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PubMed1998

Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia.

OBJECTIVES: This study was conducted to investigate complications after dural puncture. MATERIAL AND METHODS: A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20-19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27-25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week. RESULTS: Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5). CONCLUSION: Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.

Adult↗
PubMed1999

Transdermal nitroglycerine enhances spinal sufentanil postoperative analgesia following orthopedic surgery.

BACKGROUND: Sufentanil is a potent but short-acting spinal analgesic used to manage perioperative pain. This study evaluated the influence of transdermal nitroglycerine on the analgesic action of spinal sufentanil in patients undergoing orthopedic surgery. METHODS: Fifty-six patients were randomized to one of four groups. Patients were premedicated with 0.05-0.1 mg/kg intravenous midazolam and received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline or 10 microg sufentanil). Twenty to 30 min after the spinal puncture, a transdermal patch of either 5 mg nitroglycerin or placebo was applied. The control group received spinal saline and transdermal placebo. The sufentanil group received spinal sufentanil and transdermal placebo. The nitroglycerin group received spinal saline and transdermal nitroglycerine patch. Finally, the sufentanil-nitroglycerin group received spinal sufentanil and transdermal nitroglycerine. Pain and adverse effects were evaluated using a 10-cm visual analog scale. RESULTS: The time to first rescue analgesic medication was longer for the sufentanil-nitroglycerin group (785+/-483 min) compared with the other groups (P<0.005). The time to first rescue analgesics was also longer for the sufentanil group compared with the control group (P<0.05). The sufentanil-nitroglycerin group group required less rescue analgesics in 24 h compared with the other groups (P<0.02) and had lesser 24-h pain visual analog scale scores compared with the control group (P<0.005), although these scores were similar to the sufentanil and nitroglycerin groups (P>0.05). The incidence of perioperative adverse effects was similar among groups (P>0.05). CONCLUSIONS: Transdermal nitroglycerine alone (5 mg/day), a nitric oxide generator, did not result in postoperative analgesia itself, but it prolonged the analgesic effect of spinal sufentanil (10 microg) and provided 13 h of effective postoperative analgesia after knee surgery.

Analgesics, Opioid↗
PubMed2000

Transdermal nitroglycerine enhances spinal neostigmine postoperative analgesia following gynecological surgery.

BACKGROUND: Intrathecal neostigmine causes analgesia by inhibiting the breakdown of acetylcholine. Experimental data suggest that the production of endogenous nitric oxide is necessary for tonic cholinergic inhibition of spinal pain transmission. The purpose of this study was to determine whether association of transdermal nitroglycerine would enhance analgesia from a low dose of intrathecal neostigmine in patients undergoing gynecologic surgery during spinal anesthesia. METHODS: Forty-eight patients were randomized to one of four groups. Patients were premedicated with use of 0.05-0.1 mg/kg intravenous midazolam and received 15 mg bupivacaine plus 1 ml test drug intrathecally (saline or neostigmine, 5 microgram). Twenty to 30 min after the spinal puncture, a transdermal patch of either 5 mg nitroglycerin or placebo was applied. The control (Con) group received spinal saline and transdermal placebo. The neostigmine group received spinal neostigmine and transdermal placebo. The nitroglycerin group received spinal saline and a transdermal nitroglycerine patch. Finally, the neostigmine-nitroglycerin group received spinal neostigmine and transdermal nitroglycerine. Pain and adverse effects were evaluated using a 10-cm visual analog scale. RESULTS: Patients in the groups were similar regarding age, weight, height, and American Society of Anesthesiologists status. Sensory level to pin prick at 10 min, surgical duration, anesthetic duration, and visual analog scale score for pain at the time of administration of first rescue medication were statistically the same for all groups. The time to administration of first rescue analgesic (min) was longer in the neostigmine-nitroglycerin group (550 min; range, 458-1,440 min; median, 25-75th percentile) compared with the other groups (P < 0.001). The neostigmine-nitroglycerin group required fewer rescue analgesics in 24 h than did the control group (P < 0.0005), whereas the neostigmine group required less analgesics compared with the control group (P < 0.02). The incidence of perioperative adverse effects (nausea, vomiting, headache, back pain) was similar among groups (P > 0.05). CONCLUSION: Although neither intrathecal 5 microgram neostigmine alone nor transdermal nitroglycerine alone (5 mg/day) delayed the time to administration of first rescue analgesics, the combination of both provided an average of 14 h of effective postoperative analgesia after vaginoplasty, suggesting that transdermal nitroglycerin and the central cholinergic agent neostigmine may enhance each other's antinociceptive effects at the dose studied.

