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Essentials of Regional Anesthesia pp 541–553Cite as

Regional Anesthesia in the Patient with Preexisting Neurological Disease

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Abstract

Regional anesthesia has always provided benefits for patients undergoing surgical procedures. However, in patients with preexisting neurological diseases, there has been controversy surrounding whether regional anesthesia is beneficial or harmful. Using regional anesthesia with these individuals often places them at greater risk for neurological injury, and predisposes the patient to worsening disease processes, which can potentially be debilitating for the patient. Consequently, many practitioners avoid regional anesthetics in these patients, and they are often treated conservatively. The goal of this chapter is to summarize the evidence to date in order to guide physicians in their decision-making and to provide the best care possible to patients with preexisting neurologic conditions undergoing regional anesthesia.

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Author information

Authors and Affiliations

  1. Oklahoma Pain Physicians, Oklahoma City, OK, USA

    Rafael Justiz MD

  2. Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

    Rafael Justiz MD & Alexander F. Bautista MD

Authors
  1. Rafael Justiz MD
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  2. Alexander F. Bautista MD
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Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA

    Alan David Kaye

  2. Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Richard D. Urman

  3. Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA

    Nalini Vadivelu

Review Questions

Review Questions

  1. 1.

    A 67-year-old female, obese and diabetic with peripheral neuropathy, is scheduled for an exploratory laparotomy and total abdominal hysterectomy with lymph node dissection. The patient requests an epidural for postoperative pain control. Which of the following factors would put this patient at increased risk for postoperative neurologic injury?

    1. (a)

      Using bupivacaine 0.125% infusion at 5 ml/h.

    2. (b)

      Performing epidural anesthesia prior to extubation for postoperative pain control.

    3. (c)

      Utilization of ultrasound for localization of the intervertebral space.

    4. (d)

      Padding lower extremity and placement of TED hoses for DVT prophylaxis.

  2. 2.

    Which of the following is the preferred imaging modality to diagnose spinal canal pathology?

    1. (a)

      Computed tomography.

    2. (b)

      Radiographic imaging such as X-ray.

    3. (c)

      Magnetic resonance imaging.

    4. (d)

      Myelography.

  3. 3.

    Which of the following statement is true regarding regional anesthesia and peripheral nerve injury (PNI)?

    1. (a)

      Intrafascicular injections are associated with higher opening injection pressures and risk of PNI compared with perineural injections.

    2. (b)

      The use of maximum concentration of local anesthetics is not associated with an increased risk of PNI in patients with preexisting neurologic injury.

    3. (c)

      The radial nerve at the elbow and the posterior tibial nerve are at increased risk of PNI.

    4. (d)

      The use of peripheral nerve blocks (PNB) is associated with PNI after total knee arthroplasty.

  4. 4.

    Which of the following patient-specific risk factors is not associated with perioperative nerve injury in patients with preexisting neurologic disorder?

    1. (a)

      Diabetes mellitus.

    2. (b)

      Female gender.

    3. (c)

      Obesity.

    4. (d)

      Advanced age.

  5. 5.

    Multiple sclerosis (MS) is a chronic degenerative disease that causes demyelination in the spinal cord and brain. Since the etiology of MS is multifactorial, which is the least likely cause of multiple sclerosis?

    1. (a)

      MS has a genetic predilection particularly with afflicted first-degree relatives with growing evidence that MS most likely involves the B cells.

    2. (b)

      T cells in the peripheral blood become stimulated and attack foreign antigens while simultaneously attacking brain proteins that share similar molecular region of the antigen.

    3. (c)

      Environmental factors and exposure to bacterial and viral agents may lead to MS.

    4. (d)

      Low vitamin D levels may be associated with MS.

  6. 6.

    Amyotrophic lateral sclerosis is a rapidly progressive disease with progressive degeneration of motor neurons that causes muscular weakness, atrophy, fasciculations, spasticity, and hyperreflexia. With respect to neuraxial anesthesia in patients with ALS, which answer is correct?

    1. (a)

      Patents are at greater risk for hemodynamic instability compared to general anesthesia.

    2. (b)

      Neuraxial anesthesia is not associated with any respiratory comprise when compared to general anesthesia.

    3. (c)

      Neuraxial anesthesia should be avoided in patients with ALS.

    4. (d)

      Neuraxial anesthesia may be a reasonable choice but has the potential of impairing respiratory function.

  7. 7.

    Post-polio syndrome (PPS) is a condition that affects polio survivors from an initial acute attack of the poliomyelitis virus. Which of the following statements is not true?

    1. (a)

      The onset of symptoms occurs up to 30 years after the initial episode of poliomyelitis.

    2. (b)

      PPS is the most prevalent progressive neuromuscular disease reported in North America.

    3. (c)

      PPS affects men greater than women.

    4. (d)

      The most common symptoms include progressive muscle weakness, fatigue, and muscle atrophy starting in the muscles previously affected by the virus.

  8. 8.

    Peripheral nervous system disorders comprise neurological disease states that involve the cell body, axon, neuromuscular junction, and myelin sheath. Which answer is most correct?

    1. (a)

      These disorders are mostly in the periphery and involve the brain or spinal cord.

    2. (b)

      These patients suffer from the disruption of axons with distal degeneration or segmental demyelination caused by Schwann cell degeneration.

