Neuraxial anesthesia has become second nature to many practitioners, offering a reliable method for managing pain in surgery and labor. But even for seasoned anesthesiologists, the complications of neuraxial anesthesia remain a clinical reality that demands continuous innovation. While most risks are understood well, it’s important to refresh conversations with new insights to further enhance precision care, procedural workflows, and new options for prevention.
We’ve put together this quick yet comprehensive reference for staying sharp on key complications, offering a springboard for more in-depth discussion on the evolving strategies anesthesiologists can use to minimize these risks while improving patient outcomes.
1. Postdural puncture headache (PDPH)
Postdural puncture headache (PDPH) is a common complication of neuraxial anesthesia, particularly associated with spinal anesthesia, although it can also occur in epidural procedures due to an inadvertent dural puncture. PDPH results from cerebrospinal fluid (CSF) leakage, leading to a reduction in CSF pressure. Patients often experience severe headaches that worsen when upright and improve when lying flat, with additional symptoms such as nausea, neck stiffness, and photophobia. The use of large-gauge cutting needles can elevate the risk.
- Management: Initial conservative measures like bed rest, hydration, and caffeine can provide temporary relief. In persistent cases, the most effective treatment is an epidural blood patch, which seals the CSF leakage.
- Prevention: Preventive strategies include using smaller, non-cutting needles for spinal anesthesia to minimize dural trauma. For epidural procedures, careful technique to avoid accidental dural puncture is key. The Accuro Neuraxial Guidance system enhances needle placement precision, especially in challenging cases, thereby reducing the likelihood of inadvertent puncture. While promising, further large-scale trials are necessary to substantiate these findings, and ongoing attention should be paid to the complexities surrounding PDPH management and prevention until more substantial evidence is available.
2. Nerve injury
Nerve injuries, though rare, can be serious complications of neuraxial anesthesia. Injuries may result from direct trauma by the needle or catheter, ischemia, or, less commonly, compression from a hematoma. Symptoms typically manifest as numbness, persistent paresthesia, or motor weakness in the lower extremities. Patients with anatomical variations (e.g., scoliosis, high BMI) face heightened risk.
- Management: A thorough neurological assessment should be conducted immediately if nerve injury is suspected. If nerve compression from a hematoma leads to neurological impairment, surgical intervention may be required to alleviate pressure.
- Prevention: Avoiding multiple needle insertion attempts reduces the likelihood of nerve trauma. Accuro’s AI-guided imaging helps mitigate this risk by providing visualization of spinal anatomy, potentially decreasing the risk of multiple attempts that could lead to trauma and supporting safer needle placement in anatomically challenging cases.
3. Epidural or spinal hematoma
Epidural or spinal hematomas can result in permanent paralysis if not diagnosed and treated promptly. These complications of neuraxial anesthesia occur when blood accumulates in the epidural space, compressing the spinal cord. Warning signs include severe back pain, motor weakness, and bladder or bowel dysfunction. Anticoagulant therapy, clotting disorders, and multiple needle insertions increase the risk.
- Management: Immediate imaging, typically via MRI, is required to confirm the presence of a hematoma. Surgical decompression is often necessary to relieve spinal cord compression.
- Prevention: Strict adherence to anticoagulation protocols and thorough screening for clotting disorders are critical. Minimizing needle insertions can also lower the risk. Accuro’s visualization features assist clinicians in identifying the optimal insertion site, thereby reducing the number of attempts required for neuraxial anesthesia placement.
4. Spinal infection (epidural abscess)
Infections like epidural abscesses or meningitis are rare but dangerous complications following neuraxial anesthesia. Infections are most often the result of improper aseptic technique or prolonged catheterization. Immunocompromised patients are particularly vulnerable to these complications of neuraxial anesthesia.
- Management: Early imaging is crucial in diagnosing epidural abscesses. Initial management involves antibiotic therapy, but prompt surgical drainage may be required in cases of abscess formation.
- Prevention: Ensuring proper aseptic technique during catheter insertion and timely removal of catheters are critical preventive measures.
5. Local anesthetic toxicity (LAST)
Local anesthetic systemic toxicity (LAST) occurs when excessive anesthetic is absorbed into the bloodstream, leading to serious complications like seizures, cardiac arrhythmias, or cardiovascular collapse. This is often caused by accidental intravascular injection.
- Management: Early recognition of symptoms — such as tinnitus, perioral numbness, and dizziness — is crucial. Management includes stopping the procedure, securing the airway, and promptly administering lipid emulsion therapy.
- Prevention: While careful aspiration is performed, it is not foolproof, so fractionated dosing and close monitoring remain essential to minimize the risk of intravascular injection.
6. Total spinal anesthesia (TSA)
Total spinal anesthesia is one of the rare but life-threatening complications of neuraxial anesthesia. TSA is caused by the unintended injection of local anesthetic into the subarachnoid space, resulting in excessive cephalad (upward) spread of the anesthetic. Symptoms include profound hypotension, bradycardia, respiratory distress, and cardiovascular collapse in severe cases.
- Management: Immediate airway management, including oxygenation and ventilation, is essential. Intravenous fluids and vasopressors are used to manage hypotension. Intubation may be required in cases of respiratory failure.
- Prevention: Careful dosing, monitoring, and precise needle placement are key. Using Accuro Neuraxial Guidance to visualize spinal landmarks may help anesthesiologists avoid unintentional subarachnoid injections, thereby reducing the risk of TSA.
Let’s reduce the complications of neuraxial anesthesia.
Complications in neuraxial anesthesia remain a significant challenge, but proactive management and prevention are possible with the right tools and insights. At RIVANNA, we aim to equip clinicians with technologies like Accuro, which provide a clearer, more reliable path to safer procedures and better patient outcomes. By incorporating these strategies, CRNAs and anesthesiologists can continue to deliver precise, effective care while minimizing risk.