Regional Anesthesia in the Presence of Neurologic Disease


Key Points

  • Most anesthesiologists are very cautious about the use of regional anesthesia in patients with neurologic disease, mainly because of the medical legal risk. Lawyers seem to have more success linking the exacerbation of neurologic disease following regional anesthesia, than that following general. In truth we really do not have sufficient data to determine which technique is more likely to cause an exacerbation of neurologic disease. Therefore the choice of anesthetic technique should be based primarily on the preoperative assessment of the patient. As always, a thorough consideration of the risks and benefits should be performed for each patient.

  • A number of reports describe successful regional anesthesia in individuals suffering from multiple sclerosis, including obstetric patients. However, practitioners should be aware of other cases in which exacerbation of symptoms or relapse has occurred following anesthesia administration.

  • Regional anesthesia can be used for individuals with spinal cord injuries, but this can be challenging and may require use of adjunct technologies such as nerve stimulation or ultrasound. Similarly, regional blocks have been performed successfully in patients with peripheral neuropathy, but unique risks, such as hemodynamic instability in diabetic individuals, must be considered.

  • A complete neurologic exam is required for all patients with preexisting neurologic disease regardless of the choice of anesthetic technique and this information must be carefully recorded in the patient’s medical record.


Neurologic disease Regional anesthesia Multiple sclerosis Myasthenia gravis Polio/Post-polio syndrome Amyotrophic lateral sclerosis Muscular dystrophies Dystrophia myotonia Spinal cord injury Peripheral nerve injury 


