TRANSIENT NEUROLOGICAL SYMPTOMS FOLLOWING

SPINAL ANESTHESIA FOR CESAREAN SECTION

Edomwonyi NP* and Isesele TO *

Abstract

Background
Transient neurological symptoms (TNS) are defined as symmetrical bilateral pain in the back
or buttocks or pain radiating to the lower extremities after recovery from spinal anesthesia. About
80-85% of cesarean sections are performed under spinal anesthesia in our centre.
Our aim was to determine the incidence of TNS, risk factors and outcome of management in
pregnant women undergoing cesarean section.

Patients and Methods

Approval was obtained from the hospital ethic’s committee, and consent from the patients.
ASA 1 and 2 pregnant women undergoing cesarean section under spinal anesthesia formed the
subjects of this prospective study. They were evaluated and pre-medicated by the attending
anesthetists. Spinal anesthesia was performed at the L2-3 or L3-4 interspaces, using a 25G Quincke
or 25G pencil point spinal needle with 0.5% heavy bupivacaine. The investigators interviewed the
patients in the ward for three consecutive days, in order to identify those that developed TNS.

Results
One hundred and twenty consecutive patients were studied. TNS were documented in 12
(10%) patients. Backache was recorded in 8 patients (6.6%), pain in the thighs in 2 (1.7%) and pain
in the buttocks in 2 (1.7%). Onset time of symptoms was recorded as 6-12 hrs in 5 (4.2%) patients,
12-24 hrs in 5 (4.2%) and 24-48 hrs in 2 (1.6%). The patients that developed TNS were managed
accordingly with satisfactory outcome.

Conclusion

A follow-up for all patients that receive spinal anesthesia for cesarean section should constitute
a standard practice.
Key words: Anesthetic technique: spinal anesthesia, anesthetics-local: bupivacaine,
hyperbaric, surgery: cesarean section, complications: neurological.

* MD, Obstetric Unit, Department of Anaesthesia, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.
Corresponding Author: Dr. NP Edomwonyi, Department of Anaesthesia, University of Benin Teaching Hospital, PMB
1111, Benin City, Nigeria.

809 M.E.J. ANESTH 20 (6), 2010

810 Edomwonyi NP & Isesele TO

Introduction using a 25G Quincke spinal needle or 25G pencil point

Transient neurological symptoms (TNS) are (SIMS Portex). 0.5% heavy bupivacaine, 2.2-2.5 ml
defined as symmetrical bilateral pain in the back or was injected and patient repositioned supine with a
buttocks or pain radiating to the lower extremities after 15o left lateral tilt and slight head up tilt. Vital signs
recovery from spinal anesthesia1. The first report of were continuously monitored during the operation.
TNS with 5% lignocaine by Schneider and colleagues After the delivery of the fetuses, the patients were
in 19931 was confirmed later by several other studies2-4. repositioned supine. Intraoperative complications,
It is thought that a localized local anesthetic toxic such as hypotension, bradycardia, shivering were
effect may be an important contributing factor in the managed accordingly.
development of transient neurological symptoms after Standard questionnaire was used to document
spinal anesthesia with concentrated solutions5,6. The patients’ characteristics, intraoperative clinical data,
occurrence of this complication is rare after the use duration of anesthesia and surgery recovery room
of 0.5% bupivacaine for spinal anesthesia7,8. Hiller and complications in the ward, attempts at lumbar
et al reported 3% incidence of TNS following the
puncture. The type of spinal needle used was not by
use of 0.5% bupivacaine against 30% after the use of
choice but was determined by what was available at
mepivacaine9.
the time of study.
The aim of our study was to determine the
The investigators were anesthetists not primarily
incidence of transient neurological symptoms after
responsible for the conduct of the anesthesia.
spinal anesthesia for cesarean section, the risk factors
They interviewed the patients in the ward 24
and outcome of management.
hrs postoperatively, again at 48 hrs and 72 hrs
postoperatively to identify those patients that developed
Patients and Methods transient neurological symptoms, the location of pain,
This was a prospective study carried out and onset of pain after recovery of block, duration
form February to October, 2007 after approval was of pain after recovery of block, management and its
obtained from the institutional Ethic’s committee, and outcome.
consent from the patients. One hundred and twenty
consecutive, ASA 1and 2 pregnant women who
Results
presented for cesarean section formed the subjects
of study. Exclusion criteria were ASA 3 and above, One hundred and twenty patients were recruited
patients with neurological diseases, presence of back in the study. Table 1 showed their demographic
ache and pain in the buttocks and legs (as a result of characteristics. Twelve (10%) patients complained of
pressure from the fetal presentation). They were all transient neurological symptoms. Variables of spinal
seen, reviewed and pre-medicated by the anesthetists anesthesia are shown in Table 2.Quincke spinal needle
in attendance. was used in 55 (45.8%) patients and pencil point in 65
(54.2%) patients. The mean dose of bupivacaine (ml)
Premedication consisted of 30 ml of mixture
was 2.468 (0.29). The mean duration of surgery in
magnesium trisilicate, intravenous metoclopramide,
minutes was 59.92 (21.86). Block height was T2-T10
10 mg and 50 mg Ranitidine.
with T6 as median range.
In the theatre, multiparameter monitor was
attached, after obtaining baseline vital signs (pulse rate,
Table 1
blood pressure and oxygen saturation), intravenous Demographic Characteristics
access was established with 18 gauge cannulae. Mean/Sd
Preloading of the circulation was achieved with 10-15 Age (yrs) 33.08 (3.94)
ml of 0.9% normal saline.
Weight (kg) 76.5 (9.76)
Spinal anesthesia was performed at the L2-3 or
Height (cm) 160.172 (3.49)
L3-4 interspace with the patient in the sitting position,
TRANSIENT NEUROLOGICAL SYMPTOMS FOLLOWING SPINAL ANESTHESIA FOR CESAREAN SECTION
811

