1. Neurological complications of centrineuraxial blockade
Dr. S. Parthasarathy
MD, DA, DNB, Dip Diab.MD ,DCA, Dip software based statistics,
PhD (physiology)

2. History neurologic complication England on October 13, 1947.
two healthy men -,meniscectomy , hydrocele.
Both men developed permanent spastic paralysis after administration of intrathecal anesthesia.(hyperbaric dibucaine
Phenol – sterilize ampoules – crack in ampoules – danger
Sir Robert Macintosh supported this theory and testified before the court to this effect.

3. History – contd.
Recent scholarship has demonstrated that phenol was unlikely the more likely suspect was the acidic solution used to clean the sterilizer.
First patient – more severe ,,, second patient less severe
Finally, pathologic findings support the conclusion that an acidic solution was introduced into the subarachnoid space

4. Incidence
4 /10,000
0.04 %
Permanent damage is extremely rare

5. Causes Cord Trauma Needle trauma Local Anaesthetic toxicity
Cord Ischemia
Anterior Spinal Artery Syndrome
ICAT
Cord compression
Hematoma
Needle trauma
Tumor
Vascular anomaly
Bleeding disorder
Abscess (infection)
Exogenous infection via a needle
Hematogenous

6. Pre-existing neurological diseases
Multiple Sclerosis
Spinal Stenosis
Gullian – Barre Syndrome
Diabetic Neuropathy
Demyelination

7. Direct needle Trauma The spinal cord has no sensory receptors
sensory inputs from the meninges -inconsistent.
Sites
Spinal cord,
Nerve roots
Nerves

8. Risks
Direct needle or catheter trauma to the spinal cord may be associated with
inaccurate determination of vertebral levels, anatomical variation in the terminal portion of the conus medullaris,
incompletely fused ligamentum flavum
Paresthesia- needle or catheter or injection !!no
Post op paresthesia !!

9. We may not know what happens inside

10. A traumatic needle induced lesion at the conus level can cause a severe disturbance of the intramedullary circulation that could lead to the formation of a rod shaped cavity in the central region of the conus
Dangerous deficits !!
Prevention

11. Local Anaesthetic Toxicity:
prolonged exposure, high dose and concentrations at the spinal roots
Risk factors
Infusions
Already mechanically damaged ,
Adrenaline
Cauda equina ( susceptible )

12. Transient Neurologic Symptoms
Schneider et al in 1993,
appear within a few hours of spinal anaesthetic until approximately 24 hours after a full recovery from an uneventful spinal anaesthetic.
L5 – S1 dermatomal pain
The L5-S1 dermatome is most often involved and this is because the L5-S1 spinal roots lie in the most dorsal portion of the spinal canal,,,, fifth day normal
No deficit , -- MRI normal

13. 5 % hyperbaric lignocaine
Seven times more common than other local anaesthetics
Isobaric also reported

14. Cauda Equina Syndrome
varying degree of saddle anaesthesia, sphincter dysfunction resulting in bladder and bowel problems and sometimes paraplegia.
Hyperbaric lignocaine 5 %, High doses , repeat
micro catheters ,- poor mixing – more local
In vitro evidence suggests that local anaesthetics produce excitotoxic damage by depolarising neurons and increasing intracellular calcium. Local anaesthetics can cause neuronal injury by damaging neuronal plasma membrane

15. Wake up !!

16. Spinal Epidural Hematoma
The calculated incidence of neurologic dysfunction resulting from hemorrhagic complications associated with epidural anaesthesia is less than 1 in 150,000 and less than 1 in 220,000 with spinal anaesthesia.
Anticoagulants, difficult spinal, liver , renal diseases , old age and spinal abnormalities

17. Spinal Epidural Hematoma
Bleeding and hematoma occurs not only due to injury to the epidural veins but can occur spontaneously
Unprotected valveless epidural veins – increased intra abdominal pressures
The location is usually at the level at which the spinal anaesthetic was given,
may extend over a few vertebral body levels.
Spontaneous hematoma is most often located in the thoracic and cervico -thoracic region

18. Hematoma
The patient usually presents with a severe, localised constant back pain with or without a radicular component that may mimic disc herniation.
Associated symptoms may include weakness,numbness, and urinary or fecal incontinence.
Signs of spinal cord and nerve root dysfunction appear rapidly and may progress to paraparesis or paraplegia

19. Hematoma Spinal block wears off Return of weakness
24 – 48 hours – sometimes a week
MRI spine – hematoma, also vascular anomalies
0 – 6 hours – hyperacute stage
7 -72 hours acute stage
Early surgical decompression – ideal

20. Infectious complications
epidural, spinal or subdural abscess;
paravertebral, paraspinous or psoas abscess;
meningitis;
encephalitis;
osteomyelitis
discitis.

