Cauda Equina Syndrome After Continuous Spinal Anesthesia

Rigler, Mark L.; Drasner, Kenneth; Krejcie, Tom C.; Yelich, Sharon J.; Scholnick, Faith T.; DeFontes, James; Bohner, David

doi:10.1213/00000539-199103000-00001

Cited by 578 publications

(192 citation statements)

References 31 publications

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“…Although anesthesiologists attribute differential nerve fiber blockade at reversible neural block to differences in nerve fiber diameter, conduction velocity, or surrounding myelination, the real causes remain unclear (Gasser and Erlanger, 1929;Gissen et al, 1980;Fink, 1989). Irreversible neural injury caused by high concentrations of local anesthetic in spinal anesthesia has become a serious problem over the past 15 years, and the underlying mechanisms are likewise unknown (Rigler et al, 1991;Drasner et al, 1994;Sakura et al, 1995a,b). If the application of the Neurometer in an animal model can be shown to be useful, large amounts of information regarding the mechanisms of differential nerve blocking and neurotoxicity induced by local anesthetics will become available.…”

mentioning

confidence: 99%

Quantitative and Fiber-Selective Evaluation of Dose-Dependent Nerve Blockade by Intrathecal Lidocaine in Rats

Oda¹,

Kitagawa²,

Yang³

et al. 2004

J Pharmacol Exp Ther

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We investigated whether cutaneous stimulus threshold (CST), as determined using a Neurometer, could be used for quantitative and differential nerve evaluation of reversible and irreversible nerve block following intrathecal lidocaine administration in rats. Rats with intrathecal catheters were randomly assigned to one of five groups (saline or 2, 5, 10, or 20% lidocaine). Prior to and 4 days after drug administration, CST was determined at 5, 250, and 2000 Hz. In the 2% lidocaine group, CST from end of lidocaine infusion to recovery from anesthesia was also monitored. Skin-clamp testing and gait observation were performed for comparison with CST findings. Behavioral examinations revealed persistent sensory or motor impairment lasting 4 days in groups receiving Ն5% lidocaine but not in the saline and 2% lidocaine groups. With 2% lidocaine, return to baseline CSTs at 5 and 250 Hz was delayed compared with thresholds at 2000 Hz. Although CSTs in the 5% group at 5 and 250 Hz increased significantly, thresholds at 2000 Hz did not differ from those in rats administered saline. CSTs with Ն10% lidocaine displayed no differences between frequencies. At each frequency, CSTs for rats with Ն5% lidocaine increased in a clearly concentration-dependent manner. These results suggest that CST testing enables evaluation of the different nerve functions for A␤, A␦, and C fibers in rats for lidocaine concentrations Յ5% and allows quantitative assessment of persistent neurological deficit induced by lidocaine in rats.

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confidence: 99%

Quantitative and Fiber-Selective Evaluation of Dose-Dependent Nerve Blockade by Intrathecal Lidocaine in Rats

Oda¹,

Kitagawa²,

Yang³

et al. 2004

J Pharmacol Exp Ther

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“…The toxicity levels of three drugs were similar in their studies, different from the present experiments. It is not clear whether continuous infusion using a pump promoted maldistribution of the local anesthetics, for example, accumulation in the cauda equina region 24 leading to high concentrations in this region which hampered the assessment of the differences in toxicity levels among the injected local anesthetics.…”

Section: Discussionmentioning

confidence: 99%

Intrathecally administered ropivacaine is less neurotoxic than procaine, bupivacaine, and levobupivacaine in a rat spinal model

