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Year : 2013  |  Volume : 57  |  Issue : 2  |  Page : 199-201  

Total spinal anaesthesia with "Interscalene brachial plexus block by Winnie approach"

Department of Anaesthesiology and Critical Care, GSVM Medical College, Kanpur, Uttar Pradesh, India

Date of Web Publication15-May-2013

Correspondence Address:
Mukesh Kumar Sah
Senior Resident, Department of Anaesthesiology and Critical Care Dr. R. M. L. Hospital, P.G.I.M.E.R, New Delhi -1
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.111865

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How to cite this article:
Verma AK, Sah MK, Agarwal A, Singh C. Total spinal anaesthesia with "Interscalene brachial plexus block by Winnie approach". Indian J Anaesth 2013;57:199-201

How to cite this URL:
Verma AK, Sah MK, Agarwal A, Singh C. Total spinal anaesthesia with "Interscalene brachial plexus block by Winnie approach". Indian J Anaesth [serial online] 2013 [cited 2020 Feb 24];57:199-201. Available from:

   Introduction Top

Several reports have described spinal or epidural anaesthesia resulting from attempted blockade of brachial plexus by interscalene route. Total spinal anaesthesia is very rare and may be due to anatomical variations, technical performance or both. An understanding of the factors associated with these complications may help to decrease their incidence.

   Case Report Top

A 35-year-old patient of American society of anaesthesiologists ASA grade 1 with fracture dislocation of the right head of radius and fracture lateral 3 rd of the clavicle scheduled for surgery under brachial plexus block with sedation.

After local anaesthesia with 2% lignocaine, a needle was advanced between belly of anterior and middle scalene at the level of cricoid cartilage or C6 as described by Winnie. After eliciting nerve paraesthesia, a mixture of 30 ml (0.5% bupivacaine - 20 ml + tramadol - 1 ml + 9 ml normal saline (NS) was injected slowly with negative aspiration after each 3-5 ml. Even after a proper caution patient moved his neck during the last 5 ml injection. Immediately after injection, the patient became unconscious and apnoeic, with loss of muscle tone in all extremities. Blood pressure decreased from 120/80 to 90/60 mmHg and pulse rate from 100 to 80 beats/min. No seizure activity was noted. He had a Glasgow Coma Score of 3 and had fixed dilated and unresponsive pupils. Intravenous fluid was administered, the patient was ventilated with oxygen 100% with a bag mask and his trachea was then intubated without the need for a neuromuscular blocking drug. Mechanical ventilation was instituted immediately with 100% oxygen. As the patient's vital parameters noninvasive blood pressure (NIBP - 106/70, heart rate (HR) - 78 beats/min) were stable, surgery was begun. It was suspected that total spinal anaesthesia had occurred. Pupils were initially noted to be widely dilated but gradually returned to normal size over the course of 1 1 / 2 h. Patient's HR and blood pressure remained stable during 1 st h post-injection, then the HR gradually decreased to 50 beats/min. 0.5 mg of atropine was given for bradycardia, HR gradually increased to 80 beats/min.

After 1 h 15 min, spontaneous effort was seen gradually and patient was able to follow command and adequate tidal volume by 1 h 48 min. Patient was extubated with an adequate gag reflex. Patient was able to move all the extremities on the command except the operated right arm. There was no response by the patient to the surgical manipulation of the right arm. The right (operating) arm had proximal motor strength of 0/5. At 3 h post-injection, right arm strength and sensation had returned to normal. After completion of surgery, patient was shifted to an intensive care unit with oxygen via face mask. Close questioning on day one of the post-operative, revealed no recall of intra-operative events.

