The lumbar epidural analgesia is one of better ways of controlling pain during labor but it still can be followed
with complications and unintentional side effects. Neurologic complications of epidural analgesia are rare.
We present two cases of healthy women where epidural analgesia was induced during active labor. Repeated intermittent
epidural doses of local anesthetics and the left lateral decubitus position of the patients induced the cephalic spread of the
anesthetic drug along the epidural space with the appearance of unilateral brachial plexus palsy and hoarseness of the voice.
These side effects disappeared spontaneously but caused anxiety in the patients and in all medical staff. Elevated control by
anesthetists is necessary in case of epidural analgesia during active labor to avoid risky complications like the high sympathetic
block

Adriana Maretić

Dragan Belci

Lada Kalagac

Milan Prenc

English

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5Introduction: Neurological complications during lumbar epidural analgesia for labor are seldom and with unpredictable accu-rrence among the obstetric patients. We report a case of unilateral brachial plexus palsy and another case accompa-ined with the hoarseness of the voice as a rare complication during lumbar epidural analgesia in two different obstetric patient’s. Although typically a benign side effect wich often spontaneously resolves, nerve palsy is likely to cause anxiety in both the patient and the doctor. This article highlights the importance of early recognition of this transient symptom and discusses the various mechanisms of its process.Case report 1 #A healty, 29-year-old woman, gravida 2 para (ASA physi-cal status I, weigh 93 (+28) kg and high 168 cm) was admi-tted for active labour at 38 weeks gestation. Her past medical hystory was remarkable only for occasional headaches and experience of cesarean section in previous pregnancy becau-se of breech presentation of fetus.  At the cervix dilatation of 4 cm and visual analog scale (VAS) 8 score the patient request for epidural analgesia. After intravenous administration of 500ml of Ringer’s solution, the patient was put in sitting posi-tion and an 18-gauge blunt-end epidural catheter was placed without difficult via 17-gauge Tuohy needle through the L2-L3 interspace. The catheter was advaced 2-3 cm in the epidu-ral space with the needle bevel pointing cephal. A test dose of 4 ml 2% lidocaine (80 mg) with 1:200.000 epinephrine ruled out intrathecal position. After 10 minutes of lookout interval the level of analgesia according to VAS score was 6, and a bolus dose containing 11 ml of 0,25% levobupivacaine and retained analgesia of VAS score 6. Fifteen minutes after the epidural catheter was placed a dose of 5ml 0.25% levobupiva-caine was administered.This resulted in an adequate symme-tric block up to the level of dermatome Th8 that was tested by alcohol sponge test, and the analgesia score of VAS 2. The patient’s blood pressure (BP) was 115/75 mmHg,which was not different from the value prior to epidural analgesia, and she was placed on the left lateral decubitus position. After 60-70minutes after epidural catheter placement the patient complained about „funny weak feeling in the left forearm“. Examination revealed an unchanged level of sensory blocka-de of the body from dermatome Th8 to L2, and detect a par-tial numbenes over the patient’s left upper arm and brachial region. Transitory  palsy of left brachial plexus from C6 to Th1 was diagnosed . Fetal bradicardia, maternal hypothen-sion and dyspnea were not noted during the labor period.The plexus palsy resolved spontaneously approximately one hour after its onset in spite of one subsequent epidural dose of 5 ml of 0.25% levobupivacaine and 0.05 mcg of fenta-nyl followed by the continuous infusion of the same solution was at 7 ml/h. A healty infant, Apgar score 8/9 was delivered vaginally 265 minute after epidural block was established. After five hours the onset of  symptoms the weakness of the left forearm was resolved.Case report 2 #A healty 32-year-old woman (ASA physical status I, wei-ght 103 (+30) kg and hight 171 cm) was admitted in labour at 40 week’s gestation. During an uneventful first stage of labor, cervix dilatation of 4 cm and VAS 8 score, epidural analgesia was requested. Following the intravenous infusion of 500ml Ringer’s solution,with the patient in the left lateral position, an epidural catheter was easly inserted