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The clinical effects of high-volume spinal anaesthesia with bupivacaine 0.125% were studied in 30 patients presenting for postpartum sterilisation. Group A, B and C patients received 6, 8 and 10 ml of bupivacaine 0.125% respectively. Onset, duration and regression of sensory block and motor blockade, haemodynamic parameters and postoperative complications were studied. A sensory level of T10 was reliably obtained in Group B and C but not in Group A. Similarly motor blockade was unreliable in Group A compared with Group B (P < 0.05) and Group C (P < 0.05). Two segment regression times were similar in all three groups. L1 regression times were 47.9, 94.3 and 99.0 minutes in Groups A, B and C respectively. The corresponding times for complete recovery of motor power were 120, 212.3 and 182.7 minutes respectively (P < 0.01 when Group A compared to B and C). A significant incidence of high spinal anaesthesia occurred when 10 ml bupivacaine 0.125% was administered (P < 0.05 when compared with Group A). No patient experienced respiratory discomfort in spite of sensory levels of up to T1. Hypotension responded readily to intravenous fluids and small doses of ephedrine (three patients). Only one patient (Group A) developed a postdural puncture headache. In this study, high-volume spinal anaesthesia with bupivacaine 0.125% was found to be satisfactory for postpartum tubal ligation. The optimal volume of bupivacaine 0.125% was 8 ml.
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PMID:High-volume spinal anaesthesia. A dose-response study of bupivacaine 0.125%. 146 70

Post-dural puncture headache (PDPH) is a significant and well-known complication of procedures that perforate the dura mater, e.g., clinical spinal anaesthesia (SpA). The exact mechanisms leading to PDPH are still not completely understood, although several factors, particularly the patient's age, modulate the incidence. In young patients (20-30 years) previous studies reported high occurrences of PDPH in 6%-16% of cases [5, 8], decreasing the value and acceptance of SpA in this patient group. This study was undertaken to reevaluate under reproducible study conditions the incidence of PDPH and other side effects due to SpA in a larger and more homogeneous patient group. METHODS. Two hundred and two male patients between 19 and 30 years of age were included in this study. The standard anaesthetic technique consisted of oral premedication (1 mg flunitrazepam), preanaesthetic intravenous hydration with at least 0.5 l Ringer's lactate, monitoring of vital signs, and a standard lumbar puncture (lateral position, L2/3 or L3/4 interspace, 25-gauge spinal needle, parallel bevel direction). Anaesthesia was achieved using 12.5 mg hyperbaric 0.5% bupivacaine. Anaesthetic level, onset, and duration (pinprick method) and intraoperative events were recorded. Patients were randomly immobilised for either 6 or 24 h postoperatively. Patients were visited on the 2nd, 4th, and 7th postoperative day to ascertain the occurrence of PDPH and further anaesthesia-related complications. RESULTS. The 202 patients studied had homogeneous demographic characteristics (Table 1). During surgery (average duration: 36 min +/- 18; 10-100 min) with satisfactory anaesthetic levels 1 patient demonstrated a high spinal block (T1). Intraoperatively, a significant decrease in blood pressure was noted in 5 patients (2.5%) and bradycardia in 24 (11.9%). Ten minutes after local anaesthetic instillation the sensory block reached an average level of T10 and had ascended to T8 after 25 minutes (start of surgery). During the three postanaesthetic visits PHPD was present in 7 cases (3.5%); 3 other patients had non-PDPH "tension" headaches (1.5%). All PDPHs occurred on the first 2 postoperative days with a maximum duration of 4 days (1 patient). Treatment consisted of bed rest, hydration, and/or oral analgesics. No patient developed any neurologic sequelae. Moderate back pain (12.4%) and urinary retention (2.5%) were the other postoperative complications. The duration of prophylactic postoperative immobilisation had no obvious impact on PDPH occurrence. Our patients' acceptance of SpA was very high; 98.5% of them would favour SpA for future surgery. DISCUSSION. In contrast to previous studies reporting a high incidence of PDPH (6%-16%) in young adults, we found, in a stringent investigation of a large number of comparable patients in a defined age group, a PDPH rate of 3.5% and a few other minor side effects together with good anaesthetic quality, intraoperative stability, and excellent patient acceptance. Although future studies are needed to further minimise SpA complications, we found SpA a safe anaesthetic technique in our well-defined patient group.
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PMID:[The incidence of post spinal headache in a group of young patients]. 157 Aug 87

