Hemorrhage as a complication of subdural puncture.
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Cerebral Hemorrhage↗
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The tenth rib line as a new landmark of the lumbar vertebral level during spinal block.
The purpose of this study was to assess whether the tenth rib line (an imaginary line that joins the lowest points of the rib cage on the flanks) could be used as a marker of the lumbar vertebral level. Simple X-rays (n = 100) were taken with radiopaque markers attached on the lowest points of the rib cage and the uppermost points of the iliac crests on both flanks. The spinous process or interspinous space that the tenth rib or Tuffier's lines crossed was identified and recorded, respectively, in the neutral and fully flexed positions. With lumbar flexion, the tenth rib line (median (25th to 75th percentiles)) moved upward (L(2) (L(1-2) - L(2)) vs. L(1-2) (L(1-2) - L(1-2)); p < 0.01), but Tuffier's line moved downward (L(4-5) (L(4) - L(4-5)) vs. L(4-5) (L(4) - L(5)); p < 0.01). Because the ease of palpating the tenth rib line and its distribution patterns are comparable to those of the Tuffier's line, the tenth rib line may be useful as a new landmark of the lumbar vertebral level as well as a safeguard to prevent spinal puncture from being mistakenly performed at a dangerously high level.
Adult↗
Postdural puncture headache after spinal anaesthesia in young orthopaedic outpatients using 27-g needles.
PURPOSE: Two large studies reported a very low rate (0.5-1.8%) of postdural puncture headache (PDPH) with the use of 27-G spinal needles. We suspected that it might be higher in young ambulatory patients. The purpose of this study was to establish the rate prospectively in such a patient population using two types of needles. METHODS: Two hundred male and female, outpatients, 18-45 yr, undergoing knee arthroscopy under spinal anaesthesia were randomly assigned to receive spinal anaesthesia with hyperbaric lidocaine 5% using either a Quincke or a Whitacre 27-G needle. Twenty patients choosing general anaesthesia formed a comparative group. Using a previously validated questionnaire, the incidence and nature of PDPH were evaluated by telephone three to five days after surgery by an anaesthetist unaware of the anaesthetic technique used. Once all data were collected, an anaesthetist not involved in the study determined in a blinded fashion which headaches were likely to be PDPH. Grading and classification of headaches were based on several criteria: postural nature, duration, intensity and confinement to bed. RESULTS: The overall incidence of PDPH in both spinal groups was 9.3%. The incidence in women, 20.4%, was higher than in men, 5.5%, (P < 0.05). Only one patient required a blood patch. Both types of needle were comparable with respect to the incidence, severity and duration of PDPH, number of dural punctures and failed spinal blocks. CONCLUSION: The rate of PDPH was higher than in large published studies with 27-G Quincke and Whitacre needles and greater in women than in men.
Adolescent↗
[Spinal anesthesia for cesarean section].
In the community hospital of Konstanz, spinal block is the standard method of anaesthesia for caesarean section. The report below gives a review about the advantages of the method compared to other central blocks and describes the procedure in detail. The block is performed in the lateral decubitus position by paramedian approach, using 0.5% hyperbaric bupivacaine in doses of 10-12.5 mg. For postoperative analgesia, morphine 1 microgram/kg BW is added. The spinal puncture is carried out with 27-gg-pencilpoint needle which is inserted through an introducer. If necessary, cafedrine is employed for support of blood pressure.
Adult↗
The demonstration and significance of neural compression after spinal injury.
Standard metrizamide myeLography and CT myelography can accurately and safely define neural compression after a spinal injury. A lateral C1-C2 spinal puncture and a radiolucent fracture board reduce movement of the spine, and by injecting metrizamide in an isotonic concentration and by limiting the amount of contrast above a block, the risk of seizure is minimized. This capability for directly determining neural compression has important implications for the treatment of spinal fractures, and the significance of persisting posttraumatic neural compression is discussed. We believe neural compression should be the primary indication for surgical decompression after spinal injury and that evaluation for it should now be a standard part of the examination of patients with spinal fractures with potential for neurological recovery.
Diagnosis, Differential↗
[A case of multiple sclerosis with polyradiculitis and spinal subarachnoid block].
