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  • Autoimmune disease characterized by antibody-mediated demyelination in central nervous system, which leads to impaired nerve conduction. Peripheral nerves are not involved
  • Combination of genetic and environmental factors
  • 2F/1M
  • Age of onset usually 20–40, but can be seen at any age
  • Signs and symptoms related to site of CNS affected by demyelination
  • Broad spectrum—relapses and remissions, or chronic and progressive
  • Variety of triggers, such as stress and heat (fever)
  • Many signs and symptoms are possible, but more commonly seen are visual symptoms from optic nerve involvement, skeletal muscle/spasms from spinal cord involvement, bowel/bladder dysfunction, lack of coordination, paresthesias, seizures, depression, autonomic disturbances in advanced disease. Lower extremities more frequently involved than upper extremities
  • Diagnosis usually based on cerebrospinal fluid antibodies or magnetic resonance imaging
  • MS patients can be treated with a wide variety of medications, some targeting the disease and some targeting specific symptoms:
    • Treatment with corticosteroids, interferons (Avonex, Betaseron, Rebif), glatiramer (Copaxone), azathioprine (Imuran), mitoxantrone (Novantrone; cardiotoxic), natalizumab (Tysabri), cyclophosphamide (Cytoxan), and methotrexate
    • Symptomatic treatment with baclofen (lioresal), tizanidine (Zanaflex) for muscle spasms, cholinergic medications for urinary symptoms, or antidepressants for mood disturbances


  • Thorough history with careful attention to history of relapses, remissions, triggers, typical complaints, and symptoms during exacerbations
  • Complete list of medications should be reviewed prior to induction to delineate any potential interactions with anesthetic medications
  • Elicit steroid use and potential for adrenal suppression
  • Preoperative neurologic exam with focus on visual symptoms as well as skeletal muscle weakness should be performed to establish a baseline
  • Elective surgery should not be performed during periods of relapse


  • Exacerbations during the perioperative period are possible due to surgical stress, regardless of anesthetic technique or medications
  • Succinylcholine is best avoided due to possibility of increased potassium release
  • Nondepolarizing NMB: both increased sensitivity and resistance have been described; judicious use with peripheral nerve stimulator is recommended
  • Stress-dose steroids if indicated
  • Increased temperature can precipitate symptoms, monitor body temperature; avoid hyperthermia
  • Spinal anesthesia may increase risk of postoperative exacerbations, maybe because the demyelination makes the CNS more sensitive to LA neurotoxicity, but epidural and peripheral nerve block techniques appear safe
  • No evidence that general anesthesia drugs, either injected or inhaled, exacerbate MS
  • Autonomic dysfunction should be taken into consideration when monitoring hemodynamics and during fluid management


  • Reassess neurologic status
  • Look for evidence of relapses, and assess for presence of any potential triggers that may be present in the postoperative environment
  • Exercise vigilance with respect to postoperative temperature control
  • Communication with surgeon, neurologist, and primary care physician is essential
  • Baclofen withdrawal can occur, especially if long-standing therapy, with neuropsychiatric symptoms (hallucinations, anxiety, tremor), and possibly seizures, or even muscle rigidity and hyperthermia resembling neuroleptic malignant syndrome


  • Perform both a thorough history of disease progression and neurologic exam prior to surgery
  • Spinal anesthesia may increase risk of postoperative exacerbations, but no evidence that general anesthesia, epidural, or PNB exacerbates MS
  • Avoid hyperthermia
  • Platelet aggregation is increased in MH
  • Increased risk of ...

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