Intraspinal narcotic (usually intrathecal morphine) infusions with implanted pumps are increasingly used in patients with intractable chronic pain not caused by cancer. In some patients, pain control is difficult with infusions of morphine. Seven patients with diagnoses of arachnoiditis, epidural scarring, and/or vertebral body compression fracture were treated with alternative solutions in an epidural route. For maximal flexibility, Medtronic implanted programmable infusion pumps with catheters to T6-T10 were used, and pain was monitored by verbal pain scales. In three patients, epidural infusions of morphine in 0.5% bupivacaine (MS-MARC) resulted in little or no pain relief without significant side effects (e.g., headache, nausea, or vomiting). In these same patients, epidural infusions of sufentanil citrate resulted in pain scale reductions of 92%, 82%, and 40%, respectively, with no side effects. Four other patients found more effective pain relief when switched from initial sufentanil citrate infusions to MS-MARC. Pain scale reductions (with no side effects) were 92%, 76%, 59%, and 47% in these patients. Pain relief and minimal side effects with sufentanil citrate is theorized to result from its higher lipophilicity promoting local transdural diffusion to spinal cord and limiting upward diffusion to the brain stem. Sufentanil citrate is also advantageous for programmable pumps because it is 100 times more potent than morphine and therefore allows longer pump refill times and higher infusion doses. Although this study was done on a limited number of patients, sufentanil citrate and MS-MARC in epidural infusions using programmable infusion pumps for non-cancer patients provide significant alternative drug combinations and routes.
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PMID:Sufentanil citrate and morphine/bupivacaine as alternative agents in chronic epidural infusions for intractable non-cancer pain. 183 Dec 48

Forty patients undergoing elective Caesarean section were allocated randomly to receive hyperbaric 0.5% bupivacaine 2.5 ml at either the L2-3 (n = 20) or L4-5 (n = 20) interspace. Spinal injection was performed with a 29-gauge needle in 38 patients and a 25-gauge needle in two. The onset time to analgesia at T10 and T6 was significantly faster and the level of analgesia at 5 and 10 min after injection significantly higher after injection at L2-3. Maximum height and range of analgesia, the level of analgesia at 15 and 20 min after injection and the number of episodes of hypotension were not significantly different between the two groups. One case of post-dural puncture headache was recorded after use of a 29-gauge needle. Overall, the choice of lumbar interspace influenced the rate of onset of analgesia, but not the final dermatomal level (mean and range) of analgesia achieved.
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PMID:Influence of the lumbar interspace chosen for injection on the spread of hyperbaric 0.5% bupivacaine. 202 73

Ropivacaine 0.5%, 0.75% and 1.0% was investigated in an open study of extradural anaesthesia in three groups of 15 patients undergoing urological or orthopaedic surgery. Following a test dose of 3 ml of 1.0% lignocaine with 1:200,000 adrenaline, ropivacaine 20 ml was given in incremental doses over 4 min via a lumbar extradural catheter. The onset time for analgesia was short in all groups: T12 was blocked 4-6 min after the end of the injection of ropivacaine. The maximum segmental level was significantly higher in the 0.75% and the 1.0% groups (T2) than in the 0.5% group (T5). Complete motor block was obtained in seven, four and nine patients in the 0.5%, 0.75% and the 1.0% groups, respectively. Duration of analgesia increased with increasing concentration of ropivacaine: mean duration of analgesia was 203 and 266 min at T10 and 253 and 314 min at L5 for the 0.5 and 1% solutions, respectively. Mean duration of complete motor block was 94 and 192 min for the same solutions. Analgesia was satisfactory for surgery in all patients except for one in the 0.75% group. Hypotension was experienced by three, seven and three patients in the 0.5%, 0.75% and 1.0% groups, respectively. Bradycardia occurred in seven patients and was associated with hypotension in five. Backache was experienced after operation by four patients, and three patients complained of a brief mild headache. No late adverse events were seen.
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PMID:An open study of ropivacaine in extradural anaesthesia. 240 97

Three hundred and forty consecutive patients received successful spinal anaesthesia with 0.5% plain bupivacaine. A small randomised study of 40 of these cases showed little difference between 3.5 and 3 ml; however, analysis of its use in 200 patients receiving 3.5 ml (mean block T10.5 +/- 1 segment) and 100 receiving 3 ml (T10 +/- 0.5 segment) confirmed the impression that the smaller volume produced a more limited range of segmental block, which was desirable notably in the over-70-year age group. The main complications were hypotension (14.1%) and headache (1.5%).
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PMID:Plain bupivacaine 0.5%: a preliminary evaluation as a spinal anaesthetic agent. 682

