Complications Of Spinal Anesthesia

Haleem and colleagues1® from India studied audiometric changes after spinal anesthesia using different sizes of needles. One hundred and twenty-five patients were randomly divided into five groups to receive spinal anesthesia with five different sizes of spinal needle: 20-G, 22-G, 23-G, 24-G, and 25-G. All patients had baseline audiometric values recorded at 250 Hz to 500 Hz before surgery. Patients who received spinal anesthesia with 20-G and 22-G needles had a significant decrease (12% and 8%) in audiometric values on the first postoperative day (P < 0.001). These alterations returned to normal values by the fifth postoperative day. A significant alteration (8% decrease) was also noted in the group with 23-G needle (P < 0.05). There was no significant decrease in audiometric values after spinal anesthesia with the smaller 24-G and 25-G needles. Besides reducing the incidence of PDPH, small-gauge needles can also minimize audiometric alterations associated with spinal anesthesia.

In a similar study from Turkey, Oncel and coworkers1« used pure tone audiometry to investigate vestibulocochlear dysfunction after central neural blockade. Forty-five patients (age range 23 to 84 years) undergoing urologic surgery were divided into three groups and received either epidural anesthesia or spinal anesthesia with a 22-G or 25-G spinal needle. Pure tone audiometry was performed before surgery and repeated on the third and fourth postoperative days. No statistically significant hearing loss was noted in the epidural group, but the hearing loss in the 25-G group was significantly less than in the 22-G group (P < 0.01). None of the patients suffered from either headache or cranial nerve lesions. Audiometry was found to be a more sensitive indicator of cerebrospinal fluid leakage than headache. Elderly patients often have preexisting hearing impairment, and the use of the 22-G needle for spinal anesthesia may temporarily make it worse. Every effort should, therefore, be made to use smaller needles, even in this group.

PDPH continues to be reported with an incidence between 2.8% and 13.9% in different series, indicating the extensive use of spinal anesthesia for surgery.™ ™ ® Epidural blood patches have been considered as the treatment of choice for the headache after dural puncture. Pedrosa and coworkers™ from Brazil successfully treated 60 patients suffering from PDPH, aged 18 to 42 years, with epidural blood patches, using 10 mL of autologous blood. All patients could be discharged within 24 hours of receiving the patch. An alternative method for treating headache after spinal anesthesia was described by Tsenov from Bulgaria.153 The author used acupuncture to treat PDPH in 35 women after spinal anesthesia for cesarean section. Thirty out of 35 (85%) of the patients needed only one treatment, and it was effective in all after three treatments.

Epidural Anesthesia

The incidence of PDPH after spinal anesthesia led to the popularity of epidural anesthesia. Long-acting local anesthetic drugs, epidural catheters, and the ability to extend anesthesia for prolonged surgery have resulted in a widespread use of epidural anesthesia for surgery.153 153 ™ 153 153 153 153 153 163 163 Epidural and spinal anesthesia are less expensive than general anesthesia. This could be an added incentive for their widespread use in developing countries (see survey discussed later in this chapter).

Xie and Liu153 conducted a survey of the practice of epidural anesthesia in China. Questionnaires were sent to 237 hospitals over six geographic areas, including some military hospitals. The response rate was 38% (90 hospitals). There were 1,304,214 documented epidural blocks in these hospitals. The percentage of blocks performed at different levels of the spine is shown in Table 7-2 . This survey revealed that epidural anesthesia was used extensively in China for various types of surgery, ranging from the neck to the lower extremities. The success rate was 98%, and the incidence of accidental dural puncture was 0.32%. The incidence of total spinal anesthesia as a complication was reported to be only 0.013%, and about half of these cases required intubation and ventilation.

In a retrospective study, Liu and coworkers163 reviewed patients undergoing surgery for primary hyperparathyroidism

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