Table 2 number of attempts at lumbar puncture and the grade

Variables of Spinal Anaesthesia of anesthetist. Six (50%) patients were managed with
Needle type/size No of patients non-steroidal anti-inflammatory drug, Ketorolac 30 mg
6 hourly while 3 (25%) were given opioid, tramadol
Quincke/25 55
hydrochloride 100mg, 8 hourly. Both drugs were
Pencil point/ 25 65 administered intramuscularly. Three (25%) patients
Mean duration of -59.92 (21.86)
required no analgesics. The outcome of management
Surgery (minutes) was satisfactory.

Mean Volume of 0.5%

Heavy bupivacaine (mls) -2.468 (0.29) Discussion
Two attempts were made in 9 (75%) patients. Although spinal anesthesia offers many
Three attempts were made in two (16.7%) patients advantages for cesarean section, it is not without
that reported severe pain. Ten (67%) out of the twelve complications, including transient neurological
patients complained of mild to moderate pain while 2 deficits. Previous control trials have reported a
(33%) complained of severe pain. low incidence of 0-8% TNS in women undergoing
cesarean section10 or postpartum tubal ligation (3%)11.
Table 3 shows onset of pain after recovery of
Our study showed a slightly higher incidence of
block while Table 4 shows sites of symptoms.
10% TNS. In Great Britain, a number of high profile
Table 3 legal cases in the 1950s concerning complications of
Onset of pain after recovery of block (hr)
neuraxial techniques led to its decline for more than
6-12 hrs5- (41.7%) patients two decade12. Albert Woolley and Cecil Roe were
12-24 hrs-5 (41.7%) healthy, middle aged men who became paraplegic after
spinal anesthesia for minor surgery in 1947 in Britain.
24-48 hrs-2 (16.6%)
Phenol, in which the ampoules of local anesthetic had
been immersed, had contaminated the local anesthetic
Table 4
Location of pain through invisible cracks13.
Buttocks-2 (16.7%) Transient neurological symptoms were also
Thighs-2 (16.7%) described as conditions characterized by back pain
Back ache-8 (66.6%) radiating to the lower extremities without sensory
Total-12 (100%) or motor deficits, which resolved spontaneously14,15.
Injury may result from direct needle trauma to nervous
tissues at the level of the spinal cord, nerve root or
Quincke needle was used in ten (83%) of the peripheral nerve, from spinal cord ischemia, from
patients that complained of symptoms against 2 accidental injection of neurotoxic drugs or chemicals,
(17%) in the pencil point group. The difference was from introduction of bacteria into the subarachnoid or
considered statistically significant using Fisher’s exact epidural space or rarely from epidural hematoma16-18
test P = 0.0116, 95% CI: 1.462 to 33.513. With regard to and positioning (lithotomy). Avidan and colleagues,
the grade of the anesthetists who performed the block, reported details of magnetic resonance imaging of a
11 (91.7%) were done by residents (registrar1and patient with TNS after spinal lidocaine. It indicated
senior registrars) while one (8.3%) was performed by a a local inflammatory process as the possible etiology
consultant. The difference was statistically significant, for the symptoms, and concluded that TNS in some
P = 0.0253, 95% CI: 0.01009 to 0.8192. The duration cases results in permanent neurological deficit19. In
of pain in the thighs and back lasted for 24-72 hours many cases, deficits are the results of administration
and the pain in the buttocks lasted for 96 hrs. of neurotoxic doses of local anesthetic or result from
The risk factors for the development of TNS trauma after multiple attempts necessary to establish a
were the use of cutting spinal needle (Quincke), technically difficult block10,20.
M.E.J. ANESTH 20 (6), 2010
812 Edomwonyi NP & Isesele TO

