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Leg weakness not attributable to spinal anaesthesia
280
International Journal of Obstetric Anesthesia
2.
LaPorta R F, Arthur G R, Datta S. Phenylephrine in treating maternal hypotension due to spinal anaesthesia for caesarean delivery: effects on neonatal catecholamine concentrations, acid base balance and Apgar scores. Acta Anaesthesiol Stand 1995; 901-905. 3. Thomas D G, Robson S C, Redfern N, Hughes D, Boys R J. Randomised trial of bolus phenylephrine or ephedrine for maintenance of arterial blood pressure during spinal anaesthesia for caesarean section. BJA 1996; 76: 61-65. 4. Butterworth J F, Piccione W, Berrizbeitia L D, Dance G, Shemin R J, Cohn L H. Augmentation of venous return by adrenergic agonists during spinal anesthesia. Anesthesia and Analgesia 1986; 65: 612616. Weiner C P, Martinez E, Chestnut D H, Ghodsi A. Effect of pregnancy on uterine and carotic artery response to norepinephrine, epinephrine, and phenylephrine in vesselswith documented function endothelium. Am J Obstet Gynecol 1989; 161: 160551610. 6. Tong C, Eisenach J C. The vascular mechanism of ephedrine’s beneficial effect on uterine perfusion during pregnancy. Anesthesiology 1992; 76: 792-798. Alahuhta S, Rasanen J, Jouppila P, Jouppila R, Hollmen A I. Ephedrine and phenylephrine for avoiding maternal hypotension due to spinal anaesthesia for caesarean section. International Journal of Obstetric Anesthesia 1992; 1: 1299134.
hypothyroid picture with a thyroid stimulating hormone (TSH) of 76 mUnits/l (normal 0.35-5.5) and a T4 of 6 pmol/l (normal 10-23). It was felt that the clinical picture was attributable in part to the hypothyroidism, in particular to myopathic-type pain in her thighs. She was given thyroxine replacement therapy. On review 3 months after starting thyroxine, the pain and muscle weakness were resolving and her thyroid function tests returning towards normal. We feel this case is interesting as it is often difficult to exclude spinal and epidural techniques as a cause for back and lower limb CNS signs, but in this case there appears to have been a definite cause for the patient’s symptoms.
Leg weakness not attributable to spinal anaesthesia
Complications of obstetric epidurals: an audit of 10 817 cases
We report the unusual case of a previously healthy 29year-old primigravida who complained to her GP of weak and painful legs, after the birth of her baby. She had had an elective caesarean section under spinal anaesthesia for breech presentation. Her pregnancy had been uneventful except for lowback pain radiating to the right-hip region from the mid trimester onwards. The pain was constant and associated with occasional radiation down the hamstrings to the popliteal fossa, more in the right than the left leg. She was aware of an aching sensation in both thighs. There was no history of sciatic pain radiating down the entire length of either leg. She had no history of back pain, Her symptoms persisted after the baby was born. She had suffered a minor whiplash injury 4 years previously, and would occasionally have neck pain, relieved by simple analgesics. She had a history of migraine. She took ibuprofen for the low-back pain, which had forced her to take time off work since the birth of her child. There was no family history of relevance. A detailed neurological examination was normal except for some mild proximal muscle weakness (grade 4/5) in her right leg. The spinal anaesthetic technique was documented as having been uneventful. The caesarean section was routine and there were no postoperative complications. She was assessed by a neurologist who confirmed the above findings of slight proximal muscle weakness in her right leg but nothing else of note. (A CT scan of her lumbar spine was normal, in particular no disc lesions were seen.) Interestingly, her thyroid function tests showed a
J. Edgar Department of Anaesthetics Southern General Hospital NHS Trust Glasgow, UK
Paech and colleagues have recently reported a prospective analysis of 10 995 obstetric epidurals from an Australian tertiary referral obstetric unit managing 4600-5 100 deliveries per year.’ A comparable audit of 10 8 17 obstetric lumbar epidurals at the Royal Surrey County Hospital, a UK district general hospital with 2000-3200 deliveries per year, has produced remarkably similar results. The number of deliveries at the Royal Surrey County Hospital has risen from 2039 in 1987 to 3183 in 1997, with a cumulative total of 28 644. Six hundred and forty-two epidurals (31.5% of deliveries) were done in 1987 rising to 1431 (45%) in 1997, with a cumulative total of 10 817 (37.8%). Accidental dural puncture, recognized at the time of the epidural, occurred on 86 occasions (0.8%, 95% CI 0.6330.97%). There were an additional 12 parturients where a dural tap was not noted at time of epidural, who subsequently developed a low-pressure headache requiring a blood patch; giving a total of 98 (0.91%, 95% CI 0.73-1.08%). This rate is not significantly different from that of Paech et al (0.63%, 95% CI 0.48-0.78%). The rate of accidental dural puncture has fallen from 1.56% in 1987 to 0.77% in 1997 and this may be due to an increased use of loss of resistance to saline,2 from 22% in 1987 rising to 96% in 1997. The incidence of more serious complications was very similar to the Australian series. Inadvertent intravascular injection, when parturients complained of peri-oral paraesthesia, visual disturbance or tinnitus, occurred eight times (0.07%, 95% CI 0.0220.12%; Paech et al, 0.04%, 95% CI CL0.07°/). There was one subdural/extra-arachnoid injection (0.009%, 95% CI
International Journal of Obstetric Anesthesia
2.