  1. 1.
    Dripps RD, Vandam LD. Exacerbation of pre-existing neurologic disease after spinal anesthesia. N Engl J Med. 1956;255:843–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359–62.CrossRefPubMedGoogle Scholar
  3. 3.
    Osterman K, Lindholm TS. Massive ectopic calcification of the leg following nerve injury. Arch Orthop Trauma Surg. 1983;102:82–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Kishimoto T, Bollen AW, Drasner K. Comparative spinal neurotoxicity of prilocaine and lidocaine. Anesthesiology. 2002;97:1250–3.CrossRefPubMedGoogle Scholar
  5. 5.
    Lambert LA, Lambert DH, Strichartz GR. Irreversible conduction block in isolated nerve by high concentrations of local anesthetics. Anesthesiology. 1994;80:1082–93.CrossRefPubMedGoogle Scholar
  6. 6.
    Neal JM. Effects of epinephrine in local anesthetics on the central and peripheral nervous systems: neurotoxicity and neural blood flow. Reg Anesth Pain Med. 2003;28:124–34.PubMedGoogle Scholar
  7. 7.
    Crawford JS. Epidural analgesia for patients with chronic neurological disease. Anesth Analg. 1983;62:621–2.CrossRefPubMedGoogle Scholar
  8. 8.
    Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg. 2006;103:223–8. tableCrossRefPubMedGoogle Scholar
  9. 9.
    Johnson ME. Potential neurotoxicity of spinal anesthesia with lidocaine. Mayo Clin Proc. 2000;75:921–32.CrossRefPubMedGoogle Scholar
  10. 10.
    Ferguson IT, Murphy RP, Lascelles RG. Ventilatory failure in myasthenia gravis. J Neurol Neurosurg Psychiatry. 1982;45:217–22.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Loh L. Neurological and neuromuscular disease. Br J Anaesth. 1986;58:190–200.CrossRefPubMedGoogle Scholar
  12. 12.
    Klingler W, Lehmann-Horn F, Jurkat-Rott K. Complications of anaesthesia in neuromuscular disease. Neuromuscul Disord. 2005;15:195–206.CrossRefPubMedGoogle Scholar
  13. 13.
    Gartzen K, Katzarava Z, Diener HC, Putzki N. Peripheral nervous system involvement in multiple sclerosis. Eur J Neurol. 2011;18:789–91.CrossRefPubMedGoogle Scholar
  14. 14.
    Warabi Y, Yamazaki M, Shimizu T, Nagao M. Abnormal nerve conduction study findings indicating the existence of peripheral neuropathy in multiple sclerosis and neuromyelitis optica. Biomed Res Int. 2013;2013:847670.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker BG. Multiple sclerosis. N Engl J Med. 2000;343:938–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Symptoms and causes—Multiple sclerosis–Mayo Clinic. 10–1–2015. 3–10–2016.
  17. 17.
    McDonald WI, Silberberg DH. Multiple sclerosis. London: Butterworths; 1986.Google Scholar
  18. 18.
    Abramsky O. Pregnancy and multiple sclerosis. Ann Neurol. 1994;36(Suppl):S38–41.CrossRefPubMedGoogle Scholar
  19. 19.
    van Walderveen MA, Tas MW, Barkhof F, Polman CH, Frequin ST, Hommes OR, Valk J. Magnetic resonance evaluation of disease activity during pregnancy in multiple sclerosis. Neurology. 1994;44:327–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Damek DM, Shuster EA. Pregnancy and multiple sclerosis. Mayo Clin Proc. 1997;72:977–89.CrossRefPubMedGoogle Scholar
  21. 21.
    Levesque P, Marsepoil T, Ho P, Venutolo F, Lesouef JM. Multiple sclerosis disclosed by spinal anesthesia. Ann Fr Anesth Reanim. 1988;7:68–70.CrossRefPubMedGoogle Scholar
  22. 22.
    Bader AM, Hunt CO, Datta S, Naulty JS, Ostheimer GW. Anesthesia for the obstetric patient with multiple sclerosis. J Clin Anesth. 1988;1:21–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Crawford JS, James III FM, Nolte H, van Steenberge A, Shah JL. Regional anesthesia for patients with chronic neurological disease and similar conditions. Anaesthesia. 1981;36:821.CrossRefGoogle Scholar
  24. 24.
    Schapira K. Is lumbar puncture harmful in multiple sclerosis? J Neurol Neurosurg Psychiatry. 1959;22:238.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Warren TM, Datta S, Ostheimer GW. Lumbar epidural anesthesia in a patient with multiple sclerosis. Anesth Analg. 1982;61:1022–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Varner PD. Anesthesia for the patient with neurologic disease. In: 46th annual refresher course lectures and clinical update program. Schaumburg, IL: American Society of Anesthesiologists. 1995.Google Scholar
  27. 27.
    Capdeville M, Hoyt MR. Anesthesia and analgesia in the obstetric population with multiple sclerosis: a retrospective review. Anesthesiology. 1994;81(Suppl):1173.Google Scholar