The risk factors for the development of TNS, century ago24.

identified in this study were the use of cutting spinal Current therapeutic options include opioids, non-
needle (Quincke), number of attempts at lumbar steroidal anti-inflammatory drugs (NSAID), muscle
puncture and the grade of anesthetists who performed relaxants and, symptomatic therapy25. One of the
the block. A greater occurrence of neurological most successful classes of drugs for treating TNS has
symptoms was associated with the use of cutting spinal been the NSAID. Ibuprofen, naproxen and ketorolac
needles. Three attempts were made in two patients that have all been used successfully. Significant muscle
reported severe pain. Our findings showed that spinal spasm can be relieved with muscle relaxant, such as
anesthesia was performed by a registrar grade level cyclobenzaprine. Symptomatic therapy, including leg
in eight patients that complained of TNS. Although elevation on pillows and heating pads, may provide an
neurological complications may be secondary to the additional measure of patients’ comfort25. The patients
labour and delivery process, the neural block is usually that complained of transient neurological symptoms in
considered causative until proven otherwise21. our study were treated with NSAID and opioid with
Auroy et al prospectively monitored neurologic satisfactory outcome.
complications in more than 103,000 regional
anesthesia, all deficits were present within 48 hours
Conclusion
after anesthesia. Most were transient with recovery
occurring between two days and three months16. A follow-up for all patients that receive spinal
anesthesia for cesarean section should constitute a
In a similar study involving 123,000 regional
standard practice in order to identify and manage
anesthetics in parturients, 46 cases of single nerve root
associated complications.
neuropathies were reported (3.7/10,000) with complete
recovery in all patients by three months22. Most of our
patients reported an onset time of 12 to 24 hours after Aknowledgement
cesarean section and recovery lasted for two to four We thank the resident doctors in the department
days. This is in agreement with previous study16. of Anesthesia and the nurses in the maternity ward
There is a suggestion that certain patients may for their cooperation during the study. We are grateful
have a predisposition to developing neurological to Abieyuwa Ima-Edomwonyi for her assistance in
deficit after spinal anesthesia23. It is best to avoid the preparing the manuscript.
technique in such cases as recommended nearly half a
TRANSIENT NEUROLOGICAL SYMPTOMS FOLLOWING SPINAL ANESTHESIA FOR CESAREAN SECTION
813

