Horner’s syndrome and trigeminal nerve palsy after lumbar epidural analgesia for labor and delivery

Narouze, Samer; Basali, Ayman; Mandel, Morris J.; Tetzlaff, John E.

doi:10.1016/s0952-8180(02)00406-3

Cited by 19 publications

(34 citation statements)

References 12 publications

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“…Others who have tried to elucidate this mechanism speculate this response could be due to inadvertent partial dural puncture. 4 However, the unilaterality of symptoms in our patient supports epidural spread due to the well described septation present in a large number of humans that divides the epidural space. Moreover, we feel that our patient's pregnant state contributed to the cephalad spread of the anesthetic.…”

Section: Discussionsupporting

confidence: 62%

“…It is most plausible that these findings are consequences of a high sympathetic blockade from cephalad spread of local anesthetic. 4,5 Horner's syndrome may be associated with a variety of conditions; however, when associated with epidural anesthesia it is believed to be caused by disruption of the oculosympathetic pathway where second order neurons exit the spinal cord (8th cervical and 1st thoracic nerves) on their path to the superior cervical ganglion. 3 We cannot explain with certainty the exact mechanism of neurologic findings in the case of our patient, although given the temporal relationship, these findings certainly seem secondary to the anesthetic agent.…”

Section: Discussionmentioning

confidence: 99%

“…12 Similarly, other indications of a high blockade are upper extremity weakness or numbness, dyspnea, or, as with our patient, hypotension which can result in fetal bradycardia. 4 Thus, while the neurologic findings associated with Horner's syndrome are typically quite harmless, they may signal an impending high sympathetic blockade or complete cardiopulmonary arrest.…”

Section: Discussionmentioning

confidence: 99%

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Horner's Syndrome and Trigeminal Nerve Palsy following Epidural Analgesia for Labor

Lynch

Keneally²,

Hustead³

2006

The Journal of the American Board of Family Medicine

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Epidural analgesia is a widely used method of pain control in the labor and delivery setting but is not without risks. We present a case of Horner's syndrome and trigeminal nerve palsy as a rare complication of epidural analgesia in an obstetric patient. Although reported in few instances in the anesthesia literature, awareness among providers in obstetrics is critical because this could be the first sign of a high sympathetic blockade resulting in potential maternal-fetal morbidity. Case ReportA healthy 25-year-old woman, gravida 2 para 1, was admitted to the hospital for active labor at 39 weeks gestation. Her past medical history was remarkable only for occasional migraine headaches, and her prenatal course, including labs, had been unremarkable. During an uneventful first stage of labor, epidural anesthesia was requested. A lumbar epidural catheter was placed at the interspace between the third and fourth lumbar vertebrae using a midline approach and a loss of resistance to saline through a 17-gauge Touhy needle. A test dose of 3 mL of 1.5% lidocaine with 5 g of epinephrine per milliliter was administered without appreciable evidence of either intravascular or intrathecal placement of the catheter. A bolus of 10 mL of 0.2% bupivacaine with 2 g of fentanyl per milliliter was administered over 10 minutes, and then an infusion of the same solution was started at 8 mL per hour. Approximately 20 minutes after epidural catheter placement, the patient complained that the left side of her face "felt funny." On evaluation by her family physician, the patient reported decreased sensation to light touch on the left cheek in the distribution of the maxillary branch of the trigeminal nerve and was observed to have miosis and ptosis on the left side. Pinprick demonstrated the level of analgesia at the fourth thoracic segment on the left and at the fifth thoracic segment on the right. The patient's grip strength was found to be normal, and she denied dyspnea. There were no other cranial nerve abnormalities or neurologic deficits appreciated.Simultaneously, the patient's blood pressure dropped from 115/68 mm Hg to a range of 90s/30s mm Hg for several minutes. After receiving 10 mg of ephedrine IV, her blood pressure returned to 110s/50s mm Hg, but her neurologic symptoms persisted. During this period, fetal monitoring was uneventful without decelerations or bradycardia. Due to concerns for these neurologic findings, the epidural infusion was stopped, and labor allowed to progress. About 30 minutes after stopping the infusion, the patient's symptoms of facial numbness, ptosis, and miosis resolved.Within the hour, the patient desired further pain control with epidural anesthesia. Therefore, she was repositioned, and an infusion of the same solution was started at 6 mL per hour without a bolus. This was followed by an uneventful progression of labor and vaginal delivery of a healthy male infant. No further signs or symptoms of Horner's syndrome or trigeminal nerve palsy were evident during the rest of this patient's labor, de...

