Epidural Misadventures:

A review of the risk and complications

associated with epidural anaesthesia
Holly A. Muir, MD, FR!
Department of Anaesthesia, Dalhousie "niversity
#$% &race Health entre
Halifa', (ova )cotia anada
Complications from the use of regional anesthesia have been reported from the
onset of its use. The first report of spinal headache was in 1899 by August Bier
on his own experience with a spinal anaesthetic performed using a uin!e cut
needle. "e also noted a complaint of bac!ache with his experience.#1$ The now
infamous %&ooley and 'oe% case of 19() led to the almost virtual abandonment
of spinal and epidural techni*ues in Britain for more than + decades#+$.
The usual list *uoted to patients regarding ris!s associated with regional
anaesthesia include bloc! failure, bac!ache, infection #locali-ed and C./$,
headache, accidental intravascular in0ection, inadvertent total spinal, neurologic
in0ury #from peripheral nerve in0ury to paralysis$ and death or brain in0ury. As
one recites this list, the actual li!elihood of suffering this complication is often
not well communicated to the patient. This may reflect a lac! of real
comprehension by the informer, but often results from the tendency by the
patient to recall only the most sinister of complications.
Before we can ma!e an appropriate presentation to their patient on ris! and
complication of anaesthesia, we must ma!e an assessment ourselves of the
magnitude of the ris!. A report from 1991 loo!ed at malpractice claims filed
against anaesthesiologists in a 112year period from 193(2198( #4$. A
comparison was made between ob and non2ob claims. A total of 1,()1 cases
were reviewed, of which 1+5 were ob2related claims and 885 were non2ob
claims. The following comparisons were made regarding the types of in0uries
claimed. #Table 1$
*A+,E -
% non - ob claim
(n=1,351)
% ob claims
(n=190)
% ob-regional
(n=124)
% ob-general
(n=62)
Patient death 39(524) 22(41) 12(15) 42(26)
eonatal brain damage 20(38) 19(23) 24(15)
!eadache 1(10) 12(23) 19(23) 0(0)
eonatal death <0.5(1) 9(17) 7(8) 10(6)
Pain d"ring anesthesia <0.5(5) 8(16) 13(16) 0(0)
Patient ner#e damage 16(209) 8(16) 10(12) 7(4)
Patient brain damage 13(174) 7(14) 7(9) 8(5)
$motional distress 2(30) 6(12) 7(9) 5(3)
%ac& 'ain 1(8) 5(9) 7(9) 0(0)
This review demonstrated that patient death, nerve in0ury and brain damage
were more common in the non2ob population than the ob population. "owever
among the ob population, claims for more trivial events such as headache, pain
during anaesthesia, emotional distress and bac! pain were more common.
&hen the authors compared anaesthetic techni*ues in the ob group, they found
#as would be expected$ that there was a significantly higher number of claims
resulting from maternal death in the general anaesthesia group. &hile
headache, pain during anaesthesia and bac! pain were more common
complaints in the group receiving regional anaesthesia. "ow should we interpret
this data6 7a0or complications are more fre*uent in the patients who have
general anesthesia than regional anaesthesia. 'is! should be put in the context
of options available.
8n the triennial 'eport on Confidential 9n*uiries into 7aternal :eaths in the
;nited <ingdom 198821991, there were ) deaths directly attributable to
anaesthesia. #)$ Three of these were a result of pulmonary complication either
during or after general anaesthesia. =ne was due to pulmonary complications
which occurred after aggressive treatment of hypotension in a patient with an
underlying cardiac arrythmia.. Ten deaths were indirectly associated with
anaesthesia. .ine were as a result of respiratory insufficiency either due to
intraoperative or postoperative complications of general anesthesia and>or post
operative pain management. =ne was a result of severe intraoperative
haemorrhage which could not be controlled after ) hours of surgery and
resuscitative measures. This patient had an epidural anaesthetic and it was felt
that the sympathectomy could have contributed to the failure at resuscitative
efforts. #)$ &hat is all of this trying to tell us6 8 thin! it should be apparent that,
when discussing complications of regional anesthesia with patients, one should
not dwell on the fact that death could occur with regional anaesthesia, rather the
patient should be made aware that death is more of a ris! when general
anaesthesia is used in the pregnant patient.
