Anesth Analg 2000;91:1230-1231
© 2000 International Anesthesia Research Society
REGIONAL ANESTHESIA AND PAIN MEDICINE
The Successful Use of Regional Anesthesia to Prevent Involuntary Movements in a Patient Undergoing Awake Craniotomy
Ralf E. Gebhard, MD,
James Berry, MD,
William W. Maggio, MD,
Adrian Gollas, MD, and
Jacques E. Chelly, MD, PhD, MBA
Department of Anesthesiology, The University of Texas-Houston Medical School, Houston, Texas
Address correspondence and reprint requests to Jacques Chelly, MD, PhD, MBA, The University of Texas-Houston Medical School, Department of Anesthesiology, 6431 Fannin, MSB 5.020, Houston, TX 77030-1503. Address e-mail to Jacques.E.Chelly{at}uth.tmc.edu
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Abstract
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Implications: The authors demonstrate that the combination of single and continuous peripheral nerve blocks allows the control of involuntary movements in patients undergoing awake craniotomy.
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Introduction
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Regional blocks are commonly used as a sole technique, or in combination with general anesthesia, to provide adequate analgesia at the site of surgical intervention. However, in certain patients, regional anesthesia can be indicated for reasons other than pain control. We present a case in which a combination of upper and lower extremity nerve blocks prevented involuntary movements during awake craniotomy.
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Case Report
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A 48-yr-old, 140-kg man with intractable seizure disorder was scheduled to undergo craniotomy for removal of his left temporal lobe. To allow intraoperative cortical speech mapping to prevent damage to the Wernicke’s area, awake surgery using IV sedation in combination with local anesthesia at the incision site was planned. Because the patient also had involuntary spontaneous jerking of his right upper and lower extremities, the neurosurgeon consulted the regional anesthesia team to control these movements, a prerequisite for surgery. The patient was taken preoperatively to a block room and sedated with 4 mg midazolam IV under appropriate monitoring. By using a nerve stimulator (B Braun, Bethlehem, PA), an interscalene block was performed on the patient’s right upper extremity with 30 mL of bupivacaine 0.5% to prevent involuntary movements of the shoulder. In addition, blocks of the musculocutaneous and ulnar nerves were completed by using neurostimulation at the upper arm (midhumeral approach) (1) with 6 mL of bupivacaine 0.5% applied to each nerve to eliminate contractions of the elbow. Because the involuntary movements of the right lower extremity were mainly related to the quadriceps femoris muscle, a perineural femoral catheter (Contiplex; B Braun) was placed using an anterior approach for a continuous femoral nerve block.
After 45 min the right upper extremity nerve blocks were evaluated and found to be satisfactory. The patient was transferred to the operating room and appropriate monitors were placed. After a bolus of 5 mL of bupivacaine 0.5%, the femoral catheter was connected to a continuous infusion pump set to deliver 10 mL/h bupivacaine 0.25%. After securing the patient’s head on a donut, mild sedation by using a continuous propofol infusion and repetitive doses of fentanyl was started. For incision of the skin and opening of the skull, 20 mL of bupivacaine 0.25% was injected locally by the surgeon. Three hours after the start of surgery, another bolus of 10 mL of bupivacaine 0.5% was injected into the femoral catheter. Surgery lasted for 6 h and was uneventful, and no involuntary movements were noted. After cortical speech mapping, the patient’s left temporal lobe was resected. Postoperatively, no speech defect was present.
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Discussion
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The beneficial effect of infiltration anesthesia for craniotomy has been shown by several authors, whether it was used in combination with general anesthesia (2,3) or with conscious sedation in cases of awake craniotomy (4,5). However, there is no report in the literature in which peripheral nerve blocks of the limbs were necessary to perform craniotomy under awake conditions. In this case, our neurosurgeon was not prepared to perform the microsurgical mapping in the presence of any uncontrolled movement. Given this circumstance, it was crucial to the outcome of the operation to develop a strategy that would immobilize the patient’s right arm and leg. At the same time, blood concentrations of local anesthetics and the risk of local anesthetic toxicity needed to be considered, especially in the presence of a preexisting seizure disorder, which might be considered a relative contraindication for regional anesthesia. Depending on the site of the administration and the choice of local anesthetic, peak plasma concentrations are reached in a timeframe ranging from a few minutes (6) up to two hours (7). After interscalene and femoral nerve blocks with bupivacaine, maximal concentrations in the blood can be expected after 10 to 40 minutes (8) and 60 minutes (9) respectively. Therefore, the decision was made to choose a combination of a single injection for the upper extremity and a catheter technique for the lower limb, allowing minimal risk of local anesthetic toxicity. With this strategy, the administration of a large dose of local anesthetic over a short period of time could be avoided and no toxic side effects were noted. Because our primary goal was to produce a reliable motor block, we chose bupivacaine instead of ropivacaine (10). Although one might argue that toxic levels of bupivacaine might have been exceeded in our case at certain times during surgery, we feel that the beneficial effects of this anesthetic management for the patient justified the risks.
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Acknowledgments
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Supported, in part, by The University of Texas-Houston Medical School, Department of Anesthesiology, Houston, Texas.
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References
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Accepted for publication July 18, 2000.
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Abstract
Introduction