A case of 53-year-old female with multiple sclerosis was reported. In August 1987, she suffered from weakness in her legs and urinary retention. These signs had progressed with incomplete remissions and exacerbations. In March 1988, she developed sensory loss of all modalities below C2 level, spastic paralysis of upper extremities and flaccid paraplegia of lower extremities. Electromyography showed evidence of denervation in affected muscles of all extremities and paraspinal muscles. On lumber puncture, spinal fluid pressure fell to 0 mmH2O after removal of the spinal fluid of 12 ml, and the CSF protein was 740 mg/dl, indicating subarachnoid space block. The oligoclonal band was positive. MRI showed swelling in the cervical and upper thoracic cord, and multiple lesions in the periventricular white matter in the cerebrum. We diagnosed this case as multiple sclerosis in combination with acute polyradiculitis. The spinal subarachnoid block was considered to be caused by the swelling of the spinal cord.
Acute Disease↗
A technique for early Pantopaque myelography in cervical spinal cord injuries.
A simple, reliable method for early Pantopaque myelography in patients with traumatic injuries of the cervical spinal cord is presented. Myelography is accomplished with the patient prone on a Stryker frame after vertebral reduction and alignment have been achieved with axial skeletal traction. A lateral C1-2 spinal puncture and a portable ""C-arm'' image intensifier with televised fluoroscopy are used. There have been no complications and no occurrences of vertebral re-dislocation with this technique.
Humans↗
Epidural hematoma after spinal anesthesia in a patient with undiagnosed epidural lymphoma.
UNLABELLED: The incidence of hemorrhagic complications after neuroaxial anesthesia is very infrequent. We report a case of a woman developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia at the lumbar level L3-4 for removal of a wire loop in her left knee. No hemostasis altering medication had been taken before and after spinal puncture. The hematoma presenting at the lumbar level L2-3 had to be removed via laminectomy. Pathological examination of the hematoma revealed a highly vascularized centroblastic non-Hodgkin's lymphoma that was not diagnosed before surgery. The patient did not develop any neurological deficits. IMPLICATIONS: We report a case of a women developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia for removal of a wire loop in her left knee. Pathological examination of the neurosurgically removed hematoma revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma.
Anesthesia, Spinal↗
[The effect of injection speed and needle gauge on the spread of sensory blockade in spinal anesthesia].
Unanimity has not yet been reached on the influence of injection speed and needle size on the spread of sensory blockade in spinal anesthesia. While McClure et al. [6] proved that a change in injection speed had no effect on the spread of the blockade, Lanz et al. [4] showed in their investigation that increasing injection speed increases the spread of the blockade. The influence of needle size has hardly been investigated so far. Moore et al. [7] report that the needle size alone has no effect on the spread of the blockade. In this study the influence of injection speed and that of needle size on spread of sensory blockade were considered separately. MATERIALS AND METHODS. Spinal puncture was performed via the midline approach at the L3-4 interspace with the patient in a sitting position. Immediately after the induction of anesthesia the patients were placed in the supine position again. As local anesthetic 15 mg (3 ml) bupivacaine 0.5% with epinephrine 1:200000 was administered. The aim of the study was to find out how far injection speed and size of the spinal needle influenced the sensory spread in isobaric spinal anesthesia. The height of sensory blockade was assessed by means of the pin-prick method in the midline, and the onset of analgesia was determined as height of spread. The injection speeds for the local anesthetic solution were 0.25, 0.5 and 1 ml per second. The needle sizes were 22, 25, and 29 gauge. Each group consisted of 15 patients. RESULTS. It turned out that slow (0.25 ml/s) and the fast (1 ml s) injection was associated with a significantly higher level of analgesia than the medium one (0.5 ml/s). Cephalad spread was to T7 in the first two groups, while the medium injection speed only achieved a level of T9. The results are statistically significant (P less than 0.05). The comparison of different needle sizes (22, 25, and 29 gauge) used for spinal anesthesia showed a higher spread of the sensory blockade with increased diameter of the spinal needle given a constant injection speed. With the 22-gauge needles (n = 15) sensory blockade extended on average to T7, with 25-gauge needles (n = 15) to T9, and with 29-gauge needles (n = 15) to T10. It has to be mentioned, however, that with the 29-gauge needle the standard injection speed of 0.5 ml/s could not be achieved because of the small inner diameter. The differences between 22- and 25-gauge needles are statistically significant (P less than 0.05). DISCUSSION. No direct relation could be proved between the different injection speeds and the spread of the blockade. Our results are hardly comparable with those of other investigators, since other groups have used different local anesthetics or performed investigations in vitro. The use of large spinal needles is associated with spread of the spinal block to a significantly higher level than is achieved with thinner needles.(ABSTRACT TRUNCATED AT 400 WORDS)
Aged↗
Enhancement of intrathecal lidocaine by addition of local and systemic clonidine.
