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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 331-333 Table of Contents     

Spinal Myoclonus Following Bupivacainc Spinal Anaesthesia for Varicose Vein Stripping


1 Registrar, Department of Anaesthesiology, Tata Main Hospital, Jamshedpur-831001, India
2 Senior Specialist & HOD, Department of Anaesthesiology, Tata Main Hospital, Jamshedpur-831001, India
3 Senior Specialist, Department of Anaesthesiology, Tata Main Hospital, Jamshedpur-831001, India
4 Senior Registrar, Department of Anaesthesiology, Tata Main Hospital, Jamshedpur-831001, India

Date of Acceptance15-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Binita Panigrahi
D2/10, Road No 6, Sangam Vihar, Sonari, Jamshedpur-831011
India
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Myoclonic movements under anaesthesia are a less recognized phenomenon. We report here a case of 24-year old man who underwent varicose vein stripping and ligation procedure under spinal anaesthesia and developed spinal myoclonus.The movements gradually decreased in frequency and finally disappeared on the third postoperative day. The case warrants awareness about its occurrence, and anaesthetists must watch out for and recognize it.

Keywords: Myoclonus, Spinal myoclonus, Spinal anaesthesia


How to cite this article:
Panigrahi B, Samaddar D P, Mahapalra B C, Varghese K. Spinal Myoclonus Following Bupivacainc Spinal Anaesthesia for Varicose Vein Stripping. Indian J Anaesth 2008;52:331-3

How to cite this URL:
Panigrahi B, Samaddar D P, Mahapalra B C, Varghese K. Spinal Myoclonus Following Bupivacainc Spinal Anaesthesia for Varicose Vein Stripping. Indian J Anaesth [serial online] 2008 [cited 2019 May 22];52:331-3. Available from: http://www.ijaweb.org/text.asp?2008/52/3/331/60645


   Introduction Top


Involuntary, rhythmic or dysrhythmic movements characterized by rapid contractions in the extremities, developing as a result of the stimulation of medulla spi­nalis by several ways is called spinal myoclonus [1] . The most frequent causes are spinal cord compression, tumours, vascular myelopathy, infections, demyelinat­ing diseases, paraneoplastic syndromes, and trauma to the spinal cord. Drugs given through intrathecal and epidural routes can also induce it [2],[3] .Although spinal myoclonus has been reported under bupivacaine spi­nal anaesthesia for varicose vein stripping [2] and also in caesarean delivery [4],[5], yet, bupivacaine has not been implicated to cause it. Certain antibiotics, eg the cepha­losporins [6] , sulphonamides [7] , and imipenem [8] have been reported to be associated with myoclonus. Despite these reports incident still remains a lesser-known entity, and hence, is likely to be branded as a direct complication of the anaesthetic technique. We report a case of spi­nal myoclonus that was encountered under bupivacaine spinal anaesthesia.


   Case report Top


A 24-year male was referred to the pre-anaes­thesia clinic for fitness for stripping and ligation of bilat­eral varicose veins with sapheno-femoral and adduc­tor incompetence of both sides. Pre-anaesthetic checkup (PAC) revealed no history of any systemic disease. He had, however, a history of on and off head­ache with giddiness that was self-limiting and not re­stricting his normal lifestyle. There was no history of syncope, palpitation, chest pain or seizure disorder; he had a good effort tolerance. On referral to cardiologist to rule out organic cardiac disease, an echocard­iography revealed moderate aortic regurgitation with an ejection fraction of 57.46% and LV dilatation; ECG showed left ventricular hypertrophy. He was started on tablet losartan 25 mg once a day. His biochemical parameters were within normal limits. He was cleared for surgery with ASA physical status grade II risk.

Diazepam (10 mg oral) premedication was given on night before and day of surgery. Antibiotic prophy­laxis against infective endocarditis was given 30 min­utes before surgery. After recording his baseline read­ings, unilateral subarachnoid block was given with 2ml of 0.5% hyperbaric bupivacaine in the right lateral po­sition. He was made supine after 10 minutes, where­upon the motor blockade was Bromage score 3 in the right lower limb, and 1 on the left side; sensory block­ade was up to dermatome T8. Surgery was started on the right limb; patient remained haemodynamically stable barring an episode of bradycardia responding to atro­pine 0.6mg. Surgery lasted 72 minutes. While dressing was being done, patient developed sudden myoclonic jerks in the lower half of the body starting from umbili­cus downwards. There were paroxysmal rhythmic thrusting movements of the pelvis and jerky movements of the legs that recurred every 1-2 minute, persisting for 40-50 seconds. His mental functions were intact and muscle power was normal in all the four limbs. Midazolam 1 mg administered intravenously did not relieve the movements. An arterial sample was sent for blood gas analysis showed normal electrolytes and cal­cium (Na+ 141 mmol.L -1 ; K+ 3.56 mmol.L -1 ; iCa+ 0.895 mmol.L -1 ). Patient was kept in the PACU with oxygen inhalation. His haemodynamic parameters and con­sciousness level were unaffected. He was shifted to post operative ward where physician started him on oral phenytoin 100mg thrice daily. The frequency of sei­zures gradually came down over the next two days; being observed only during the awake state. On the second postoperative day EEG was done that ruled out an epileptic disorder. By the third post operative day seizures had disappeared totally, and he was dis­charged with advice for follow up. Subsequent follow up revealed no recurrence of the seizure.

