Permanent Asymmetric Neurologic Deficits After Spinal Anesthesia with Bupivacaine

Abstract

To the Editor: Of the currently available local anesthetics, neurologic complications after spinal anesthesia are reported more often in association with lidocaine.1–3 We present a case of permanent multiradiculopathy after spinal anesthesia with bupivacaine. An ASA physical status I 48-yr-old man underwent surgery for varicose veins. With the patient in the sitting position, spinal anesthesia was performed at L3-4, with a 25G pencil-point needle (B. Braun). After free flow and aspiration of 2 mL of clear cerebrospinal fluid, a single dose of 3.0 mL of 0.5% hyperbaric bupivacaine (Marcaina®-AstraZeneca, bupivacaine hydrochloride [5 mg/mL], glucose [80 mg/mL]) was injected. No other drug was added to the solution. The sensory level reached T8. Needle placement, drug injection, and the surgical procedure were uneventful. In the postanesthesia care unit, his left lower limb recovered adequately, but there was only partial recovery in the right leg. Neurologic examination detected right lower limb motor deficits, absence of the right patellar and Achilles reflexes, normal plantar reflex, and hypoesthesia for all sensory modalities below the right T10 level. The electromyography showed normal sensory action potentials and acute motor denervation in right L4-5-S1 (severe) and left L5-S1 (moderate) segments, suggesting multiradiculopathy. A thoracolumbar 1.5T MRI was unremarkable. After slight improvement in sensory functions during the first several weeks, the motor and sensory deficits remained unchanged during a 2-yr follow-up. The asymmetric neurologic presentation differentiates this case from that previously reported after bupivacaine.4 Additionally and as reported by Chabbouh et al.,4 in the absence of another reasonable explanation, we attribute the injury in this patient to bupivacaine neurotoxicity. Considering their rarity, single case reports become important to establish the full spectrum of neurologic manifestations after spinal anesthesia with bupivacaine. Jose Eduardo Lima, MD, PhD Division of Neurology Department of Medicine School of Medicine Federal University of São Carlos São Carlos, São Paulo, Brazil [email protected] Marino M. Bianchin, MD, PhD Division of Neurology Department of Internal Medicine School of Medicine Federal University of Rio Grande do Sul Porto Alegre, Rio Grande do Sul, Brazil Wilson Marques, Jr., MD, PhD Department of Neurology School of Medicine at Ribeirao Preto University of São Paulo Ribeirao Preto, São Paulo, Brazil