BACKGROUND: Enhancement of local anesthetic-produced regional blocks by clonidine seems well established. There are insufficient data about dose-effect relationship of combinations of clonidine with individual agents, efficiency of local versus systemic administration of clonidine, and comparative evaluation of clonidine with vasoconstrictors. Because of unavailability of long-acting local anaesthetics at the time of study, our aim was to evaluate augmentation of lidocaine spinal block with local or systemic clonidine and to compare the results with the efficacy of intrathecal phenylephrine. METHODS: Ninety pts of age 50-72 yrs with ASA 1-4 physical status, scheduled for open prostatectomies, hysterectomies or ostheosynthesis of fractured hip were randomized to one of 6 treatment groups, 15 pts in each. Patients received intrathecally (L3-L4) either 100 mg of plain lidocaine (group L100); or a mixture of lidocaine 40 and 80 mg with clonidine 100 micrograms (groups L40-C100 and L80-C100); or a combination of lidocaine 40 and 80 mg with clonidine 300 micrograms orally 60 min before spinal puncture (L40-C300 and L80-C300). Addition of intrathecal phenylephrine 5 mg to 80 mg of lidocaine was also investigated (L80-P5). RESULTS: There were no significant intergroup differences concerning demographic data or type of surgery. All operations (duration up to 150 min) were completed without need for analgesic supplementation. The addition of clonidine resulted in a significant reduction of the onset time of spinal block and prolongation of the duration of sensory and motor blocks compared to plain lidocaine or lidocaine with phenylephrine. In spite of the well-known hypotensive action of alpha 2-agonists, haemodynamic depression only in group L80-C300 was significantly more pronounced than in L100 and L80-P5 groups. The least decrease of BP and minimal need of rescue ephedrine among all patients studied were recorded in the group receiving low dosage of lidocaine with intrathecal clonidine (L40-C100). Sedation occurred in most patients receiving clonidine. CONCLUSION: Our results indicate that addition of clonidine to lidocaine, irrespective of the route of administration, prolongs the duration of spinal block and permits a reduction of the lidocaine dose needed for a given duration of block. Addition of phenylephrine results in a less pronounced statistically significant prolongation of anaesthesia. The regression of sensory block before restoration of motor function seems to be a specific (and unfortunate) effect of both clonidine and phenylephrine.
Adrenergic alpha-Agonists↗
[Prospective comparative study of postspinal headaches in young patients (less than 51 years)].
1.009 patients (less than 51 years) were investigated for the frequency of postspinal headaches developing when using different types of needles (22 G and 25 G with Quincke-cut and 22 G Whitacre-needle). It was shown, as expected, that puncture with the smaller needles caused with 6% only about half as many headaches as did taps with the two bigger types of needles, which did not demonstrate any statistical difference between each other. After classifying the complaints as doubtful and definite postspinal headaches the rates of real headaches of the total series was about 5%. The highest frequency of complaints was reported by female patients in the 5th decade. An increase with lesser age was not noticed. Technical difficulties associated with spinal puncture were of almost no importance in influencing the rate of headaches. Definite bloody taps were associated with significantly higher complaint rates. The drugs used (mepivacaine and bupivacaine) did not appear to have any influence. An advantage of the more expensive Whitacre-needle is not seen except in patients with disturbances of coagulation factors.
Adolescent↗
Enoxaparin associated with hugh abdominal wall hematomas: a report of two cases.
Enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.
Abdominal Muscles↗
[The use of low dose midazolam for the management of spinal anesthesia].
The purpose of this study was to evaluate the effects of low dose midazolam (MZ) on memories and ease of management of spinal anesthesia. The low doses of MZ were administered to 70 patients (ASA 1-2), of whom 37 patients were premedicated with atropine sulfate 0.5 mg and pethidine hydrochloride (group P), with 33 patients receiving no premedication (group N). Double blind randomized trials were conducted with the doses of MZ (0, 0.03, 0.06 mg.kg-1), and MZ was administered i.v. to patients just prior to spinal puncture. The short-term and long-term memories were impaired after administration of MZ in both groups. We conclude that MZ appears to be a suitable replacement for other benzodiazepines for relieving anxiety of patients during surgery.
Adolescent↗
Nausea and vomiting during spinal anaesthesia. Effect of metoclopramide and domperidone: a double-blind trial.