at the L3-4 interspace and directed 4 cm cephalad. A test dose of 3ml 2% lidocaine (60mg) with 1:200.000 epinephrine was admi-Stručni radProfessional articleBRACHIAL PLExUS PALSy AND HOARSENESS Of THE VOICE DURING LUMBAR EPIDURAL ANALGESIA fOR LABOR AND DELIVERy: A CAUTIONARy TALEKalagac fabris Lada, Maretic Adriana1, Belci Dragan, Prenc Milan21Department of Anesthesia and ICU, 2Department of  obstetrics and gynecologyGeneral Hospital Pula , Pula, CroatiaSummary: The lumbar epidural analgesia is one of better ways of controlling pain during labor but it still can be followed with complications and unintentional side effects. Neurologic complications of epidural analgesia are rare.We present two cases of healthy women where epidural analgesia was induced during active labor. Repeated intermittent epidural doses of local anesthetics and the left lateral decubitus position of the patients induced the cephalic spread of the anesthetic drug along the epidural space with the appearance of unilateral brachial plexus palsy and hoarseness of the voice. These side effects disappeared spontaneously but caused anxiety in the patients and in all medical staff. Elevated control by anesthetists is necessary in case of epidural analgesia during active labor to avoid risky complications like the high sympa-thetic block.Key words: epidural analgesia in obstetrics, brachial plexus palsy, voice hoarseness, sympathetic block.6Glas. pul. boln. 2011; godište 8 L. Kalagac Fabris i suradnici: Brachial plexus palsy and hoarseness of the voice during lumbar...nistered without evidence of either intravascular or intrat-hecal placement of the catheter. After 10 minutes the  VAS score was 7 and additional dose of 10ml of 0.25% levobupi-vacaine and 0.05mcg of fentanyl was applied.Twenty minutes following the epidural top-up dose, a further dose of 6 ml of 0.25% levobupivacaine and 0.05mcg of fentanyl were administerd. This resulted in good analgesia and an asymmetric block with a dermatome level of Th12 on the right side and Th8 dermatome on the left tested by spon-ge test. The patient was placed in the left lateral decubitus position and a continuous infusion of 0.125% bupivacaine was started at the rate of 10 ml/h. Blood pressure remained unchanged at 120/75 mmHg, fetal monitoring was uneven-tful without deceleration or bradycardia. Approximaly half an hour later the husband complained about wife’s deep ho-arseness of the voice, weakness of her left arm and numbe-ness in the distribution of the ulnar nerve (C8 dermatome). Due to concerns for these neurologic findings, the epidural infusion was stopped and labor allowed to progress. About 30minutes after stopping the epidural infusion the patient’s symptoms resolved.After 215 minute of the onset of the epidural block a he-alty infant was delivered vaginally. The patients was dischar-ged from the delivery unit with no neurological deficits.DiscussionEpidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturient’s given intrapartum epidural analgesia is reported to be in-creased at many institutions in the Europe. The procedure has few contraindications such as patient refusal, maternal hemorrhage and coagulopathy. Induction of epidural anal-gesia in early labor remains controversial. However, many physicians induce analgesia as soon as the diagnosis of acti-ve labor has been established and the patient has requested pain relief. The most common complications occurring with epidural analgesia are maternal hypotension and postdural puncture headache. Neurologic complications of epidural or spinal analgesia/anesthesia are rare. However, there are some clinical report about occurrence of Horner’s syndrome, trigeminal nerve palsy, hoarseness of the voice and brachial plexus anesthesia following epidural analgesia application (1,2,3,4,5). Brachial plexus palsy or Horner’s syndrome complicating epidural anesthesia usually occurs unilaterally, which may be due to a subdural injection, asymmetrical positioning of the catheter in the extradural space or anatomical changes in the extradural space of pregnant women (2,5). The most lo-gical explanation is the cephalic spread of the anesthetic drug along the epidural space while placed in a supine position. Gravity and the posture affect the spread and patient positio-ning may be the reason for unilateral sympathetic blockade. Lateral positioning tends to increase analgesia concentrati-ons on the side that is lower during injection of the anesthetic