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Section: Discussionsupporting

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Horner's Syndrome and Trigeminal Nerve Palsy following Epidural Analgesia for Labor

Lynch

Keneally²,

Hustead³

2006

The Journal of the American Board of Family Medicine

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“…More serious complications as intraspinal or intravenous injection of epidural drugs, neurological injury and sequeles, epidural hematoma and epidural infection have been reported, although rare. 4,6,39,40,51,53,[81][82][83][84][85] Back pain is a common symptom after childbirth, but in a study by Loughnan and a review from the Cochrane Collaboration, they found no significant differences between EDA and systemic opioid 4,86 toms, and take immediate action when 6,50 Spinal analgesia…”

Section: Regional Analgesiamentioning

confidence: 99%

Remifentanil as analgesia for labour pain

Tveit

2013

Acta Anaesthesiol Scand

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Background To collect updated information about pharmacological labour analgesia in Norway, especially systemic opioids and epidural. Evaluation of efficacy and safety with remifentanil intravenous patient‐controlled analgesia (IVPCA) for pain relief during labour. To compare remifentanil IVPCA with epidural analgesia (EDA) regarding efficacy and safety during labour. Methods In paper I, two national surveys identified Norwegian labour analgesia methods and changes during the study period (2005–2008). Paper II is a prospective, observational study of analgesic efficacy and safety with remifentanil IVPCA. Paper III is a prospective, randomized controlled trial comparing remifentanil IVPCA with EDA regarding analgesic efficacy and safety. Results The surveys in paper I found the frequency of EDA in Norwegian hospitals to be increasing, but still low (25.9%) compared with other western countries. Nitrous oxide and traditional systemic opioids, like pethidine, were frequently used. In paper II, remifentanil IVPCA was found to give satisfactory labour analgesia in more than 90% of the parturients with an average maximal pain reduction of 60%. Maternal oxygen desaturation and sedation were acceptable, and neonatal data reassuring. In paper III, a randomized controlled trial found remifentanil IVPCA and EDA to be comparable both regarding analgesic efficacy (pain reduction; Fig. ) and maternal satisfaction. Remifentanil IVPCA produced more maternal sedation and oxygen desaturation; neonatal outcome was reassuring in both groups. Reduction in pain score [visual analogue scale (VAS)] during labour analgesia with patient‐controlled intravenous remifentanil and continuous epidural infusion with ropivacaine and fentanyl. Conclusion The frequency of epidural labour analgesia in Norway has increased, but is still relatively low. Nitrous oxide and traditional systemic opioids are frequently used. The clinical practice seems conservative; newer short‐acting opioids are seldom used for systemic labour analgesia. The studies on remifentanil IVPCA revealed adequate pain relief, high maternal satisfaction, and no serious neonatal side effects. There were no differences in analgesic efficacy, maternal satisfaction, and neonatal outcome when comparing remifentanil IVPCA with EDA. However, remifentanil caused maternal sedation and oxygen desaturation. We recommend the use of IVPCA remifentanil as labour analgesia instead of traditional opioids as pethidine and morphine when EDA is not an option. The presence of skilled personnel and close monitoring is mandatory.

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“…Horner's syndrome (triad of miosis, ptosis and enophthalmos, associated with vasodilatation and anhydrosis) is also a rare complication of epidural blockade, but its incidence is greater in obstetrical patients (0.4-5%). [3][4][5][6][7] The subdural space is a potential space containing a small volume of serous fluid between the dura and arachnoid mater or, as some authors think, an iatrogenic dissection of a cellular layer between the dura and the arachnoid. 8,9 Subdural cannulation has been described as a complication of intended regional blocks (epidural, intrathecal, interscalene and paravertebral block).…”

Section: Introductionmentioning

confidence: 99%

Trigeminal nerve palsy and Horner’s syndrome following epidural analgesia for labor: a subdural block?

Gala

Reyes

Avellanal

et al. 2007

International Journal of Obstetric Anesthesia

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Horner’s syndrome and trigeminal nerve palsy after lumbar epidural analgesia for labor and delivery

Cited by 19 publications

References 12 publications

Horner's Syndrome and Trigeminal Nerve Palsy following Epidural Analgesia for Labor

Horner's Syndrome and Trigeminal Nerve Palsy following Epidural Analgesia for Labor

Remifentanil as analgesia for labour pain

Trigeminal nerve palsy and Horner’s syndrome following epidural analgesia for labor: a subdural block?

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