A randomised, double-blind investigation was undertaken into the value of metoclopramide and domperidone as anti-emetics in orthopaedic patients who received spinal anaesthesia. Seventy-seven patients were divided into three statistically comparable groups: Group I received 10 mg metoclopramide, Group II 10 mg domperidone, and Group III NaCl as placebo. These substances were given intravenously before the spinal puncture. There was a comparable decrease in mean arterial blood pressure (MAP), level of sensory block and dose of tetracaine in all three groups. The patients who were nauseated and/or vomited showed a greater decrease in MAP. The incidence of nausea and/or vomiting in the metoclopramide and the placebo group were similar, 20% and 15% respectively, whereas this complication was apparent in 35% of patients who received domperidone. We conclude that metoclopramide and domperidone in the dosages used are ineffective in alleviating nausea and vomiting after spinal anaesthesia.
Aged↗
Vertebral infection.
Vertebral infection represents 2-4% of all cases of osteomyelitis. An increase in the incidence of pyogenic as well as granulomatous spondylitis has been noticed. Early radiological diagnosis is of great importance for prompt treatment and prevention of clinically significant consequences which include neural compromise and late spinal deformities. The most frequent causative pyogenic micro-organisms are gram-negative bacteria especially Staphylococcus aureus. An important form of nonpyogenic granulomatous infection is tuberculous spondylitis which represents the most common form of extrapulmonary tuberculosis. The routes of spinal infection include hematogenous spread, postoperative infections, direct implantation during spinal punctures and spread from a contiguous focus. The role of imaging is an early diagnosis, evaluation of extent of infection with special regard to potential neural compromise, differential diagnosis, guidance of diagnostic biopsy, planning of eventual operative procedures and assessment of therapeutic response. Imaging modalities include bone scintigraphy, radiography, CT and MRI. In practice, usually a combination of a sensitive and a specific method is utilised. The only imaging modality which combines high sensitivity with satisfactory specificity is MRI. This is the reason that MRI frequently has become the first imaging modality in clinically suspect spinal infection. The MRI is the method of choice for direct demonstration of extension of infection, especially of eventual epidural abscess or phlegmon and consecutive neural compression. Using MRI monitoring of therapeutic efficiency is possible.
Biopsy↗
[Neurologic complication following spinal anesthesia for manual detachment of the placenta].
Long-term paralysis of the lower extremities was observed in a 31-year-old fourth-gravida patient, undergoing a curettage under spinal anaesthesia because of placenta accreta. The patient recovered within three days from her neurological signs and symptoms, consisting of complete paresis of the hip and knee flectors and severe headache. Clinical investigations including a neurological examination, spinal puncture, x-ray pictures of the lumbosacral area and haemograms revealed no evidence for an infection, abscess or haematoma. With regard to the fact, that neurological deficiency disappeared completely within three days, it seems probable, that the symptoms were caused by the longer lasting gynaecological position (Steinschnitt-position) during the period of delivery and curettage thereafter.
Adult↗
Central nervous system reactions to cervical myelography.
In a double blind prospective study of side effects to cervical myelography 38 patients were evaluated with neurologic examination, electroencephalography (EEG), brainstem evoked response (BER), somatosensory evoked responses (SSER), and continuous reaction times prior to and at 6 h and 24 h after myelography with either metrizamide or iohexol. A difference in the incidence of side effects (for example headache, dizziness, nausea, and neck pain) to the two different contrast media indicated that the inconveniences related to myelography were not only due to the spinal puncture. A contrast medium effect on the central nervous system varying from one agent to another was present. A high frequency of EEG deteriorations among patients with adverse clinical reactions and on only discrete affection upon BER indicated the reaction to be located to the cerebral cortex. Weakened tendon reflexes and reduced strength in the upper extremities were probably caused by blockade in the motor roots as SSER were normal indicating no affection of the sensory pathways. This hypothesis is in agreement with the fact that the patients were in the prone position in the first phase of the investigation causing the highest concentration of contrast medium around the motor roots and the anterior part of the spinal cord. Difference in metabolic effect may explain differences in side effects of metrizamide and iohexol.
Adult↗
Prevention of postdural puncture headache after spinal anaesthesia for extracorporeal shockwave lithotripsy. An assessment of prophylactic epidural blood patching.
The prevention of postdural puncture headache after spinal anaesthesia for extracorporeal shockwave lithotripsy was investigated by a controlled clinical trial which compared epidural injection of 10 ml of autologous blood with 10 ml of normal saline immediately after intrathecal injection of local anaesthetic. The incidence of postdural puncture headache was 8.3% in the group that received blood compared with 45% in the group that received saline, a significant reduction (p less than 0.01). The incidences of backache and lower limb paraesthesiae were similar in both groups. No serious complications were reported.
Adult↗