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      Déficit motor asociado a analgesia epidural en paciente con patología neurológica preexistente no conocida Translated title: Motor deficits associated with epidural analgesia in patients with preexisting neurological disease of unknown


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          Existen múltiples estudios que afirman que las complicaciones neurológicas asociadas a la práctica de un bloqueo neuroaxial pueden tener una mayor incidencia en los pacientes que presentan enfermedades neurológicas preexistentes como la estenosis espinal. Esta incidencia puede ser especialmente relevante si no se cuenta con un diagnóstico previo de dichas patologías. En el presente trabajo describimos nuestra experiencia con una mujer de 60 años de edad, diagnosticada de isquemia crónica de miembro inferior derecho, que presentó un déficit motor importante tras la colocación de un catéter epidural para el manejo del dolor.

          Translated abstract

          There are many studies that suggest that the neurological complications associated with the practice of neuraxial blockade may have a higher incidence in patients with preexisting neurological conditions such as spinal stenosis. This effect may be particularly relevant if there is no previous diagnosis of these pathologies. We describe our experience with a 60-year-old woman diagnosed with chronic ischemia of the right leg which presented an important motor deficit following epidural catheter insertion for pain management.

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          Most cited references28

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          Severe neurological complications after central neuraxial blockades in Sweden 1990-1999.

          Central neuraxial blockades find widespread applications. Severe complications are believed to be extremely rare, but the incidence is probably underestimated. A retrospective study of severe neurologic complications after central neuraxial blockades in Sweden 1990-1999 was performed. Information was obtained from a postal survey and administrative files in the health care system. During the study period approximately 1,260,000 spinal blockades and 450,000 epidural blockades were administered, including 200,000 epidural blockades for pain relief in labor. : The 127 complications found included spinal hematoma (33), cauda equina syndrome (32), meningitis (29), epidural abscess (13), and miscellaneous (20). Permanent neurologic damage was observed in 85 patients. Incidence of complications after spinal blockade was within 1:20-30,000 in all patient groups. Incidence after obstetric epidural blockade was 1:25,000; in the remaining patients it was 1:3600 (P < 0.0001). Spinal hematoma after obstetric epidural blockade carried the incidence 1:200,000, significantly lower than the incidence 1:3,600 females subject to knee arthroplasty (P < 0.0001). : More complications than expected were found, probably as a result of the comprehensive study design. Half of the complications were retrieved exclusively from administrative files. Complications occur significantly more often after epidural blockade than after spinal blockade, and the complications are different. Obstetric patients carry significantly lower incidence of complications. Osteoporosis is proposed as a previously neglected risk factor. Close surveillance after central neuraxial blockade is mandatory for safe practice.
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            Neurological complications after regional anesthesia: contemporary estimates of risk.

            Regional anesthesia (RA) provides excellent anesthesia and analgesia for many surgical procedures. Anesthesiologists and patients must understand the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Many studies that have investigated neurological complications after RA are dated, and do not reflect the increasing indications and applications of RA nor the advances in training and techniques. In this brief narrative review we collate the contemporary investigations of neurological complications after the most common RA techniques. We reviewed all 32 studies published between January 1, 1995 and December 31, 2005 where the primary intent was to investigate neurological complications of RA. The sample size of the studies that investigated neurological complications after central and peripheral (PNB) nerve blockade ranged from 4185 to 1,260,000 and 20 to 10,309 blocks, respectively. The rate of neuropathy after spinal and epidural anesthesia was 3.78:10,000 (95% CI: 1.06-13.50:10,000) and 2.19:10,000 (95% CI: 0.88-5.44:10,000), respectively. For common PNB techniques, the rate of neuropathy after interscalene brachial plexus block, axillary brachial plexus block, and femoral nerve block was 2.84:100 (95% CI 1.33-5.98:100), 1.48:100 (95% CI: 0.52-4.11:100), and 0.34:100 (95% CI: 0.04-2.81:100), respectively. The rate of permanent neurological injury after spinal and epidural anesthesia ranged from 0-4.2:10,000 and 0-7.6:10,000, respectively. Only one case of permanent neuropathy was reported among 16 studies of neurological complications after PNB. Our review suggests that the rate of neurological complications after central nerve blockade is <4:10,000, or 0.04%. The rate of neuropathy after PNB is <3:100, or 3%. However, permanent neurological injury after RA is rare in contemporary anesthetic practice.
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              Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders.

              Historically, the use of regional anesthetic techniques in patients with preexisting central nervous system (CNS) disorders has been considered relatively contraindicated. The fear of worsening neurologic outcome secondary to mechanical trauma, local anesthetic toxicity, or neural ischemia is commonly reported. We examined the frequency of new or progressive neurologic complications in patients with preexisting CNS disorders who subsequently underwent neuraxial blockade. The medical records of all patients at the Mayo Clinic from the period 1988 to 2000 with a history of a CNS disorder who subsequently received neuraxial anesthesia or analgesia were retrospectively reviewed. One-hundred-thirty-nine (n = 139) patients were identified for study inclusion. Mean patient age was 60 +/- 17 yr. Gender distribution was 86 (62%) males and 53 (38%) females. An established CNS disorder diagnosis was present a mean of 23 +/- 23 yr at the time of surgical anesthesia, with 74 (53%) patients reporting active neurologic symptoms. Spinal anesthesia was performed in 75 (54%) patients, epidural anesthesia or analgesia in 58 (42%) patients, continuous spinal anesthesia in 4 (3%) patients, and a combined spinal-epidural technique in 2 (1%) patients. Bupivacaine was the local anesthetic most commonly used in all techniques. Epinephrine was added to the injectate in 72 (52%) patients. There were 15 (11%) technical complications, with the unintentional elicitation of a paresthesia and traumatic needle placement occurring most frequently. A satisfactory block was reported in 136 (98%) patients. No new or worsening postoperative neurologic deficits occurred when compared to preoperative findings (0.0%; 95% confidence interval, 0.0%-0.3%). We conclude that the risks commonly associated with neuraxial anesthesia and analgesia in patients with preexisting CNS disorders may not be as frequent as once thought and that neuraxial blockade should not be considered an absolute contraindication within this patient population.

                Author and article information

                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Revista de la Sociedad Española del Dolor
                Rev. Soc. Esp. Dolor
                Inspira Network Group, S.L (Madrid, Madrid, Spain )
                August 2013
                : 20
                : 4
                : 176-179
                [01] Sevilla orgnameHospital Universitario de Valme orgdiv1Departamento de Anestesiología y Reanimación

                This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 International License.

                : 03 June 2012
                : 03 February 2012
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 16, Pages: 4

                SciELO Spain

                Analgesia epidural,toxicidad de anestésicos locales,complicaciones neurológicas,polineuropatía,Epidural analgesia,local anesthetic toxicity,neurological complications,polyneuropathy


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