References
1. Schneider M, Ettlin T, Kaufmann M, Schumacher P, Urwyler A, Anaesthesia; 84:121-126, 2000.
Hampl K, Von Hochstetter A: Transient neurologic toxicity after 14. Hodgson PS, Liu SS: New developments in spinal anesthesia.
hyperbaric subarachnoid anesthesia with 5% lidocaine. Anesthesia Anesthesiol Clin North America; 18:235-249, 2000.
and Analgesia; 76:1154-1157, 1993. 15. Horlocker TT: Complications of spinal and epidural anesthesia.
2. Hampl KF, Schneider M, Drasner K, Stotz G, Drewe J: 5% Anesthesiol Clin North America; 18:235-249, 2000.
hyperbaric lidocaine: A risk factor for transient radicular irritation? 16. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K: Serious
Anesthesiology; 79:3A, A875, 1993. complications related to regional anesthesia: results of a prospective
3. Tarkkila P, Huhtala J, Tuominen M: Transient radicular irritation survey in France. Anesthesiology; 87:479-486, 1997.
after spinal anaesthesia with hyperbaric 5% lignocaine. Br J Anaes; 17. Wlody D: Complications of regional anesthesia in obstetrics. Clin
74:328-329, 1995. Obstet Gynecol; 46:667-678, 2003.
4. Salmela L, Aromaa U, Cozanitis DA: Leg and back pain after 18. Zaric D, Christiansen C, Pace NL, Punjasawadwon Y: Transient
spinal anaesthesia involving hyperbaric 5% lignocaine. Anaesthesia; neurologic symptoms TNS following spinal anaesthesia with
51:391-393, 1996. lidocaine versus other local anaesthetics. Cochrane Database Syst
5. Lambert LA, Lambert DH, Strichartz GR: Irreversible conduction Rev; CD003006, 2003.
block in isolated nerve by high concentrations of local anesthetics. 19. Avidan A; Gomori M, Davidson E: Nerve root inflammation
Anesthesiology; 80:1082-1093, 1994. demonstrated by magnetic resonance imaging in a patient with
6. Bainton C, Strichartz G: Concentration dependence of lidocaine- transient neurologic symptoms after intrathecal injection of
induced irreversible conduction loss in frog nerve. Anesthesiology; lidocaine. Anesthesiology; 97:257-8, 2002.
81:657-667, 1994. 20. Dahlgren N, Tornebrandt K: Neurological complications after
7. Hampl K, Schneider M, Ummenhofer W, Drewe: Transient anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics
neurologic symptoms after spinal anaesthesia. Anaes and Analg; performed over three years. Acta Anaesthesiol Scand; 39:872-880,
81:1148-1149, 1993. 1995.
8. Tarkkila P, Huhtala J, Tuominen M: Transient radicular irritation 21. Chestnut DH: Anesthesia and maternal mortality. Anesthesiology;
after bupivacaine spinal anesthesia. Reg Anaes; 21:26-29, 1996. 86:273-276, 1997.
9. A Hiller and PH: Rosenberg, Transient neurological symptoms after 22. Scott DB, Tunstall ME: Serious complications associated with
spinal anaesthesia with 4% mepivacaine and 0.5% bupivacaine. Br J epidural/spinal blockade in obstetrics:a two year prospective study.
Anaes, 79:301-305, 1997. Int J. Obstet Anesth; 4:133-139, 1995.
10. Aouad M, Siddik S, Jalbout M, Baraka A: Does pregnancy 23. Aldrete JA: Anaesthetic substances in the spine. In Arachnoiditis:the
protect against intrathecal lidocaine-induced transient neurologic silent Epidemic J. Aldrete (ed). Futuremed: Denver, CO, 77-101,
symptoms. Anesth Analg; 92:401-404, 2001. 2000.
11. Philip J, Sharma S, Gottumukkla V, Perez B, Slay-Maker E, Wiley 24. Vandam LD, Dripps RD: Exacerbation of pre-existing neurological
J: Transient neurologic symptoms after spinal anaesthesia with disease after spinal anaesthesia with lidocaine. N Engl J Med;
lidocaine in obstetric patients. Anesth Analg; 92:405-409, 2001. 255:843 (Medline), 1956.
12. Cope RW: The Wooley and Roe Case. Anesthesia; 50:162-173, 25 Pullock JE: Transient Neurologic Symptoms: Etiology, Risk
1995. Factors, and Management. Regional Anesthesia and Pain Medicine,
13. Maltby JR, Hutter CDD, Clayton KC: The Woolley and Roe Case. vol. 27, no. 6 (November-December), pp. 581-586, 2002.

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