Twenty adult male patients undergoing anorectal surgery in the jackknife position under spinal anaesthesia were studied for the anaesthetic properties of 5 ml hypobaric 0.1% bupivacaine. The patients were positioned in the prone, jack-knife position with a pillow under the hips and with an operating table break angulation of 30 degrees with head down tilt of 20 degrees. In this position a 25-gauge Quincke spinal needle was inserted intrathecally through L3-4 and 5 ml solution, prepared by mixing 1 ml bupivacaine 0.5% with 4 ml of distilled water with a specific gravity of 1.001 at 20 degrees C, was given over 15-20 sec. Onset time, progression and upper level of sensory blockade evaluated by pin prick, and the extent of motor block (1 = full motor movement at ankle and knee joint, 2 = restricted motor movements, 3 = full motor block, no movements) were measured at one minute intervals for the first five minutes, then every five minutes for 30 min. The number of dermatomes blocked was also noted. The median level of cephalad sensory blockage was of L1, with a range from T10-L3. On average, nine dermatomes were blocked (range 7-12). Motor blockade was not observed in any patient. Changes in heart rate and blood pressure were minimal. The average duration of postoperative analgesia was 339.5 +/- 182.9 min. Post-spinal headache was not observed in any patients. In conclusion, 5 ml intrathecal hypobaric bupivacaine, 0.1%, provided excellent perioperative analgesia without motor blockade and haemodynamic stability in patients undergoing anorectal surgery in jackknife position.
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PMID:Hypobaric spinal anaesthesia with bupivacaine (0.1%) gives selective sensory block for ano-rectal surgery. 758 7

One hundred and twenty-eight ASA I-III patients less than 40 yr of age, undergoing orthopaedic or trauma lower limb surgery, were allocated randomly to receive either continuous spinal anaesthesia (CSA) using a 32-gauge polyimide microcatheter with a permanent stylet (Rusch/TFX Medical, Duluth, GA, USA) or single-dose spinal anaesthesia (SDSA) with a 24-gauge x 103-mm Sprotte spinal needle (Pajunk, Germany). Plain bupivacaine (0.5%) was used as the local anaesthetic. The initial doses were 1 ml (5 mg) of CSA and 3 ml (15 mg) of SDSA, while the re-injection doses were 1 ml (5 mg) in the CSA group. SDSA was quicker to perform: mean 4.4 (SD 1.6) min compared with 6.2 (2.6) min for CSA (P < 0.01). Times to onset and surgical anaesthesia were also significantly greater in the CSA group (P < 0.01). The quality of the block was better in the SDSA group (P < 0.05), but was associated with greater haemodynamic instability (P < 0.05). The segmental level of analgesia was significantly lower in the CSA group (median T10 (range T12-T8)) than in the SDSA group (T9 (T11-T5)) (P < 0.05). There were no significant differences in the incidence of postoperative complications, with two mild spinal headaches in both groups. We conclude that CSA using a microcatheter in young patients is difficult to perform and affords no advantages over SDSA with a small gauge atraumatic needle.
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PMID:Comparison of continuous spinal anaesthesia using a 32-gauge catheter with anaesthesia using a single-dose 24-gauge atraumatic needle in young patients. 788 Jun 57

A 67-year-old woman with a one-year history of tinnitus and headache had multiple cranial nerve palsies of V, VII, VIII, IX, X, XI and spastic paraparesis. She also had a secretory otitis media. Gd-DTPA-enhanced magnetic resonance imaging (MRI) revealed hypertrophy of the dura of the posterior fossa and spinal epidural mass which extended from C7 to T10. A biopsy of the epidural mass showed chronic granulomatous change. These lesions were completely cured with administration of antibiotics. We believe this case of double-lesion of hypertrophic cranial pachymeningitis and spinal epidural granulomatous lesion originated from a bacterial infection secondary to the secretory otitis media.
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PMID:Hypertrophic cranial pachymeningitis with spinal epidural granulomatous lesion. 856 27

A six year old girl was admitted to the Kenyatta National Hospital paediatric unit with history of headaches, fever, neck stiffness and paraesthesias of the lower limbs. She was empirically commenced on antimeningitic treatment. Her neurological state deteriorated over a period of two months to paraparesis and paraplegia of the lower limbs with urinary and stool incontinence. A neurology review revealed a sensory level at T10 with power grade 2 in the lower limbs. A myelogram revealed a block of contrast at T12. An impression of cord compression by an intraspinal tumour was made. Laminectomy and posterior midline myelotomy was performed. At operation a greyish-white intramedullary mass lesion was found. Histology revealed a schistosoma mansoni ovum surrounded by granulomatous tissue with giant cells and polymorphoneuclear leucocytes. The child was commenced on paziquantel 1000 mg and dexamethasone 24 mg per day in divided doses. There was marked neurological improvement and the patient went home one month later. She was able to walk without support and was continent of urine and stool at the time of discharge.
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PMID:Schistosoma mansoni of the conus medularis: case report. 1550 44


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