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evo:

Complications of Spinal Anaesthesia.


Headache: a characteristic headache may occur following spinal anaesthesia. It begins within 12-24 hours and may last a week or more. It is postural, being made worse by raising the head and relieved by lying down. It is often occipital and may be associated with a stiff neck. It is frequently accompanied by nausea, vomiting, dizziness and photophobia.

It is more common in the young, in females and especially in obstetric patients. It is thought to be caused by the continuing loss of CSF through the hole made in the dura by the spinal needle. This results in descent of the brain and traction on its supporting structures.

The incidence of headache is related directly to the size of the needle used. A 16 gauge needle will cause headache in about 75% of patients, a 20 gauge needle in about 15% and a 25 gauge needle about 3%. It is, therefore, sensible to use the smallest needle available especially in high risk obstetric patients.

As the fibres of the dura run parallel to the long axis of the spine, if the bevel of the needle is parallel to them, it will part rather than cut them and therefore, leave a smaller hole. Make a mental note of which way the bevel lies in relation to the notch on the hub and then align it appropriately.

It is widely considered that pencil-point needles (Whiteacre or Sprotte) make a smaller hole in the dura and are associated with a lower incidence of headache than conventional cutting-edged needles (Quincke). [Fig 7]

As the sacral autonomic fibres are among the last to recover following a spinal anaesthetic, urinary retention may occur. If fluid pre-loading has been excessive, a painful distended bladder may result and the patient may need to be catheterised.

Permanent neurological complications are extremely rare. Many of those that have been reported were due to the injection of inappropriate drugs or chemicals into the CSF producing meningitis, arachnoiditis, transverse myelitis or the cauda equina syndrome with varying patterns of neurological impairment and sphincter disturbances.

If inadequate sterile precautions are taken, bacterial meningitis or an epidural abscess may result although it is thought that most such abscesses are caused by the spread of infection in the blood.

Finally, permanent paralysis can occur due to the "anterior spinal artery syndrome". This is most likely to affect elderly patients who are subjected to prolonged periods of hypotension and may result in permanent paralysis of the lower limbs.

It used to be thought that bedrest for 24 hours following a spinal anaesthetic would help reduce the incidence of headache, but this is now no longer believed to be the case. Patients may get up once normal sensation has returned, if surgical considerations so allow.

http://www.nda.ox.ac.uk/wfsa/html/u03/u03_009.htm

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