Anaesthesia, 1973, Volume 28, pages 441-445

CASE REPORT

Accidental total spinal analgesia with bupivacaine

I. D. S. GILLIES AND M. M O R G A N

Total spinal analgesia is now a well documented complication of attempted epidural

analgesia and of injections of local anaesthetic agents in the paravertebral region.
Most of the recorded cases have occurred with the drug lignocaine. We report here
three cases of accidental total spinal analgesia with bupivacaine.

Case histories
Case 1
The patient was a 43-year-old female, scheduled for stripping of varicose veins. After
pre-operative medication with papaveretum and hyoscine, an epidural block was
performed at the third lumbar interspace using a 19 gauge Harris needle. The space
was identified by the loss of resistance to normal saline. No cerebro-spinal fluid was
aspirated and no fluid dripped out of the end of the needle. A test dose of 2 ml of 0.5%
bupivacaine with 1 :200,000 adrenaline produced no obvious signs of spinal analgesia
in the next 5 minutes, after which time a further 18 ml was injected. At the termination
of the injection, with the needle still in situ, the patient was asked to move her toes but
there was no response; she was then turned onto her back, and found to be pulseless,
apnoeic and unconscious, with widely dilated pupils.
The patient was intubated and ventilated with 100% oxygen. The administration
of methylamphetamine 15 mg intravenously together with the rapid infusion of 1 litre
of Hartmann’s Ringer lactate solution restored her blood pressure to pre-operative
levels. The operation was performed and lasted 1 hour.
Spontaneous ventilation was noted I20 minutes after the bupivacaine injection.
Consciousness returned after a further 65 minutes and, at this stage the patient was
completely analgesic below the level of C2. Recovery of sensation then occurred
gradually, and was complete after 9 hours with no residual effect.

I. D. S. Gillies, BSc, MB, ChB, FFARCS, Senior Registrar, M. Morgan, MB, BS, DA, FFARCS,
Lecturer and Honorary Consultant, Department of Anaesthetics, Royal Postgraduate Medical
School, Hammersmith Hospital, Du Cane Road, London W12 OHS.

44 1
442 I. D . S. Gillies and M. Morgan

Case 2
The patient was a 65-year-old female who required a vaginal hysterectomy. She
received papaveretum and atropine as pre-operative medication, and was given
droperidol 5 mg intravenously in the anaesthetic room.
An epidural was performed at the third lumbar interspace using a 19 gauge Harris
needle, the space being identified by loss of resistance to normal saline. There was no
overt evidence of a spinal tap, and, after a test dose of 2 ml of 0.5% bupivacaine with
1:2OO,OOO adrenaline with no signs of spinal analgesia, a further 20 ml was given.
Respiration gradually diminished and finally ceased after 15 min. The blood pressure
fell from 100 mmHg systolic to 60 mmHg and consciousness was lost, but the pupils
did not dilate. The patient was intubated easily, with no coughing, and the lungs were
ventilated. The blood pressure was restored by methoxamine 2.5 mg administered
intravenously.
The operation lasted I + hours. Spontaneous respiration started 95 minutes after
the injection. Consciousness returned 25 minutes later and, after a further hour,
sensation was present above T2. Full recovery took 5 1 hours.

Case 3
The third patient was a 57-year-old man who had undergone a cholecyst-jejunostomy
after the discovery of an inoperable carcinoma of the head of the pancreas. He had
constant, severe, central back pain, which kept him awake at night. It was decided to
attempt to alleviate this pain by a coeliac ganglion block, initially with local anaesthetic
solution.
The patient was placed in the prone position and a 12 cm 20 gauge needle was
inserted at an angle of 45", four finger-breadths to the right of the spine of the first
lumbar vertebra. The needle was withdrawn slightly after striking bone, and then
angled forwards and advanced a further 2 cm. No blood or fluid was aspirated, and
30 ml of 0.25% bupivacaine with 1 :400,000 adrenaline was injected. The patient was
drowsy, but able to obey commands when he was turned on to his back, but during
the next 5 minutes the respirations gradually ceased, and, after a further 5 minutes,
he was unconscious with widely dilated pupils. The blood pressure fell from 170/110
to 80 mmHg systolic.
He was intubated and ventilated, and the blood pressure was restored with metar-
amino1 1 mg given intravenously.
Sixty-five minutes after the injection of local anaesthetic he opened his eyes on
command although his pupils were still dilated and, after 105 minutes, respiration
returned; at this stage he was completely analgesic below C2. Full recovery of sensa-
tion took 6 hours.