solution (6). In postpartum epidurography performed in a patient who developed Horner’s syndrome during delivery, Adam et al. have succeeded in showing unusually high uni-lateral cephalic spread (“channeling”) of contrast medium on the affected side(7). Our patients developed left-sided, unilateral brachial plexus palsy, which could be explained by the patient positioning (dependent side) during the epidural injection with left uterine displacement.Burn has shown that large (40 ml) volumes of radio-opaque media consistently reach thoracic and cervical levels in non-pregnant patients whereas 20 ml volumes fail to do so (8). Bromage has suggested that during intense labor small amounts of local anesthetic may be driven cephalic.(9) Du-ring the second stage of labor, initiation of the Valsalva ma-neuver when the patient “bears down” compresses the epi-dural space and may also force small amounts of local ane-sthetic cephalic. It is also well known that, in order to achieve equal levels of anesthesia, parturient’s need only one-third to one-half as much anesthetic as non-pregnant patients.(10) In our case the patient did not receive an excessive volume nor was she in active labor. Although the precise mechanism is not clear, a plausible explanation may be that the cervical sympathetic nerve fibers are very sensitive to anesthetic bloc-kade, as probably only a small amount of the original dose reached the C4-C7 level. The fact that the signs reappeared after a second dose one-half the volume of the first may be accounted for by invoking Bromage’s concept of epidural spread following “in the wake of the pathfinding dose”,(9) in which the tissue planes are spread by the initial volume and a smaller volume later might able to spread over a large area.Local anesthetics including levobupivacaine, bupivacai-ne, lidocaine, or ropivacaine are often used in epidural ane-sthesia and analgesia.Levobupivacaine showed a lower risk of cardiovascular and central nervous system(CNS) toxicity than bupivacaine not only in animal studi-es, but also in human volunteers:it has less negative inotropic effect, less effect on the dura-tion of the QRS complex, at intravenous doses >75 mg  pro-duces less prolongation of the QTc interval and lessdecrease of the stroke index than bupivacaine.(11,12) Be-cause of the low affinity to cerebral tissue, levobubivacaine causes fewer changes indicative of CNS depression on EEG than bupivacaine.(13,14) Based on these data, levobupivaca-ine seems to be a valid and safe for obstetric epidural anal-gesia. But even in a diluted solutions, with a relatively low sensory level (Th8) of epidural labor analgesia or a low dose regimen, (13,14) local anesthetics may cause transient neu-rological complications.(15,16)In conclusion, this report suggests that even when appro-priate volumes of local anesthetic are used during lum-bar epidural anesthesia for labor one might encounter an unexpectedly high anesthetic level.  The importance of early recognition of transient neurologic complications may pre-vent unnecessary anxiety for the patient and potential initi-ation of unnecessary diagnostic workup. Epidural analgesia, as a acceptable method of pain control in the labor setting, is not without risk and awareness among providers is always required.7Glas. pul. boln. 2011; godište 8 L. Kalagac Fabris i suradnici: Brachial plexus palsy and hoarseness of the voice during lumbar...References1. Holzman R. Unilateral Horner’s syndrome and brachial plexus anesthesia during lumbar epidural blockade. 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Differential effects of levo- and racemic bupivacaine on the EEG in volun-teers. Reg Anesth Pain Med 1998;23:48.15. Borgia ML, Cristodulu CL, Errico L, Pizzicaroli C, Aragona P. Intrathecal levobupivacaine combined with sufentanil and morphine for cesarean section. A com-parison with racemic bupivacaine. Minerva Anestesiol 2002;68(2 Suppl 9): 146.16. McLoad GA. Density of spinal anaesthetic solutions of bupivacaine, levobupivacaine, and ropivacaine with and without dextrose. Br J Anaesth 2004;92:547-51.Corresponding author: Lada Kalagac Fabris, MD.Department of Anaesthesiology and Intensive Care, General Hospital Pula,  Pula – 52100 , CroatiaE-mail: lada1966@gmail.com lada.kalagac@pu.htnet.hr

BRACHIAL PLEXUS PALSY AND HOARSENESS OF THE VOICE DURING LUMBAR EPIDURAL ANALGESIA FOR LABOR AND DELIVERY: A CAUTIONARY TALE

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