Neurological complications of central neuraxial blockade

Van Zundert, Andre, Bruinsma, Annemarieke, van Kruchten, Pauline, Pieters, Barbe, Niesten, Ed, Weber, Eric and van der Ham, Willem (2009) Neurological complications of central neuraxial blockade. Bol, 10 2: 35-42.

Author Van Zundert, Andre
Bruinsma, Annemarieke
van Kruchten, Pauline
Pieters, Barbe
Niesten, Ed
Weber, Eric
van der Ham, Willem
Title Neurological complications of central neuraxial blockade
Journal name Bol   Check publisher's open access policy
ISSN 1640-324X
Publication date 2009
Sub-type Critical review of research, literature review, critical commentary
Open Access Status Not Open Access
Volume 10
Issue 2
Start page 35
End page 42
Place of publication Krakow, Poland
Publisher Polskie Towarzystwo Badania Bolu
Language eng
Formatted abstract
Regional anesthesia has an excellent safety record with multiple benefits compared to general anesthesia, including reduced morbidity and mortality, superior per- and postoperative analgesia and a good cost-benefit outcome. Neurological injuries are rare but do occur after regional anesthesia, with incidences of 0.04% (neurological complications following central neuraxial blocks (CNB). Permanent neurological injury after regional anesthesia is rare in the contemporary anesthetic practice. Following central neuraxial blocks complications may occur: e.g. 1) spinal infections (meningitis and epidural abscess); 2) spinal hematoma; 3) wrong injections errors (high/total spinals and IV toxicity); 4) neurologic deficits and neural injury (paralysis, paresis); 5) transient neurologic symptoms and postdural puncture headache. As the practice of regional anesthesia continues to gain worldwide popularity, knowledge of risks of neurological injury associated with central neuraxial blocks is imperative. Historically, neurological complications after central neuraxial block were published underscoring the safety of spinal, epidural and combined spinal-epidural anesthesia techniques. A more reliable and valid method to capture the true incidence of rare neurological complications would be a prospective, international, multicenter, standardized trial. Central neuraxial blocks should first be mastered in the operation room, and later in the obstetric anesthesia patient and all patients should be monitored adequately. Use a meticulous aseptic technique for all regional anesthesia blocks, whereby hand washing remains the most crucial component of asepsis. Verify the exact position of epidural needles and catheters by passive return (gravity) and a correctly performed aspiration test (for blood and CSF). Use a pharmacological test dose (with sufficient local anesthetic plus an IV marker) to rule out accidental subarachnoid or intravascular injection. An accidental injection of local anesthetics intended for the epidural space will result in high or total spinal blocks, while accidental IV injection of local anesthetics can produce signs and symptoms of CNS toxicity. Give yourself the time to evaluate any onset of the block. Test the results of any injection for its adequacy of sensory and motor blockade. Excessive sensory block/analgesia should make us alert, especially when a substantial motor block with early onset is seen. Whenever you run into an accidental subarachnoid block or IV toxic reaction, don’t panic. A prolonged resuscitation might be needed, but the end result should be a complete recovery. Probably the most feared complication associated with regional anesthesia is permanent neurologic impairment. Spinal infections and hematoma may result in permanent injuries, while transient neurologic symptoms and postdural puncture headache are considered to have a temporary neurologic impact. Delay in the diagnosis of spinal abscesses and hematomas may result in severe permanent morbidity (paresis and paralysis) and even death. It is therefore crucial to be aware of the presenting signs and symptoms of neurological CNB complications. Ask for help, including a neurologist, see your patient again, document what you have found on a regular basis, but above all act swiftly to obtain a correct diagnosis (MRI) and therapy to prevent even more damage. The decision to perform a regional anesthetic technique must be made on an individual basis considering the anesthetic alternatives, the benefits of regional anesthesia, and the risks of central nervous system infection (e.g. in bacteremic or immunocompromised patients) and hematoma formation (e.g. in the anticoagulated patient). Complications after central neuraxial blocks do occur. Recognize the relatively typical clinical presentation of neurological complications following CNB in a timely matter to allow correct diagnostic and therapeutic measures to be taken promptly to maximize the patient’s chance of complete recovery. Be sure to know how to handle these complications.
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status Unknown

Document type: Journal Article
Sub-type: Critical review of research, literature review, critical commentary
Collection: School of Medicine Publications
Version Filter Type
Citation counts: Google Scholar Search Google Scholar
Created: Wed, 20 May 2015, 13:32:12 EST by Andre Van Zundert on behalf of Anaesthesiology and Critical Care - RBWH