Administration, Cutaneous↗
PubMed1979

[Late manifestation of alternating Horner's signs in spinal cord injury due to dura-cord adhesion (author's transl)].

It has been said that late manifestation of transient alternating Horner's signs in cases of spinal cord injury is caused by intramedullary cavity formation in which some movement of fluid stimulates the sympathetic system corresponding to their positioning. We had a patient complaining of alternating Horner's signs which became manifest 8 years after the injury. We could not find any intramedullary cavity formation, in spite of a spinal puncture at operation, but the symptoms made a striking improvement after the operation simply by making free the spinal cord from the dura mater at operation. So we suppose that late manifestation of transient alternating Horner's signs will be manifested not only in cases of intramedullary cavity, but also in cases of dense adhesion between the spinal cord and the dura mater. In addition to this, we propose the new term "Poromyelia" for the intramedullary cavity because of its resemblance to "Porencephalia" in the cerebrum, and because of the confusing usage of the word "Syringomyelia" for this condition of "Poromyelia". It has been said that "Syringomyelia" in the spinal cord is similar to "Hydrocephalia" in the cerebrum.

Adult↗
PubMed1993

Intrathecal anaesthesia in patients under 45 years: incidence of postdural puncture symptoms after spinal anaesthesia with 27G needles.

Postoperative headache and backpain has limited the use of intrathecal anaesthesia in younger patients (15-45 years). We studied postoperative complaints among 133 healthy young patients (mean age 30.0 years, 47% females) who received spinal anaesthesia with a 27G needle. Postoperatively, 5 patients (4%) complained of postdural puncture headache (PDPH), 18 (14%) reported nonspecific headache, while 27 (20%) suffered from backpain. PDPH was not related to sex, age, day-care surgery, number of puncture attempts, or obstetric procedures. Backpain was significantly more common among females, and among in-patients. One hundred and sixteen patients (87%) would accept spinal anaesthesia if they were to undergo the same surgical procedure again. Compared to other studies, we find the incidence of postanaesthetic complaints to be acceptable, also among day-care patients. The PDPH seemed to be lightly incapacitating, and only one patient required blood patching.

Adolescent↗
PubMed1977

[Associated maxillofacial and cerebrocranial injuries].

By analyzing the experience with the treatment of 192 cases of jaw fractures the authors show that in 23.9% of cases these fractures are associated with a cerebrocranial trauma. In such cases the spinal puncture is of great diagnostic and therapeutic value. The treatment of such cases should be complex, depending on the severity of the patient's condition, spinal fluid analysis findings and intracranial pressure.

Brain Injuries↗
PubMed1986

Comparative effects of intrathecal bupivacaine and tetracaine on analgesia, cardiovascular function and plasma catecholamines.

