Prevention of side-effects during cesarean section under spinal anesthesia

R. E. Grady, T. T. Horlocker, R. D. Brown, P. M. Maxson, D. R. Schroeder

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Abstract

INTRODUCTION: Needle-related neural trauma, local anesthetic toxicity, and spinal cord ischemia have been implicated in causing neural dysfunction following spinal and epidural anesthesia,1,2 Subarachnoid or epidural needle placement in an anesthetized patient is controversial due to the fact that anesthesia and muscle relaxation may mask neural trauma. However, in neurosurgical patients, placement of a needle or catheter in the subarachnoid space for the purpose of cerebral spinal fluid (CSF) drainage is frequently performed while the patient is anesthetized. Lumbar CSF drain insertion has been linked to transient or permanent peripheral nerve damage.34 The purpose of this study was to assess the types of neurological complications attributable to spinal drainage and their rates of occurrence in anesthetized neurosurgicai patients with particular emphasis on those complications due to needle insertion. METHODS: This study was approved by the Institutional Review Board of the Mayo Clinic. The hospital charts were examined from 493 consecutive patients who underwent transsphenoidal surgery in conjunction with intraoperative lumbar CSF drainage from 1985 to 1997. All patients were anesthetized during CSF drain placement. The indication for surgery and preexisting diagnoses, if present, of diabetes, lumbar spinal cord diseases, or lower extremity dysfunction were recorded. Type of spinal drain inserted, attempts at multiple vertebral levels, and presence of blood in the CSF were noted. The amount of air injected, CSF drained, or type and dose of any medication infused into the CSF were recorded. All cases of possible neurological dysfunction related to spinal drainage during the postoperative hospital stay and during any subsequent follow-up visits were reviewed by a neurologist. In addition, patients developing post durai puncture headache (PDPH) and those requiring epidural blood patch were documented. The percentage of patients experiencing neurologic complications and PDPH were calculated, along with their exact 95% confidence intervals (C.I.). RESULTS: 478 (277 male, 201 female) patients underwent 493 transsphenoidal procedures with lumbar CSF drainage for pituitary tumors (477), craniopharyngiomas (12), and other central nervous system pathology (4). Age, height, and weight (mean ±s.d.) were 49±16 y, 178±75 cm, and 85±37 kg, respectively. Malleable needles (19-gauge Hingson-Edwards Continuous Caudal Anesthesia Needle) were placed in 442 (90%) patients. Subarachnoid catheters (20-gauge epidural catheter placed via an 18-gauge Hustad needle or a 16-gauge CSF drainage catheter placed via a 14-gauge Tuohy needle) were placed in 15 (3%) patients. In 35 (7%) patients, the type of drain was unspecified. 16 (3.2%) of patients had attempts at drain insertion at multiple intervertébral levels while only 4 (0.8%) noted grossly bloody drainage at the time of insertion. The drains were utilized for air injection or CSF removal in 265 (54%) and 202 (41%) patients, respectively. No drains were used for intrathecal drug administration. No new neurologic deficits attributable to spinal drain insertion (0%, exact 95% C.I. 0.0 - 0.8%) were detected in the immediate postoperative period or at postoperative visits within 1 year of surgery. 12 patients developed PDPH (2.4%, exact 95% C.I. 1.3 4.2%) requiring epidural blood patch in 6 instances (1.2%, exact 95% C.I. 0.5 - 2.6%). DISCUSSION: Controversy surrounds the insertion of epidural or spinal needles in anesthetized patients for fear of causing unrecognized neural damage. Paresthesias during needle placement have been associated with the development of postoperative neurological deficits in patients undergoing spinal anesthesia.1'5 Recent studies report the incidence of neurological sequelae from spinal anesthesia to be 0.06 to 0.66%.12|S The low (0%) incidence of neurologic injury from spinal drain insertion in this study may be due to the lack of local anesthetic neurotoxicity, since no intrathecal local anesthetics were administered through the spinal drains. The overall incidence of PDPH and those requiring epidural blood patch in this study is in agreement with the findings of previous investigations..

Original languageEnglish (US)
Number of pages1
JournalRegional Anesthesia and Pain Medicine
Volume23
Issue number3 SUPPL.
StatePublished - Dec 1 1998

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

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    Grady, R. E., Horlocker, T. T., Brown, R. D., Maxson, P. M., & Schroeder, D. R. (1998). Prevention of side-effects during cesarean section under spinal anesthesia. Regional Anesthesia and Pain Medicine, 23(3 SUPPL.).