A ma0or category of in0ury which is remembered by patients is the ris! of nerve
in0ury. This encompasses a very broad spectrum of in0ury from transient
peripheral nerve palsy to paralysis. An analysis of closed claims revealed that
nerve in0ury is more li!ely with general anaesthesia than regional anaesthesia
#?1 vs 4?5$. #($ ;lnar nerve palsy and brachial plexus in0ury were the most
common, followed by lumbosacral nerve root in0ury.
&hen one examines the issue of nerve in0ury, we must !eep in mind the high
incidence of nerve in0ury associated with obstetrical delivery itself #without the
use of epidural bloc!$. The incidence of obstetric related neurologic
complication is reported from 1@+111 to 1@?)11.#?$ The types of neurologic in0ury
seen, which related to the pregnant state or delivery, are detailed in Table +.
*A+,E .
(eurolo/ic #n0ury Associated with !re/nancy and Delivery
(om'lication )s"al (a"se *ensor+ ,e-icit .otor ,e-icit
Prolapsed disc
spontaneous occurrence in
1:6000 deliveries
variale variale
!u"osacral trun#
!4$!5
co"pression o% &ead
a'ainst sacru"$ &i'&er
incidence (it& use o%
"id)&i'& %orceps
&*poest&esia lateral
cal% and %oot
(ea# &ip adductor
%oot drop (ea#
+uad
,e"oral nerve
!2$!3$!4
lit&oto"*$ &*peracute &ip
%le-ion (it& pus&in' and
retractors at .)/
&*poest&esia ant t&i'&
and "edial cal%$
asent patellar re%le-
+uad paral*sis
(it& i"paired
#nee e-tension
!ateral %e"oral
cutaneous !2$!3
lit&oto"* or retractors
nu"ness
anterolateral t&i'&
/ciatic nerve
!4$!5$/1$/2$/3
lit&oto"* or 01 in2ection
pain %ro" post 'luteal
to %oot
inailit* to %le-
le'
3turator nerve
!2$!3$!4
lit&oto"*$ acute %le-ion o%
t&i'&
&*poest&esia "edial
t&i'&
inailit* to adduct
le'
.o""on Peroneal
!4$!5$/1$/2
lit&oto"* (it&
co"pression o% t&e lateral
aspect o% t&e #nee
anterolateral cal% and
dorsu" o% %oot and
toes
plantar %le-ion
(it& inversion
de%or"it* 4drop
%oot
/ap&enous nerve
!2$!3$!4
lit&oto"* position
"edial %oot and
antero"edial aspect
lo(er le'
9pidural anesthesia can be associated with neurologic problems, ranging from
headache to paralysis. The in0uries which immediately come to mind include@
prolonged neural bloc!ade, bac!ache, trauma to nerve roots, cauda e*uina
syndrome, epidural hematoma, epidural abscess, adhesive arachnoiditis,
meningitis and postdural puncture headache.
Aoo!ing bac! on the data collected by Chadwic! et al, #4$ it is apparent that the
anesthesiologist is more li!ely to be involved in a suit for a minor in0ury than a
ma0or in0ury. =ne should therefore be prepared to discuss these minor issues
with their patients. The incidence of bac! pain following epidural bloc! continues
to be an area of controversy. "eadache has also been identified as a
complication associated with high ris! of suit. The ris! of accidental dural
puncture #A:B$ depends on the s!ill of the operator. A rate of 15 is generally
*uoted.
:irect trauma to the spinal cord after epidural anesthesia for labor would be
very rare, as the epidural space is usually entered below the conus medullaris.