Forty otherwise healthy male patients, scheduled for elective inguinal herniotomy, were randomly allocated to spinal anaesthesia with 3 ml 0.5% hyperbaric tetracaine or bupivacaine under double-blind conditions. The extent of blockade (pin-prick and cold sensation), blood pressure and heart rate and plasma catecholamines were measured before and 5, 10, 15, 20 and 30 min after injection, before skin incision. Cephalad spread of sensory and temperature analgesia was insignificantly higher after tetracaine. The mean time taken to reach maximal spread of analgesia was 22 min in both groups. Mean arterial pressure showed a more pronounced decrease in the tetracaine group (22 vs 12%, P less than 0.009). Heart rate fell slightly and similarly in both groups, while rate-pressure product was significantly lower in the tetracaine group. The correlation between the decrease in mean arterial pressure and the cephalad spread of sensory analgesia was similar in the two groups, suggesting that at identical levels of sensory analgesia changes in blood pressure were similar after tetracaine and bupivacaine. Plasma norepinephrine and epinephrine measurements before spinal puncture and at maximal decrease in mean arterial pressure showed a depressed response to fall in blood pressure in the tetracaine group. It is concluded that spinal anaesthesia with 3 ml hyperbaric 0.5% tetracaine is followed by a more pronounced fall in blood pressure compared to an identical dose of bupivacaine. The more pronounced sympathetic blockade, confirmed by plasma catecholamine measurements, following tetracaine is probably due to a higher cephalad spread of neurogenic blockade, rather than a differential effect on sympathetic nerve fibres.

Adult↗
PubMed1991

[Spinal anesthesia with bupivacaine without glucose in the elderly: effect of concentration and volume on the hemodynamic profile].

This study aimed to compare the haemodynamic effects of two different glucose-free bupivacaine solutions is thirty patients aged more than 70 years (mean age 82 years) undergoing hip surgery under spinal anaesthesia. They were randomly assigned to two groups, group A to receive 2.5 ml of a 0.5% bupivacaine solution, and group B 10 ml of a 0.125% solution in normal saline. All the patients were therefore given the same dose of bupivacaine, 12.5 mg. Lorazepam (1 mg orally) was administered to all for premedication two hours beforehand. Those patients taking antihypertensive agents were given their last dose on the eve of surgery. Lactated Ringer's solution (500 ml) was infused to all before the spinal puncture. Systolic (Pasys), mean and diastolic arterial pressures, and heart rate, were recorded every minute before volume loading, and for 30 minutes after the start of the spinal anaesthesia. Ephedrine (3 mg every two minutes if required) was given whenever Pasys decreased by more than 30% of the pre-induction value. The upper level of sensory blockade was assessed by the pin-prick test, and the quality of motor blockade with the Bromage scale. The cephalad spread of the solutions was similar, as well as the haemodynamic profile in each group. The total dose of ephedrine required in each group was not significantly different. It may therefore be concluded that, in the elderly, the upper level of, and the haemodynamic changes due to, spinal anaesthesia do not depend on the concentration or the volume of glucose-free bupivacaine solution.

Age Factors↗
PubMed2003

The effect of combined spinal-epidural (CSE) anaesthesia and size of spinal needle on postoperative hearing loss after elective caesarean section.