Takenami

Wang

Nara

et al. 2012

Can J Anesth/J Can Anesth

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Purpose The aim of this study was to compare the neurotoxicity of intrathecal procaine, bupivacaine, levobupivacaine, and ropivacaine in an animal model. Methods The study comprised two experiments. In the concentration experiment, rats (n = 78) were administered 0.12 lLÁg -1 body weight (BW) of 2% or 20% procaine, 0.5% or 5% bupivacaine, 0.5% or 5% levobupivacaine, or 0.5% or 5% ropivacaine. Based on the findings, the doses were increased by volume in the subsequent volume experiment using 0.12, 0.24, or 0.48 lLÁg -1 BW of 6% procaine, 6% levobupivacaine, or 6% ropivacaine (n = 79). Walking behaviour and sensory threshold were analyzed, and a histological examination of the spinal cord, posterior and anterior roots, and cauda equina was performed. Results The concentration experiment showed abnormalities only in the 5% bupivacaine group, and these abnormal findings were in the posterior root (PR) and posterior column (PC). The volume experiment revealed that procaine 0.24 lLÁg -1 was neurotoxic, mainly affecting the PR. At 0.48 lLÁg -1 , severe injury was observed in the PR and PC in all six procaine rats and four of six levobupivacaine rats, while milder injury was limited to the PR in one of six ropivacaine rats, which differed significantly from the former two groups (P = 0.006 and P = 0.014, respectively). Electron microscopy showed axonal degeneration. Conclusion All four local anesthetics seemed to cause identical neurotoxic lesions commencing in the PR and Author contributions Tamie Takenami designed and initiated this study, took part in all aspects of the experiments, collected data for statistical analysis, and wrote the manuscript. Guoqin Wang performed statistical tests, assisted with the statistical analysis, and proposed the method of statistical analysis to validate the injury score. Yoshihiro Nara assisted with catheterization, drug injection, and securing the catheters. He also performed evaluations for the ambulation and paw stimulation tests. Sayano Fukushima assisted with the assessment of the injury scores. Saburo Yagishita verified the pathological changes. Hiromi Hiruma and Tadashi Kawakami allowed use of their laboratory during the study and reviewed the manuscript. Hiromi Hiruma, Tadashi Kawakami, and Hirotsugu Okamoto offered their advice. 123Can J Anesth/J Can Anesth (2012) 59: 456-465 DOI 10.1007/s12630-012-9685-9 extending to the PC by axonal degeneration. Bupivacaine appeared to be the most neurotoxic of the four drugs, and the neurotoxicity at higher doses increased by volume with procaine [ levobupivacaine [ ropivacaine. RésuméObjectif L'objectif de cette e´tude e´tait de comparer la neurotoxicite´intrathe´cale de la procaı¨ne, de la bupivacaı¨ne, de la le´vobupivacaı¨ne et de la ropivacaı¨ne dans un mode`le animal. Méthodes L'e´tude a comporte´deux expe´rimentations. Dans une expe´rience sur la concentration, des rats (n = 78) ont reçu 0,12 lLÁg -1 de poids corporel de procaı¨ne a`2 % ou 20 %, de bupivacaı¨ne a`0,5 % ou 5 %, de le´vobupivacaı¨ne a`0,5 % ou 5 % ou de...

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“…A recent review of its use in obstetrical anesthesia 12 reflects the long history of using this technique and how it had become obsolete after the report of severe neurologic sequelae. 13 Although it was postulated that these complications were caused by the use of high-concentration local anesthetics through small-calibre microcatheters, the reluctance to place larger catheters intrathecally still exists secondary to the high incidence of PDPH. 14 Nevertheless, Palmer 12 suggests specific clinical circumstances in which the use of intrathecal catheters is warranted, including challenging epidural catheter placement and a difficult airway.…”

Section: Discussionmentioning

confidence: 99%

Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: a novel explanation

Hoffman

Zaphiratos

Girard

et al. 2012

Can J Anesth/J Can Anesth

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Purpose Ankylosing spondylitis (AS) is a chronic progressive multisystemic disease. Patients with AS present a specific set of anesthesia-related challenges, and the parturient with AS presents particular anesthetic considerations. We report our experience with a parturient with advanced AS and offer a novel explanation for the high incidence of epidural failures in this patient population. Clinical features We present the case of a 36-yr-old primigravida parturient with a very difficult airway and a history of severe AS. The initial treatment plan was to use a continuous epidural for labour analgesia. Despite two successful placements of lumbar epidural catheters, adequate rostral spread of local anesthesia to control her labour pain was never achieved via the epidural route. Thus, continuous spinal anesthesia was used, which provided effective labour analgesia in this patient. Conclusion We hypothesize that this patient's advanced calcified posterior longitudinal ligament caused a physical barrier to rostral spread of local anesthesia solution within her epidural space. This hypothesis is supported by a recent study highlighting the importance of this ligament in allowing adequate distribution of solution within the epidural space. In addition, the successful use of continuous spinal analgesia adds to the growing body of literature supporting the safety and efficacy of intrathecal catheters for labour analgesia in specific situations. RésuméObjectif La spondylarthrite ankylosante (SpA) est une maladie chronique e´volutive affectant plusieurs syste`mes. Les patients souffrant de SpA posent une se´rie de de´fis spe´cifiques lie´s à l'anesthe´sie et les proble`mes d'une parturiente souffrant de SpA ne´cessitent une approche encore plus e´labore´e. Nous de´crivons notre expe´rience avec une parturiente atteinte de SpA avance´e et proposons une nouvelle explication pour l'incidence e´leve´e d'e´checs de la pe´ridurale dans cette population de patientes. Caractéristiques cliniques Nous pre´sentons le cas d'une parturiente de 36 ans, primipare, ayant des ante´ce´dents de SpA se´ve`re et des voies ae´riennes difficiles. Le plan the´rapeutique initial consistait a`utiliser une pe´ridurale continue pour l'analge´sie au cours du travail. Malgre´la mise en place re´ussie de deux cathe´ters pe´riduraux par voie lombaire, une diffusion rostrale approprie´e de l'anesthe´sie locale pour atte´nuer sa douleur n'a jamais e´teó btenue par voie pe´ridurale. En conse´quence, une

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Cauda Equina Syndrome After Continuous Spinal Anesthesia

Cited by 578 publications

References 31 publications

Quantitative and Fiber-Selective Evaluation of Dose-Dependent Nerve Blockade by Intrathecal Lidocaine in Rats

Quantitative and Fiber-Selective Evaluation of Dose-Dependent Nerve Blockade by Intrathecal Lidocaine in Rats

Intrathecally administered ropivacaine is less neurotoxic than procaine, bupivacaine, and levobupivacaine in a rat spinal model

Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: a novel explanation

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