8n 915 of adults, the cord ends above the second lumbar vertebrae. "owever,
in 115 of adults, it extends to the third lumbar vertebrae. .erve root trauma has
been reported in 1.135 of patients after epidural anesthesia. Bain and>or
paraesthesia during needle placement, or in0ection of medication, usually warn
of ris! for in0ury and should be acted upon.
7ore catastrophic nerve in0ury has been reported. These have been in
association with epidural hematoma, epidural abscess, adhesive arachnoiditis,
anterior spinal artery syndrome or cauda e*uina syndrome. &hen one
discusses these complications, it is important to !eep in perspective their very
low incidence. 9pidural abscess has been reported in a fre*uency of 1@(1(,111
patients who had epidurals. #The incidence is +@11,111 in patients without
regional anesthesia.$#1+$
Anterior spinal artery syndrome is the conse*uence of decreased arterial supply
to the cord and results in motor wea!ness, or paralysis and loss of pain and
temperature sensation. 8n approximately 1(5 of the population the artery of
Adam!iewic- originates from as high as the T( level. 8n this population the
conus medularis is supplied by branches from the internal iliac artery. 8t is
postulated that there may be an increased ris! of cord ischemia due to fetal
head compression of the branches of the internal iliac artery.
Cauda e*uina syndrome and adhesive arachnoiditis share a common etiology 2
chemical toxicity. Cauda e*uina syndrome has been reported as a
conse*uence of local anesthetic toxicity. 'ecently, controversy has arisen over
the use of hyberbaric (5 lidocaine for spinal anesthesiaC however, lidocaine in
the epidural space still appears to be safe.#1)$
9pidural hematoma is a complication which we learn about early in our career
and many spend a great deal of time fearing someday they will see one. The
actual incidence of epidural hematoma is un!nown. 8t is reported to occur
spontaneously in patients who have not received regional anaesthesia #1?$ and
in patients who have received regional anesthesia #13$,#18$ 8n a review of the
literature from 191?2199) by Dandermeulen et al. identified ?1 cases of spinal2
epidural hematoma, )? of which were associated with epidural anesthesia.
Twenty three of the )? epidural cases were associated with the use of
anticoagulants, ) were associated with thrombocytopenia and the remaining 19
cases had no ris! factors reported. Eive of these cases were in pregnant
women. Two of these were reported to have thrombocytopenia, 1 had an
epidural ependymona and + had no identifiable ris! factors. 'is! factors for
epidural hematoma have included difficult or bloody tap, pre existing
coagulopathy and use of anti coagulants. The ris! of a bloody tap in the
obstetric population has been reported to be as high as 185.
Thrombocytopenia is identified as a ris! factor, however the platelet count
below which it is ris!y to use regional anesthesia is still somewhat controversial.
8n the review by =wens et al #13$ no patients were identified with hematoma and
a platelet count F(1,111 in those whom thrombocytopenia was considered a
ris! factor. Current dogma uses a platelet count F111,111 as the safe threshold.
"owever many experienced anaesthesiologist would challenge this. &hen
*uestioning the use of regional anesthesia for fear of epidural hematoma one
must always consider the ris!s of alternate treatments #general anesthesia$ and
the benefits regional anesthesia may afford the mother and fetus.
8nfection or meningitis as a complication is rare as well. Concern in obstetric
practice has focus around the use of regional bloc! anaesthesia in the presence
of maternal chorioamnionitis. Aaboratory studies suggest that if the C/E is
entered after systemic administration of antibiotic that ris! of contamination with
bacteria is nil. #19$
The use of epidural anesthesia>analgesia has become the standard of care in
obstetrical practice. As with any adventure in life it can be associated with
complications. Eortunately the incidence of serious complication with epidural
anesthesia is rare in experienced hands. They do however occur even with the
most experienced and good intentioned practitioner. The ris!s of general
anaesthesia in obstetrics are well documented. #+1$ =ne must temper these ris!
against the potential complications associated with epidural anaesthesia in your
discussion with the patient.
