NAP3 2009: Neuraxial Complications

(See Learning Points slides at the end)



List of disasters

·      Vertebral canal haematoma

·      Spinal cord ischaemia

·      Nerve and spinal cord injury

·      Abscess

·      Meningitis

·      Subdural haematoma

·      Total spinal

·      Cardiovascular collapse

Biggest disasters

·      Paraplegia or death: 1 in 50-100k

·      Permanent nerve injury: 1 in 25-50k

High risk groups

·      Frail + elderly + major surgery + epidural (haematoma)

·      Anticoagulated (haematoma)

·      Immunocompromised (infection, abscess)


·      2/3 “severe injuries” resolve

·      Canal haematoma and cord ischaemia cause lasting damage


General learning points: do not…

·         Fail to monitor neurology

·         Fail to take limb weakness seriously. Red flags include

o   Thoracic epidural + weakness

o   Unexpectedly dense motor block

o   Not resolved after 4 hours cessation

·         Fail to get MRI ASAP when indicated

·         Fail to contact neurosurgery ASAP when indicated


Specific learning points:

Vertebral canal haematoma

·      50% develop upon removal of epidural catheter

Spinal cord ischaemia

·      Hypotension contributes

·      MRI may not pick it up


·      May present after discharge

·      May presents as sepsis without localizing symptoms or signs

·      Material risk if >2 days, higher risk if >5-7 days


·      Post-neuraxial headache is probably simple PDPH

·      But beware SDH and meninigitis if a) multiple attempts b) atypical headache

·      Failed epidural top up followed by spinal causes unpredictable block height. Do CSE.

Wrong route

·      Most common in obstetrics

·      Keep trays separate

·      Keep local connected to epi, or chuck it out (my note)

Cardiovascular collapse

·      Must have IV fluid and vasoactives available if doing neuraxial

·      Don’t do neuraxial in a hypovolaemic patient (my note)


·      CSEs are overrepresented in complications and we don’t know why


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