   Discussion Top

After interscalene blocks, various complications have been reported, including total spinal anaesthesia and Horner's syndrome. [1],[2]

In our case, the possibility of intrathecal injection of anaesthetic agent should be considered. Local anaesthetics can enter the spinal space through at least three different routes. First, the drug may be injected directly intrathecally. Second, a dural cuff sometimes may accompany a nerve root distal to the intervertebral foramen, which may be accidentally punctured, making direct intrathecal injection possible. All authors who reported total spinal anaesthesia claimed to have had negative aspiration tests, which therefore, did not guarantee absolute safety. Finally, local anaesthetics injected intraneurally could spread in a central direction to the spinal space. After near completion of block last few millilitre of anaesthetic was injected either to epidural or subarachnoid space at C6 probably by advancement of needle into the intervertebral foramina. Rapidity with which symptoms developed (unconsciousness, apnoea) argues for some degree of subarachnoid injection, although short needle used was intended to minimize the risk of this complication. The observation of initially dilated non-reactive pupil consistent with the loss of efferent parasympathetic activity from Edinger westphal nucleus and the observed bradycardia can be most easily explained by cervicothoracic spinal anaesthesia with the blockade of cardiac accelerator fibres (T1-T4). [3] This early sign persisted for 45 min, at which time HR decreased to 50 beats/min. This evidence of the high, but not intracranial blockade persisted for approximately 1 1 / 2 h. At the conclusion of the case, patient appeared to have recovered completely.

In our case, there is no recall of events which was consistent with previously published reports by Ross and Scarborough. [4] There was no seizure activity or myocardial depression that might have resulted from intravenous injection of lidocaine or bupivacaine. [5] Durrani and Winnie [6] have described a lock in syndrome resulting from probable intra-arterial injection accompanying a successful brachial plexus block but there was no seizure activity and this rules out intravascular injection of local anaesthetics. Unlike intravenous or intra-arterial injection, cerebrospinal fluid administration of local anaesthetics such as procaine caused nystagmus, defecation, vomiting, respiratory depression, loss of consciousness after 15-30 min but was not associated with seizure activity in a dog. [7]

Despite high sympathectomy and some degree of the parasympathetic blockade at the brain stem level patient's HR and blood pressure remained at an acceptable level throughout and the patient did not require vasopressors or chronotropic drugs. [8],[9] Direct application of local anaesthetics at the medullary region of the central nervous system results in hypotension, bradycardia, ventricular arrhythmias. [10]

   Conclusion Top

In summary, we once again emphasise the importance of careful technique, monitoring, immediate access to resuscitation equipment while performing block.

   References Top

1.Fernández-Meré LA, Sopena-Zubiria LA, Gil-Soria L, Alvarez-Blanco M. Spinal anesthesia after brachial plexus block with the posterior approach. Rev Esp Anestesiol Reanim 2008;55:63-4.  Back to cited text no. 1
2.Frasca D, Clevenot D, Jeanny A, Laksiri L, Petitpas F, Debaene B. Total spinal anesthesia after interscalenic plexus block. Ann Fr Anesth Reanim 2007;26:994-8.  Back to cited text no. 2
3.Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970;49:455-66.  Back to cited text no. 3
4.Ross S, Scarborough CD. Total spinal anesthesia following brachial-plexus block. Anesthesiology 1973;39:458.  Back to cited text no. 4
5.Tuominen MK, Pere P, Rosenberg PH. Unintentional arterial catheterization and bupivacaine toxicity associated with continuous interscalene brachial plexus block. Anesthesiology 1991;75:356-8.  Back to cited text no. 5
6.Durrani Z, Winnie AP. Brainstem toxicity with reversible locked-in syndrome after intrascalene brachial plexus block. Anesth Analg 1991;72:249-52.  Back to cited text no. 6
7.Haranath PS, Venkatakrishna-Bhatt H. Procaine perfused into cerebral ventricles and subarachnoid space in conscious and anaesthetized dogs. Br J Pharmacol 1968;34:408-16.  Back to cited text no. 7
8.McGlade DP. Extensive central neural blockade following interscalene brachial plexus blockade. Anaesth Intensive Care 1992;20:514-6.  Back to cited text no. 8
9.Dutton RP, Eckhardt WF 3 rd , Sunder N. Total spinal anesthesia after interscalene blockade of the brachial plexus. Anesthesiology 1994;80:939-41.  Back to cited text no. 9
10.Thomas RD, Behbehani MM, Coyle DE, Denson DD. Cardiovascular toxicity of local anesthetics: An alternative hypothesis. Anesth Analg 1986;65:444-50.  Back to cited text no. 10


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