21. Infection fever, backache, headache,
erythema and tenderness at the insertion site.
Additional -stiff neck, photophobia, radiating pain, loss of motor function and confusion may indicate further development of infectious complication.
either manifest within few hours or weeks
Periodic evaluation is essential for early identification of infectious complications.

22. Infection !! Routine blood evaluation CSF Catheter tip culture
Immunocompromised !!
Appropriate antibiotics
Antisepsis
Drainage
Physician consult

23. Post. Inf. Cerebellar and vertebral
Posterior - 2
Anterior - 1

24. Anterior Spinal artery Syndrome
Posterior
Anterior
End arteries

25. Adamkiewicz

26. Adamkiewicz
typically arises from a left posterior intercostal artery, which branches from the aorta, and supplies the lower two thirds of the spinal cord via the anterior spinal artery.
Not complications of neuraxial blockade
Surgical aneurysm repair
Bronchial artery embolization

27. Anterior Spinal artery Syndrome
Systemic hypotension ,Adrenaline
Atherosclerosis , Old age
Aortic or spinal cord procedure
Adamkiewicz  is not present or abnormal
sudden onset of flaccid paralysis of lower extremities, after recovery from the effect of spinal anaesthetic.
Classically proprioception and sensation is spared or preserved relative to the motor loss

28. What is what ??

29. Arachnoiditis and spinal drug administration
arachnoiditis results from spinal administration of approved spinal drugs. – unlikely
Wrong drugs – yes
Occult bleeds, injuries can increase the chances

30. Arachnoiditis
extensive sclerosis of arachnoid membranes with constriction of the vascular supply to the neural tissue
Cauda Equina Syndrome.
The symptoms of arachnoiditis include constant burning pain in low back and legs, urinary frequency or incontinence, muscle spasm in the back and legs and variable sensory loss or motor dysfunction.

31. Limit , diagnose and treat
Injury –
Disease and anticoagulation
Tumors
Drug and dosage and infusions
MRI – if urgent CT
Compressing – do surgical intervention , antibiotics

32. Spinal anaesthesia in patients with preexisting neurological disease.
Although the use of spinal anaesthesia in patients with preexisting neuropathies is controversial, the reported incidence of neurological injury in these subgroup of patients is very low.
Is there an increase in damage if nerves are already damaged ?
Risk benefit ratio ??

33. '‘Double Crush” phenomenon
patients with preexisting neurological compromise may be more susceptible to injury at another site,when exposed to secondary insult
Secondary insult means – toxic, ischemic , traumatic etc..

34. However spinal anaesthesia may be advantageous in patients with degenerative diseases such as Parkinson's Disease, Alzheimer's Disease and in Amyotrophic Lateral Sclerosis.
In patients with chronic spinal cord injury spinal anaesthesia may be a valuable tool to prevent autonomic hyperreflexia.

35. In demyelinating diseases ,
Spinal
Gullian – Barre Syndrome,
worsening neurologic symptoms, prolonged duration of action of local anaesthetics, triggering of underlying disease and cardiac arrest after low subarachnoid block have been reported in the literature

36. Spinal stenosis
Spinal stenosis is a risk factor for postoperative cauda equina syndrome and paraperesis even after uneventful spinal anaesthetic.
But reports of uneventful spinal after laminectomy reported
Imaging !!

37. Diabetic neuropathy Already nerve damage – more prone
Ischemia – more drug for the nerves
Chances !!
Human data lacking

38. Overall Risk benefit ratio
less potent local anesthetic, minimizing local anesthetic dose, volume, and/or concentration, and avoiding or using a lower concentration of vasoconstrictive additive

39. Summary History Incidence Causes Needle trauma
TNS, cauda equina , spinal artery
Pre existing diseases

40. Thank you all