8n 19() Aord Gustice :enning in his 0udgement of the &ooley and 'oe case
made a very insightful comment on complications of medical procedures. H&e
should be doing a disservice to the community at large if we were to impose
liability on hospitals and doctors for everything that happens to go wrong. &e
must insist on due care for the patient at every point, but we must not condemn
as negligence that which is only a misadventure.H #+$ 8t is unfortunate that
today%s legal community are not as forgiving.
REFERE(E)
1. ,in# 5 6. 7istor* o% 8eural 5loc#ade. 0n: .ousins 19$ 5ridenau'& P3 (:ds):
8eural 5loc#ade$ 95 !ippincott$ P&iladelp&ia 1988.
+. Cope '&. The &ooley and 'oe Case. Anaesthesia 199(C(1@1?+2134.
4. Chadwic! et al. A comparison of obstetric and non2obstetric anesthesia
malpractice claims. Anesthesiology 1991C3)@+)+29.
). 7etters G/ et al eds. 'eport on Confidential 9n*uiries into 7aternal :eaths
in the ;nited <ingdom 198821991. Aondon "7/=199)
(. <roll et al. .erve in0ury associated with anaesthesia. Anesthesiology
1991C34@+1+23
?. 'osenbaum 'B, et al. Bheripheral nerve and neuromuscular disorders.
.eurologic Clinics 199)C 1+#4$@)?12)38$
3. 7acarthur C et al. 9pidural anaesthesia and long term bac!ache after
childbirth. Br 7ed G 1991C411@921+
8. Breen T&, et al. Eactors associated with bac! pain after childbirth.
Anesthesiology 199)C81@+924).
9. 7ac:onald '. A dural puncture rate of 15 is unacceptable in epidural
practice. Controversies in =bstetric Anaesthesia. 8nternational Gournal of
=bstetric Anaesthesia 199)C4C(12(1.
11. .orris 7C, et al. .eedle bevel direction and headache after inadvertent
dural puncture. Anesthesiology 1989C31@3+9241.
11. .orris 7C, et al. Complications of labor analgesia@ epidural verses
combined spinal epidural techni*ues. Anesth Analg 199)C39@(+9243.
1+. "lavin 7A, et al. /pinal epidural abscess@ a ten year perspective. .eurology
1991C+3@133.
14. Bromage, B'. .eurologic complications of regional anaesthesia for
obstetrics. 8n@ /hnider /. and Aevinson I #9ds$@ Anesthesia for =bstetrics.
&illiams and &il!ins, Baltimore, 1994C)442(4.
1). deGong, '". Aast round for a heavy weight6 Anesth Analg 199)C38@42).
1(. Eu!uda T et al. ;nintentional epidural administration of thiamyal. 'eg
Anesth 199)C19@4?1.
1? /cott BB. /pinal epidural hematoma.GA7A 193?C+4(@(14.
13. =wens 9A et al. /pinal subarachnoid hematoma after lumbar puncture and
heparini-ation@ A case report, review of the literature, and discussion of
anesthetic implications. Anesth Analg 198?C?(@1+1123.
18. Dandermeulen 9B et al. Anticoagulants and spinal epidural anesthesia.
Anesth Analg 199)C39@11?(233.
19. Carp " et al. The association between meningitis and dural puncture in
bacteremic rats. Anesthesiology 199+C3?@349.
+1. Daddadi A et al. 9pidural anesthesia in women with chorioamnionitis@ a
retrospective study Anesthesiology 1989C31@A8?4
+1 7uir ". Ieneral anaesthesia for obstetrics, is it obsolete6 Can G Anaesth
199)C)1@'+12+(.
1Dr Holly Muir, -223. !rinted copies can 4e made for non5profit educational
use.
6ther use re7uires permission from the author.
85Dec523, Revised 35Mar529
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