LaPorta R F, Arthur G R, Datta S. Phenylephrine in treating maternal hypotension due to spinal anaesthesia for caesarean delivery: effects on neonatal catecholamine concentrations, acid base balance and Apgar scores. Acta Anaesthesiol Stand 1995; 901-905. 3. Thomas D G, Robson S C, Redfern N, Hughes D, Boys R J. Randomised trial of bolus phenylephrine or ephedrine for maintenance of arterial blood pressure during spinal anaesthesia for caesarean section. BJA 1996; 76: 61-65. 4. Butterworth J F, Piccione W, Berrizbeitia L D, Dance G, Shemin R J, Cohn L H. Augmentation of venous return by adrenergic agonists during spinal anesthesia. Anesthesia and Analgesia 1986; 65: 612616. Weiner C P, Martinez E, Chestnut D H, Ghodsi A. Effect of pregnancy on uterine and carotic artery response to norepinephrine, epinephrine, and phenylephrine in vesselswith documented function endothelium. Am J Obstet Gynecol 1989; 161: 160551610. 6. Tong C, Eisenach J C. The vascular mechanism of ephedrine’s beneficial effect on uterine perfusion during pregnancy. Anesthesiology 1992; 76: 792-798. Alahuhta S, Rasanen J, Jouppila P, Jouppila R, Hollmen A I. Ephedrine and phenylephrine for avoiding maternal hypotension due to spinal anaesthesia for caesarean section. International Journal of Obstetric Anesthesia 1992; 1: 1299134.
hypothyroid picture with a thyroid stimulating hormone (TSH) of 76 mUnits/l (normal 0.35-5.5) and a T4 of 6 pmol/l (normal 10-23). It was felt that the clinical picture was attributable in part to the hypothyroidism, in particular to myopathic-type pain in her thighs. She was given thyroxine replacement therapy. On review 3 months after starting thyroxine, the pain and muscle weakness were resolving and her thyroid function tests returning towards normal. We feel this case is interesting as it is often difficult to exclude spinal and epidural techniques as a cause for back and lower limb CNS signs, but in this case there appears to have been a definite cause for the patient’s symptoms.
Leg weakness not attributable to spinal anaesthesia
Complications of obstetric epidurals: an audit of 10 817 cases
We report the unusual case of a previously healthy 29year-old primigravida who complained to her GP of weak and painful legs, after the birth of her baby. She had had an elective caesarean section under spinal anaesthesia for breech presentation. Her pregnancy had been uneventful except for lowback pain radiating to the right-hip region from the mid trimester onwards. The pain was constant and associated with occasional radiation down the hamstrings to the popliteal fossa, more in the right than the left leg. She was aware of an aching sensation in both thighs. There was no history of sciatic pain radiating down the entire length of either leg. She had no history of back pain, Her symptoms persisted after the baby was born. She had suffered a minor whiplash injury 4 years previously, and would occasionally have neck pain, relieved by simple analgesics. She had a history of migraine. She took ibuprofen for the low-back pain, which had forced her to take time off work since the birth of her child. There was no family history of relevance. A detailed neurological examination was normal except for some mild proximal muscle weakness (grade 4/5) in her right leg. The spinal anaesthetic technique was documented as having been uneventful. The caesarean section was routine and there were no postoperative complications. She was assessed by a neurologist who confirmed the above findings of slight proximal muscle weakness in her right leg but nothing else of note. (A CT scan of her lumbar spine was normal, in particular no disc lesions were seen.) Interestingly, her thyroid function tests showed a
J. Edgar Department of Anaesthetics Southern General Hospital NHS Trust Glasgow, UK
Paech and colleagues have recently reported a prospective analysis of 10 995 obstetric epidurals from an Australian tertiary referral obstetric unit managing 4600-5 100 deliveries per year.’ A comparable audit of 10 8 17 obstetric lumbar epidurals at the Royal Surrey County Hospital, a UK district general hospital with 2000-3200 deliveries per year, has produced remarkably similar results. The number of deliveries at the Royal Surrey County Hospital has risen from 2039 in 1987 to 3183 in 1997, with a cumulative total of 28 644. Six hundred and forty-two epidurals (31.5% of deliveries) were done in 1987 rising to 1431 (45%) in 1997, with a cumulative total of 10 817 (37.8%). Accidental dural puncture, recognized at the time of the epidural, occurred on 86 occasions (0.8%, 95% CI 0.6330.97%). There were an additional 12 parturients where a dural tap was not noted at time of epidural, who subsequently developed a low-pressure headache requiring a blood patch; giving a total of 98 (0.91%, 95% CI 0.73-1.08%). This rate is not significantly different from that of Paech et al (0.63%, 95% CI 0.48-0.78%). The rate of accidental dural puncture has fallen from 1.56% in 1987 to 0.77% in 1997 and this may be due to an increased use of loss of resistance to saline,2 from 22% in 1987 rising to 96% in 1997. The incidence of more serious complications was very similar to the Australian series. Inadvertent intravascular injection, when parturients complained of peri-oral paraesthesia, visual disturbance or tinnitus, occurred eight times (0.07%, 95% CI 0.0220.12%; Paech et al, 0.04%, 95% CI CL0.07°/). There was one subdural/extra-arachnoid injection (0.009%, 95% CI