Prolonged neurological deficit following neuraxial blockade for caesarean section

Acute intrathecal haematoma following neuraxial anaesthesia: diagnostic delay after apparently normal radiological imaging

“…7 Alternative postoperative analgesic regimens without the use of local anaesthetic PCEA may be more appropriate in the obstetric population. Prolonged neurological deficit following routine neuraxial blockade for CS has been reported, with time to full recovery of up to 48 h. 8 In our case report the patient received a low-dose CSE for CS and was able to move her legs immediately thereafter, it was therefore unlikely her postoperative sensorimotor symptoms were secondary to a prolonged effect from intrathecal anaesthesia.…”

Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020

“…An epidural haematoma can cause irreversible neurological damage if not evacuated within 8-12 h [8][9][10]. Delayed detection of symptoms and signs may be exacerbated by delay in clinical diagnosis and referral for appropriate imaging, especially in a busy unit and out of hours [22]. The inability to straight-leg raise at 4 h might not necessarily suggest any underlying pathology, for example, if there has been steady resolution of sensory and/or motor block during that period, albeit without meeting this target, especially if large doses of local anaesthetic have been used.…”

“…However, if there is concern over the extent of the neuraxial block, for example, no resolution of block or increasing motor block, the anaesthetist should consider urgent escalation of care including urgent imaging of the spine. This may require formal neurological, neurosurgical or radiological referral before it can be done, depending on local arrangements [12,22], and each unit/Trust should have guidelines/policies in place to enable rapid escalation and referral in order to achieve this, including outside office hours. Such guidelines/policies should reflect acceptance by all teams that prompt investigation of women with delayed recovery after neuraxial block will, by necessity, include a significant number of women in whom no pathology is found and who go on to make a full recovery, with no cause found for the delay.…”

“…Magnetic resonance imaging (MRI) of the spine is the preferred imaging modality for suspected cases [25][26][27], even though computerised tomography has been advocated as it may be more easily accessible, especially out of hours [22]. Policies should therefore account for the ease of local access to MRI and the possible need for further referral.…”

“…Recovery of sensorimotor block after caesarean section has been reported as typically taking 2-3 h after intrathecal bupivacaine [18,19] and 3-5 h after epidural bupivacaine and/or lidocaine [19][20][21], although definitions vary considerably, and recovery can be highly variable. Furthermore, unexpectedly and dramatically prolonged blocks (up to 24-48 h) may occur rarely in otherwise routine cases and with no explanation found [22]. As a screening tool, the Working Party recommends that all women recovering from neuraxial anaesthesia should be tested for straight-leg raising at 4 h from the time of the last epidural/ spinal dose of local anaesthetic.…”