The surgeon recalled a similar episode during sur­gery on the other leg a week back. The anaesthesiologist then, had administered general anaesthesia, and attrib­uted it to a waning effect of muscle relaxant, hence did not document it in the case notes. There was no recur­rence.


   Discussion Top


Myoclonus is defined as sudden brief shock-like involuntary movements due to contraction of a group of muscle fibres, triggered by an event within the cen­tral nervous system. Its origin may be cortical, subcor­tical or spinal. Spinal myoclonus may be segmental or propiospinal. Fridreich in 1881 suggested the spinal origin of myoclonus; Lhermitte in 1919 established it. Myoclonus is usually a positive phenomenon causing synchronized muscle contractions in single or multiple muscle groups. Negative myoclonus consists of sud­den and brief loss of muscle tone associated with loss of electromyogram (EMG) activity [9] .

It occurs due to deficient inhibitory gycinergic transmission in the spinal cord. Usually spinal myoclo­nus is not associated with pathological lesions, but vacu­olar degeneration and chromatolysis of the anterior horn cells has been found [10] . In many cases treatment is not necessary. Drugs like clonazepam, sodium valproate, piracetam, levetiracetam, tetrabenazine, botulinum toxin, primidone and fluoxetine are effective.

The episodic rhythmic nature of the movements in our patient was diagnostic of myoclonus. The fre­quency of attack, occurrence only during the waking hours, normal EEG, and absence of neurological defi­cit pointed towards the diagnosis of spinal myoclonus. However, unlike in the report by Celik and colleagues 2, we could not attribute it only to spinal anaesthesia since it had occurred under general anaesthesia also (though it was not given importance for it was only one episode). The difference in our case was the long time it took for the movements to subside. Whether it was a response to phenytoin or a natural course of the inci­dent is yet to be answered, since phenytoin is not the drug of choice in this condition. The rarity of incidence in our experience probably made diagnosis difficult. There is no evidence in literature to say that these pa­tients are prone to have it again under anaesthesia. Is spinal anaesthesia the cause of this myoclonus? Should this person again require surgery can spinal anaesthe­sia be re-administered? Is general anaesthesia the an­swer to spinal myoclonus? These are the questions that anaesthesiologist should keep in mind while encoun­tering such situations. More awareness regarding this event is needed, since there is possibility of the anaesthesiologist being blamed of a faulty technique.

 
   References Top

1.Brown P. Spinal myoclonus In: Marsden CD, Fahn S. Eds. Movement disorders 3. Cambridge; Butterworth­Heinemann 1994; 459-76.  Back to cited text no. 1      
2.Celik Y, Bekir Demirel C, Karaca S, Kose Y. Transient seg­mental spinal anaesthesia with bupivacaine. J Postgrad Med 2003;49:286-286.  Back to cited text no. 2  [PUBMED]  Medknow Journal  
3.Ford B, Pullman SL, Khandji A, Goodman R. Spinal myo­clonus induced by an intrathecal catheter. Mov Disord 1997; 12:1042-5.  Back to cited text no. 3      
4.Das KP, Patnaik S. Multifocal myoclonus after spinal anaesthesia. Ind J Anaesth 1992; 40: 263-4.  Back to cited text no. 4      
5.Menenzes FV, Venkat N. Spinal myoclonus following combined spinal-epidural anaesthesia for caesarean sec­tion. Anaesthesia 2006; 61: 597-600.  Back to cited text no. 5      
6.Martin MG. Encephalopathy with myoclonic jerks result­ing from ceftazidime therapy: an under-recognised po­tential side effect when treating febrile neutropenia. Leuk Lymphoma 2007; 48: 413-4.  Back to cited text no. 6      
7.Jundt F, Lempert T, Dorken B, Pezzutto A. Trimethoprim­sulfamethoxazole exacerbate posthypoxic action myoclo­nus in a patient with suspicion of Pneumocystis jiroveci infection. Infection 2004; 32: 176-8.  Back to cited text no. 7      
8.Lan KK, Kink RJ, Jones DP. Myoclonus associated with intraperitoneal imipenem. Pediatr Nephrol 2004; 19: 700­1.  Back to cited text no. 8      
9.Krauss GL, Mathews GC. Similarities in mechanisms and treatments for epileptic and nonepileptic myoclonus. Epilepsy Curr 2003; 3: 19-21.  Back to cited text no. 9      
10.Shivapour F, Teasdall RD. Spinal myoclonus with vacu­olar degeneration of anterior horn cells. Arch Neurol 1980; 37:451-453.  Back to cited text no. 10      




 

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