The exact aetiology of vestibulocochlear dysfunction after spinal anaesthesia is unknown. Low-frequency hearing loss occurs after spinal anaesthesia. The aim of this study was to investigate the effects of combined spinal-epidural (CSE) anaesthesia and size of spinal needle on vestibulocochlear dysfunction, using pure tone audiometry performed pre- and on the first and the second day postoperatively. Forty-five patients who were to undergo elective caesarean section were evaluated. In group I, CSE anaesthesia (18 G Tuohy, 25 G Whitacre pencil-point-design spinal needles) was performed in 15 patients. In group II, spinal anaesthesia was performed in 15 patients with 25 G Whitacre pencil-point-design spinal needles and, in group III, spinal anaesthesia was performed in 15 patients with 22 G Whitacre pencil-point-design spinal needles. In the pre- and on the first and the second day postoperatively, the pure tone audiogram was performed in the audiology laboratory of our hospital, using a calibrated Kamplex Diagnostic Audiometer AC 40 in a noise-free room. When the CSE anaesthesia group and 22 G spinal group were compared for change in hearing between the pre- and postoperative periods, a statistically significant difference was observed at R-right ear 125 Hz (P < 0.025) and at L-left ear 125 Hz (P < 0.023), and at L-left ear 1000 Hz (P < 0.036) and at R-right ear 1500 Hz (P < 0.006), and at L-left ear 1500 Hz (P < 0.022). At other frequencies, the difference was insignificant. When the CSE anaesthesia group and 25 G spinal group were compared for change in hearing between the pre- and postoperative periods, no statistically significant difference was detected at any frequency tested. When 22 G spinal group and 25 G spinal group were compared for change in hearing between the pre- and postoperative periods, there was some hearing loss at low frequency, although this difference did not reach statistical significance. The positive correlation of low-frequency hearing loss and increased pressure in the epidural space (which decrease the risk of cerebrospinal fluid leakage through the dura) suggests that cerebrospinal fluid leakage via the spinal puncture hole is not the only factor involved. Perioperative fluid replacement alone may not prevent hearing loss but CSF loss through the dural puncture site should also be prevented.

Adult↗
PubMed2006

[Removal of an epidural catheter under ongoing antithrombotic therapy].

A rare though extremely harmful complication in neuraxial anaesthesia is an epidural hematoma which can be associated with deleterious consequences for the patient, e. g. persistent paraplegia. The risk of epidural haematomas after neuraxial blockade is dependent on abnormal anatomy of the spine, difficult and multiple punctures and coagulation disorders. Especially when patients undergo therapy with anticoagulants like low molecular heparin or platelet inhibitors (tyclopidine) or a combination of them, the indication for neuraxial blockade must strictly outweigh risk of spinal bleeding. In this context, the precautions and contraindications are the same for spinal puncture and catheter insertion as for catheter removal. We describe the case of a patient who underwent emergency coronary angioplasty in combination with coronary stent implantation due to acute postoperative myocardial infarction following knee replacement in continuous epidural anaesthesia. Under the symptoms of a beginning local infection at the puncture site the epidural catheter had to be removed in spite of ongoing antithrombotic therapy. A possible management of such cases is discussed with regard to risk minimization.

Aged↗
PubMedDate not supplied

Levobupivacaine versus racemic bupivacaine for spinal anaesthesia in orthopaedic major surgery.

AIM: Levobupivacaine, a new local anaesthetic, has been recently introduced into clinical practice because of its lower toxic effects for heart and central nervous system. It has been already investigated in epidural and loco-regional techniques, but more has to be known regarding its characteristics in spinal anaesthesia. The aim of our study was to compare clinical and anaesthetic features of levobupivacaine and racemic bupivacaine when intrathecally administered in 60 patients undergoing major orthopaedic surgical procedures. METHODS: Three ml of glucose-free levobupivacaine 0.5% (group L) or 3 ml of isobaric bupivacaine 0.5% (group B) were administered in 30 patients each. Sensory and motor blockades were evaluated by the pinprick test and a modified Bromage score, respectively. Vital parameters, postoperative VAS and rescue analgesia were recorded as well. RESULTS: No statistically significant differences between groups were observed either in anaesthetic potencies or postoperative pain. Either heart rate or mean arterial pressure slightly decreased in both groups, with no preoperative significant differences. Nevertheless, spinal puncture was accompanied by severe hypotension and bradycardia in 2 patients of group B. In both cases, hemodynamics were promptly and successfully treated, with no sequelae. CONCLUSIONS: In conclusion, levobupivacaine results a valid alternative to racemic bupivacaine for spinal anaesthesia, the latter remaining a cheap and effective local anaesthetic yet. Notwithstanding the complete absence of any significant hemodynamic complications in the patients of group L, further and larger studies are needed in order to assess if levobupivacaine is preferable to bupivacaine for minimizing the possible cardiovascular impact of spinal anaesthesia.

Adult↗