  28. 28.
    Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med. 1998;339:285–91.CrossRefPubMedGoogle Scholar
  29. 29.
    Vukusic S, Hutchinson M, Hours M, Moreau T, Cortinovis-Tourniaire P, Adeleine P, Confavreux C. The Pregnancy In Multiple Sclerosis Group: pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post-partum relapse. Brain. 2004;127:1353–60.CrossRefPubMedGoogle Scholar
  30. 30.
    Bouchard P, Caillet JB, Monnet F, Banssillon V. Spinal anesthesia and multiple sclerosis. Ann Fr Anesth Reanim. 1984;3:194–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Kytta J, Rosenberg PH. Anaesthesia for patients with multiple sclerosis. Ann Chir Gynaecol. 1984;73:299–303.PubMedGoogle Scholar
  32. 32.
    Racosta JM, Sposato LA, Morrow SA, Cipriano L, Kimpinski K, Kremenchutzky M. Cardiovascular autonomic dysfunction in multiple sclerosis: a meta-analysis. Mult Scler Relat Disord. 2015;4:104–11.CrossRefPubMedGoogle Scholar
  33. 33.
    Racosta JM, Sposato LA, Morrow SA, Cipriano L, Kimpinski K, Kremenchutzky M. Corrigendum to “Cardiovascular autonomic dysfunction in multiple sclerosis: a meta-analysis” [Mult. Scler. Relat. Disord. 4 (2015) 104–111]. Mult Scler Relat Disord. 2015;4:385.CrossRefPubMedGoogle Scholar
  34. 34.
    Pasternak JJ, Lanier Jr WL. Diseases of the autonomic and peripheral nervous systems. In: Hines RL, Marschall K, editors. Stoelting’s anesthesia and co-existing disease. 6th ed. Philadelphia: Elsevier Saunders; 2012. p. 264–73.Google Scholar
  35. 35.
    Kiernan MC, Vucic S, Cheah BC, Turner MR, Eisen A, Hardiman O, Burrell JR, Zoing MC. Amyotrophic lateral sclerosis. Lancet. 2011;377:942–55.CrossRefPubMedGoogle Scholar
  36. 36.
    Kochi T, Oka T, Mizuguchi T. Epidural anesthesia for patients with amyotrophic lateral sclerosis. Anesth Analg. 1989;68:410–2.CrossRefPubMedGoogle Scholar
  37. 37.
    Sertoz N, Karaman S. Peripheral nerve block in a patient with amyotrophic lateral sclerosis. J Anesth. 2012;26:314–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Agnoletti V, Corso R, Cattano D, Novi A, Piraccini E, Folli S, Gambale G. Thoracic paravertebral block for breast surgery in a patient with amyotrophic lateral sclerosis. Minerva Anestesiol. 2013;79:822–3.PubMedGoogle Scholar
  39. 39.
    Warren T, Fletcher M. Anesthetic management of the obstetric patient with neurologic disease. Clin Anaesth. 1986;4:291–304.Google Scholar
  40. 40.
    Broecker BH, Hranowsky N, Hackler RH. Low spinal anesthesia for the prevention of autonomic dysreflexia in the spinal cord injury patient. J Urol. 1979;122:366.PubMedGoogle Scholar
  41. 41.
    Lambert DH, Deane RS, Mazuzan Jr JE. Anesthesia and the control of blood pressure in patients with spinal cord injury. Anesth Analg. 1982;61:344–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Ravindran RS, Cummins DF, Smith IE. Experience with the use of nitroprusside and subsequent epidural analgesia in a pregnant quadriplegic patient. Anesth Analg. 1981;60:61–3.PubMedGoogle Scholar
  43. 43.
    McSwain JR, Doty JW, Wilson SH. Regional anesthesia in patients with pre-existing neurologic disease. Curr Opin Anaesthesiol. 2014;27:538–43.CrossRefPubMedGoogle Scholar
  44. 44.
    Gawne AC, Halstead LS. Post-polio syndrome: historical perspective, epidemiology and clinical presentation. Neuro Rehabilitation. 1997;8:73–81.PubMedGoogle Scholar
  45. 45.
    CDC Global Health. Updates on CDC’s polio eradication efforts. 2–29–2016. 3–10–2016.
  46. 46.
    Gonzalez H, Olsson T, Borg K. Management of postpolio syndrome. Lancet Neurol. 2010;9:634–42.CrossRefPubMedGoogle Scholar
  47. 47.
    Windebank AJ, Litchy WJ, Daube JR. Prospective cohort study of polio survivors in Olmstead County, Minnesota. Ann N Y Acad Sci. 1995;753:81–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Higashiwaza T, Sugiura J, Takasugi Y. Spinal anesthesia in a patient with hemiparesis after poliomyelitis. Masui. 2003;52:1335–7.Google Scholar
  49. 49.
    Lucas LF, Tsueda K. Cardiovascular depression after brachial plexus block in two diabetic patients with renal failure. Anesthesiology. 1990;73:1032–5.CrossRefPubMedGoogle Scholar
  50. 50.
    Ropper AH, Samuels MA. Diseases of the peripheral nerves, Adams and Victor’s principles of neurology. 9th ed. New York: McGraw-Hill; 2009. p. 1251–325.Google Scholar
  51. 51.