Discussion
The three cases reported here show typical features of total spinal analgesia, including
fall in blood pressure, cessation of respiration and loss of consciousness. Table 1
shows that, in the literature, the duration of the effect on respiration and consciousness
of a massive intrathecal dose of bupivacaine is longer than that of lignocaine. Ekblom
& Widman showed that in deliberate spinal analgesia in twenty patients, 0.75%
bupivacaine was shown to have a mean duration of action of 274 minutes.'
 Accidental total spinal analgesia 443

Wilkinson & Lund’ have studied cerebro-spinal fluid (CSF) bupivacaine levels
after epidural administration. They showed that the half life of bupivacaine in CSF
varied from 2.4 to 3.6 hours, and pointed out that this was not significantly different
from the half-life of shorter acting drugs, such as lignocaine and prilocaine. Tucker et
aI.3 found no significant binding of bupivacaine and lignocaine in CSF, but showed4
that bupivacaine was far more extensively bound to plasma proteins than lignocaine. It
has therefore been suggested’ that binding of these agents to tissue proteins would
follow the same pattern as to plasma proteins, and that this could explain the longer
duration of action of bupivacaine.

Table 1. Time of return of respiration and consciousness from time of injection in some of the cases in
the literature in which total spinal analgesia developed

Respiration Conscious
Author Number Drug Adrenaline (min) (min)

Adriani,’ 3 Lignocaine 10 ml - 20 45
Parmley & Ochsner 1% procaine 10 ml - Died
1% procaine 10 ml Died

1::
-
Jones16 2 Nupercaine 60 mg
Yes 360 240
Procaine 600 mg
Nupercaine 60 mg
YeS 3 60 240
Procaine 600 mg
De Saram17 3 1.5% lignocaine 17 ml Yes 45 125
1.75% lignocaine 24 ml Yes 60 240
1.75% lignocaine 24 ml Yes 90 210
Bonica et aL6 1 2% lignocaine 10 ml - 30 60
Sykes’ 1 1.5% lignocaine 23 ml Yes 60 113
Scott & Kyles18 1 1.5% lignocaine 20 rnl - 60 60
Morrow* 1 1.5% lignocaine 20 ml - 115 115

It is noteworthy that in Cases 1 and 2 test doses were given. The Harris needle
could have been advanced through the dura during injection of the definitive dose, but
assuming that it was intrathecal when the test dose was given, it is clear that this
precautionary action was ineffective in demonstrating the incorrect siting of the
needle tip. It is necessary to consider whether a volume of 2 ml of a hypobaric solu-
tion of bupivacaine (specific gravity 1005 at 20°C and 0998 at 38°C) is sufficient to
produce obvious signs of spinal analgesia, and whether a period of 5 minutes is an
adequate length of time for a drug such as bupivacaine (which is known to have a long
latency) to produce signs of spinal analgesia.
Two leading a~thorities’,~ on the technique of epidural blockade agree that the
use of a test dose does not constitute an absolute safeguard against the development
of total spinal analgesia, but Bonica et aL6 regard such a manoeuvre as extremely
valuable; they state that in an analysis of 3637 cases of epidural block seventeen cases
of total spinal analgesia could have occurred if it had not been for the use of a test
dose, but unfortunately details of these cases and the volume of the test dose used are
not given. It is felt that in the absence of any evidence to the contrary it may be wiser
to use a test dose of 5 ml bupivacaine and to allow a longer period of time to observe
its effects.
444 I. D. S. Gillies and M . Morgan

The second case was not entirely typical in that apnoea was delayed some 15minutes
after injection and the pupils did not dilate. The possibility of a massive epidural was
considered. The fact that the patient became deeply unconscious and the ease with
which intubation was carried out (indicating cranial nerve involvement) suggests that
intrathecal spread of the drug had occurred.
Sykes' has reported a case of accidental total spinal analgesia in which the signs
were delayed 15 minutes, but in that case the dura had been previously punctured at a
different interspace. Morrow* described a case in which the signs were delayed 40 min,
and although unconsciousness occurred, the pupils remained constricted throughout.
Stovner' has described sub-total spinal analgesia following a thoracic paravertebral
block in which respiration ceased but the anterior cranial nerves were spared and
consciousness was retained. These cases do not fit completely either the phenomenon
of total spinal analgesia or massive extradural block. It is felt that the possible explana-
tion for these cases and for our second case may be that only part of the dose had been
injected intrathecally.
The rapid onset in Case 3 would suggest that the needle point was advanced
through an intervertebral foramen and the dose given intrathecally. It would appear,
however, that it is not always necessary to inject the drug directly into the CSF to
produce spinal analgesia.'0,' ' Injection of drugs in the paravertebral region is known,
on occasion, to produce spinal a n a l g e ~ i a , ~ * and
' ~ * ' ~paravertebral block with
alcoh01'~and efocaine" have resulted in permanent spinal cord damage.

Summary
Three cases of accidental total spinal analgesia with bupivacaine are described. In two
patients the course of events was similar but the third showed some unusual features.
Complete recovery with no residual effects occurred on each occasion.

References
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L. & WIDMAN,
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G.R. & LUND,P.C. (1970) Bupivacaine levels in plasma and cerebrospinal fluid
2. WILKINSON,
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distribution. Anesthesiology, 33, 304.
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 Accidental total spinal analgesia 445
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