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Patients with preexisting neurologic disease present a unique challenge to the anesthesiologist. Knowledge of the pathophysiology of the disease and the effect of anesthetic drug therapy on the disease process is essential for the safe management of anesthesia for these patients. Both active and dormant neurologic diseases may worsen in the perioperative period, independent of the chosen anesthetic method. However when regional techniques are used, the cause of postoperative neurologic deficits may be difficult to evaluate as neural injury can be related to a wide variety of reasons, ie, surgical trauma, tourniquet pressure, improper positioning, or anesthetic technique.1 The possibility of needle-induced trauma, local anesthetic toxicity, or neural tissue ischemia or damage during regional anesthesia has led many anesthesiologists to avoid regional techniques in patients with underlying neurologic diseases.

Many of these patients can benefit from regional techniques. Greater autonomic stability, the ability to provide selective anesthesia and analgesia, greater hemodynamic stability (especially with peripheral nerve block anesthesia in patients with concurrent cardiomyopathy), and the avoidance of side effects related to general anesthetics and opioids are a few of the advantages.2,3 Careful preoperative neurologic evaluation, evaluation of the risk/benefit ratio, and a comprehensive discussion with the patient about the anesthetic plan and the possibility of worsening neurologic signs and symptoms unrelated to the anesthetic technique is important for successful implementation of regional techniques in this patient population.

Although perioperative nerve injuries have been well recognized as a complication of spinal and epidural anesthesia, severe or disabling neurologic complications occur relatively rarely. In 1999, Cheney and colleagues examined the American Society of Anesthesiologists Closed Claims database to determine what percentage of the claims were related to nerve damage in malpractice cases.4 Of the 4183 claims reviewed, 670 (16%) were anesthesia-related nerve injuries. Ulnar neuropathies were the most frequently reported, followed by other injuries to the brachial plexus, lumbosacral nerve roots, and spinal cord. The injuries were bilateral in 14% of the ulnar injuries and in 12% of the brachial plexus injuries. The important factor in this analysis is that the incidence of ulnar and brachial plexus injuries was greater with general anesthesia than with regional anesthesia.5,6 Horlocker and coworkers examined the cause of perioperative nerve injury in a review of 607 patients undergoing 1614 axillary blocks for upper extremity surgery. Various surgical variables (direct trauma, stretch, hematoma, vascular compromise, case or tourniquet ischemia) were thought to be the cause of neurologic complications in the majority of the cases (89%).7

In the Closed Claims Analysis 189 (4%) involved either the lumbosacral root or the spinal cord. Injuries to these areas were more frequently associated with regional anesthesia. The lumbosacral root injuries were thought to be related to paresthesias during needle or catheter placement or pain on injection of local anesthetic. The spinal cord injuries were related to blocks for chronic pain or neuraxial blocks on patients receiving systemic anticoagulation. These injuries ...

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