    3. (c)

      These conditions typically start proximally and spread in a distal fashion leading to the classic “glove and stocking” distribution of decreased sensation, weakness, and diminished reflexes.

    4. (d)

      Electromyogram and nerve conduction velocity studies typically will not reveal evidence of denervation and any changes in nerve conduction velocity.

  9. 9.

    Autonomic hyperreflexia (AH) is a dangerous clinical syndrome that develops as a sequela to spinal cord injury. Which of the following statements is true?

    1. (a)

      Eighty-five percent of spinal cord injury patients are at risk for developing hyperreflexia symptoms if the lesion involves the T8 spinal cord level or lower.

    2. (b)

      Spinal cord injury can produce acute uncontrolled hypertension with the introduction of a noxious stimulus above the level of the lesion.

    3. (c)

      The leading trigger that stimulates AH is typically distention of the urinary bladder or colon.

    4. (d)

      The pathophysiology involves an imbalanced reflex sympathetic discharge that involves inhibited spinal reflexes that leads to hypertension and reflex bradycardia.

    5. (e)

      General anesthesia has been shown to inhibit spinal reflexes better than spinal anesthesia below the lesion which inhibits the associated autonomic reflex.

Answers

  1. 1.

    (b) Patients under general anesthesia or deep sedation lack the ability to verbalize or report warning signs and can place a patient at risk for neurologic injury. Warning signs such as paresthesia or pain on injection of local anesthetics would indicate needle proximity to neuraxis. The use of dilute local anesthetics and appropriate patient positioning with adequate padding help prevent further neurologic compromise. Even though the use of ultrasound in neuraxial blockade has not been shown to reduce the risk of peripheral nerve injury, it would beneficial to aid proper anatomic localization.

  2. 2.

    (c) Magnetic resonance imaging is the diagnostic modality of choice in patients suspected with neuraxial lesions. However, computed tomography should be used for rapid diagnosis if MRI is not immediately available especially if neuraxial compression injury is suspected.

  3. 3.

    (a) Local anesthetic toxicity is time- and concentration-dependent. The ulnar nerve and the common peroneal nerve are at increased risk of PNI. PNB is not associated with PNI after TKA.

  4. 4.

    (b) There is a plethora of factors that can contribute to PNI especially in patients with preexisting neurologic disorder. These include diabetes mellitus, extremes of habitus, male gender, and advanced age.

  5. 5.

    (a) The etiology of MS is not fully understood, but multiple factors may be involved. MS has a genetic predilection particularly with afflicted first-degree relatives with growing evidence that MS most likely involves the T cells. There is a possibility that T cells in the peripheral blood become stimulated and attack foreign antigens while simultaneously attacking brain proteins that share similar molecular region of the antigen. It has also been associated with environmental factors and exposure to bacterial and viral agents. Lastly, there is a correlation of low vitamin D levels with MS.

  6. 6.

    (d) Amyotrophic lateral sclerosis (ALS) leads to progressive degeneration of motor neurons and causes muscular weakness, atrophy, fasciculations, spasticity, and hyperreflexia. A concerning problem with ALS is general anesthesia; these patients may have extreme hemodynamic responses with progressive weakness, muscle atrophy, and risk for aspiration and ventilator dependence. ALS patients have better outcomes when general anesthesia can be avoided entirely; therefore, regional anesthesia should be considered whenever possible. Epidural anesthesia may be a reasonable choice in selected cases but has the potential of impairing respiratory function by producing intercostal muscle weakness.

  7. 7.

    (c) The onset of symptoms may occur up to 30 years after the initial episode of poliomyelitis. PPS is the most prevalent progressive neuromuscular disease reported in North America with a greater rate in women than in men. The most common symptoms include slowly progressive muscle weakness, fatigue, and gradual muscle atrophy starting in the muscles previously affected by the virus.

  8. 8.

    (b) Peripheral nervous system disorders occur in the periphery and do not involve the brain or spinal cord. These patients suffer from the disruption of axons with distal degeneration or segmental demyelination caused by Schwann cell degeneration which will result in peripheral neuropathies. Such conditions typically start distally and spread in a proximal fashion leading to the classic “glove and stocking” distribution of decreased sensation, weakness, and diminished reflexes. Electromyogram and nerve conduction velocity studies will often reveal evidence of denervation and decreased nerve conduction velocity.

  9. 9.

    (c) Approximately 85% of spinal cord injury patients are at risk for developing hyperreflexia symptoms if the lesion involves the T6 spinal cord level or higher. This injury can produce acute uncontrolled hypertension with the introduction of a noxious stimulus below the level of the lesion, leading to a peripheral sympathetic response producing vasoconstriction below the injured level. The leading trigger that stimulates AH is typically distention of the urinary bladder or colon. The pathophysiology involves an imbalanced reflex sympathetic discharge that involves uninhibited spinal reflexes. Regional anesthesia has been used successfully in patients with autonomic hyperreflexia. Particularly, spinal anesthesia has shown to inhibit spinal reflexes below the lesion which inhibits the associated autonomic reflex.

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Justiz, R., Bautista, A.F. (2018). Regional Anesthesia in the Patient with Preexisting Neurological Disease. In: Kaye, A., Urman, R., Vadivelu, N. (eds) Essentials of Regional Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-74838-2_31

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  • DOI: https://doi.org/10.1007/978-3-319-74838-2_31

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