5 hours after spinal anesthesia on waking he complained of severe low back pain, and although he had no symptoms of urinary retention, urinary catheterization yielded 900 ml of urine with immediate relief of symptoms. 

Cauda equina syndrome occurred in a 55-year-old woman who underwent spinal anesthesia with a 22 G needle in the L4-5 interspace (214). On needle insertion, she felt radiating pain in her right leg. The needle was immediately withdrawn and repositioned. Pain-free intrathecal injection of 2.0 ml of hyperbaric cinchocaine 0.24% with adrenaline 66 micrograms resulted in block to LI. Surgery was carried out in the supine position. Three days postoperatively, she had enuresis and reduced perineal sensation, without bowel dysfunction or lower limb symptoms. There was sensory loss at S2-5. The symptoms persisted, required self-catheterization and systemic steroids, and disappeared on the 19th postoperative day. 

The incidence of transient radicular irritation with two different local anesthetics used for single-dose spinal anesthesia has been studied in 60 ambulatory patients given spinal anesthesia for knee arthroscopy (235). None of those who were given 1.5% mepivacaine 45 mg developed transient radicular irritation. Six of those given 2% lidocaine 60 mg developed transient radicular irritation, but all symptoms resolved by 1-5 days. The difference between the two groups was significant. 

When 90 patients received spinal anesthesia for gynecological procedures with 2% hdocaine, 2% prUocaine, or 0.5% bupivacaine (all 2.5 ml in 7.5% glucose), nine of the 30 patients who received lidocaine had transient radicular irritation, defined as pain or dysesthesia in the legs or buttocks, compared with none of the 30 patients who received bupivacaine (236). The symptoms resolved within 48 hours. One of the 30 patients who received prilocaine had transient radicular irritation that lasted for 4 days. 

Urinary retention as a true transient neurological symptom developed after accidental total spinal anesthesia with mepivacaine, which is often considered to be the best agent for intrathecal anesthesia, owing to its low incidence of transient radicular irritation (268). 

Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anesthesia an epidemiologic study of 1,863 patients. Anesthesiology 1998 89(3) 633 1. 

Liguori GA, Zayas VM, Chisholm MF. Transient neurologic symptoms after spinal anesthesia with mepivacaine and lidocaine. Anesthesiology 1998 88(3) 619-23. 

Axelrod EH, Alexander GD, Brown M, Schork MA. Procaine spinal anesthesia a pilot study of the incidence of transient neurologic symptoms. J Clin Anesth 1998 10(5) 404-9. 

Philip J, Sharma SK, Gottumukkala VN, Perez BJ, Slaymaker EA, Wiley J. Transient neurologic symptoms after spinal anesthesia with lidocaine in obstetric patients. Anesth Analg 2001 92(2) 405-9. 

Eberhart LH, Morin AM, Kranke P, Geldner G, Wulf H. Transiente neurologische Symptome nach Spinalanasthesie. Eine quantitative systematische Ubersicht (Metaanalyse) randomisierter kontrollierter Studien. [Transient neurologic symptoms after spinal anesthesia. A quantitative systematic overview (meta-analysis) of randomized controlled studies.] Anaesthesist 2002 51(7) 539 6. 

Adachi Y, Watanabe K, Uchihashi Y, Sato T. [Urinary retention as a transient neurologic symptom after accidental total spinal anesthesia with mepivacaine hydrochloride..] Masui 1999 48(9) 1009-10. 

There have been responses to last year s report of occurring after the addition of phenylephrine to tetracaine spinal anesthesia. It has been suggested that sodium bisulfite, a preservative in phenylephrine solutions for injection, may have been responsible for transient neurological symptoms that have been observed in some patients (7). However, the original authors rejected this, since the dose of bisulfite was small and since there is uncertain evidence whether the compound is neurotoxic in any case. Another correspondent commented that tetracaine itself may be more toxic than other local anesthetics the authors did not address this point in their reply (8). 

Edomwonyi NP, Isesele TO. Transient neurological symptoms following spinal anesthesia for cesarean section. Middle East J Anesthesiol 2010 20 809-13. 

A 52-year-old woman developed spinal myoclonus 60 minutes after receiving 60 mg of hyperbaric prilocaine 5%. She had involuntary, asymmetrical, brief movements of the legs at a frequency of 10-20/minute. Treatment with intravenous diazepam 5 mg blunted the symptoms but did not abolish them they resolved completely 60 minutes after full recovery from spinal anesthesia. There were no residual signs of neurological impairment. 

Nervous system A 26-year-old woman undergoing emergency cesarean delivery under spinal anesthesia with bupivacaine 10 mg was pre-medicated with intravenous ranitidine 50 mg and metoclopramide 10 mg, and received intramuscular diclofenac for postoperative analgesia [32 ]. Starting at 12 hours postoperatively she was given intravenous ondansetron 6 mg every 12 hours for nausea and vomiting. About 2 hours after the first dose she developed a severe headache, which persisted for over 90 hours and was characterized by aggravation of symptoms in coincidence with doses of ondansetron. The headache resolved completely a few hours after ondansetron withdrawal. 

Nervous System A recent review analysed the available data on chloroprocaine and its use in intrathecal anesthesia [35 ]. The authors conclude that preservative-free chloroprocaine is an effective alternative to lidocaine to provide spinal anesthesia for short cases with a much lower rate of transitory neurological symptoms (TNS). Its recent approval in Europe may herald increased utilisation and availability. 

Pollock JE, Burkhead D, Neal JM, Liu SS, Friedman A, Stephenson C, Polissar NL. Spinal nerve function in five volunteers experiencing transient neurologic symptoms after lidocaine subarachnoid anesthesia. Anesth Analg 2000 90(3) 658-65. 

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