    Hughes R. Campylobacter jejuni in Guillain-Barre syndrome. Lancet Neurol. 2004;3:644.CrossRefPubMedGoogle Scholar
  52. 52.
    Dierdorf SF, Walton JS, Stasic AF. Rare coexisting diseases. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, editors. Clinical anesthesia. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013. p. 612–40.Google Scholar
  53. 53.
    Lichtenfeld P. Autonomic dysfunction in the Guillain-Barre syndrome. Am J Med. 1971;50:772–80.CrossRefPubMedGoogle Scholar
  54. 54.
    van den Berg B, Bunschoten C, van Doorn PA, Jacobs BC. Mortality in Guillain-Barre syndrome. Neurology. 2013;80:1650–4.CrossRefPubMedGoogle Scholar
  55. 55.
    McGrady EM. Management of labour and delivery in a patient with Guillain-Barre syndrome. Anaesthesia. 1987;42:899.CrossRefPubMedGoogle Scholar
  56. 56.
    Connelly M, Shagrin J, Warfield C. Epidural opioids for the management of pain in a patient with the Guillain-Barre syndrome. Anesthesiology. 1990;72:381–3.CrossRefPubMedGoogle Scholar
  57. 57.
    Rosenfeld B, Borel C, Hanley D. Epidural morphine treatment of pain in Guillain-Barre syndrome. Arch Neurol. 1986;43:1194–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Berger JM, Ontell R. Intrathecal morphine in conjunction with a combined spinal and general anesthetic in a patient with multiple sclerosis. Anesthesiology. 1987;66:400–2.CrossRefPubMedGoogle Scholar
  59. 59.
    Udd B, Krahe R. The myotonic dystrophies: molecular, clinical, and therapeutic challenges. Lancet Neurol. 2012;11:891–905.CrossRefPubMedGoogle Scholar
  60. 60.
    Duncan PG. Neuromuscular diseases. In: Katz J, Steward DJ, editors. Anesthesia and uncommon pediatric diseases. 2nd ed. Philadelphia: WB Saunders; 1993. p. 672–94.Google Scholar
  61. 61.
    Ropper AH, Samuels MA. The muscular dystrophies, Adams and Victor’s principles of neurology. 9th ed. New York: McGraw-Hill; 2009. p. 1366–83.Google Scholar
  62. 62.
    Ramani R. Skin and musculoskeletal diseases. In: Hines RL, Marschall K, editors. Stoelting’s anesthesia and co-existing disease. 6th ed. Philadelphia: Elsevier Saunders; 2012. p. 437–65.Google Scholar
  63. 63.
    Ropper AH, Samuels MA. Disorders of muscle characterized by cramp, spasm, pain, and localized masses, Adams and Victor’s principles of neurology. 9th ed. New York: McGraw-Hill; 2009. p. 1434–44.Google Scholar
  64. 64.
    Mudge BJ, Taylor PB, Vanderspek AF. Perioperative hazards in myotonic dystrophy. Anaesthesia. 1980;35:492–5.CrossRefPubMedGoogle Scholar
  65. 65.
    Cope DK, Miller JN. Local and spinal anesthesia for cesarean section in a patient with myotonic dystrophy. Anesth Analg. 1986;65:687–90.CrossRefPubMedGoogle Scholar
  66. 66.
    Paterson RA, Tousignant M, Skene DS. Caesarean section for twins in a patient with myotonic dystrophy. Can Anaesth Soc J. 1985;32:418–21.CrossRefPubMedGoogle Scholar
  67. 67.
    Weingarten TN, Hofer RE, Milone M, Sprung J. Anesthesia and myotonic dystrophy type 2: a case series. Can J Anaesth. 2010;57:248–55.CrossRefPubMedGoogle Scholar
  68. 68.
    Bader AM. Neurologic and neuromuscular disease. In: Chestnut DH, Wong CA, Tsen LC, Ngan Kee WD, Beilin Y, Mhyre JM, editors. Chestnut’s obstetric anesthesia: principles and practice. 5th ed. Philadelphia: Elsevier Saunders; 2014. p. 1113–40.Google Scholar
  69. 69.
    Roe CF, Cohn FL. The causes of hypothermia during spinal anesthesia. Surg Gynecol Obstet. 1972;135:577–80.PubMedGoogle Scholar
  70. 70.
    Marchiori PE, dos Reis M, Quevedo ME, Scaff M, Cossermelli W, Assis JL, de Oliveira RM. Acetylcholine receptor antibody in myasthenia gravis. Acta Neurol Scand. 1989;80:387–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Hofstad H, Ohm OJ, Mork SJ, Aarli JA. Heart disease in myasthenia gravis. Acta Neurol Scand. 1984;70:176–84.CrossRefPubMedGoogle Scholar
  72. 72.
    Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1980;53:26–30.CrossRefPubMedGoogle Scholar
  73. 73.
    Rolbin WH, Levinson G, Shnider SM, Wright RG. Anesthetic considerations for myasthenia gravis and pregnancy. Anesth Analg. 1978;57:441–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of AnesthesiaUniversity of Wisconsin MadisonMadisonUSA
  2. 2.Department of Intensive CareThe Austin HospitalHeidelbergAustralia
  3. 3.Department of SurgeryThe Austin HospitalHeidelbergAustralia

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