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Myoclonus after Spinal Anesthesia for Cesarean Delivery: A Case Report.
Abstract Number: FCC-93
Abstract Type: Case Report Case Series
Myoclonus following a neuraxial placement is a rare occurrence. Myoclonus is described as sudden, brief, shock-like involuntary movements that may occur at rest, during voluntary movement, or secondary to provoked stimuli . We present a case of myoclonic jerks following spinal anesthesia for a repeat cesarean delivery.
The patient is a 35-year-old female, G3P1011 at 39-week gestation, who presented for scheduled repeat cesarean. Her past medical history is significant for pregnancy-induced gastric reflux for which she is taking omeprazole. Family history is notable for seizures.
On arrival to the operating room standard ASA monitors were placed. With the patient in the sitting position, a single shot spinal was performed at L3-L4 interspace, with a 25-gauge pencil-point needle and hyperbaric bupivacaine 0.75%-1.5cc, preservative free morphine 150 mcg and fentanyl 15 mcg injected. The patient was then positioned supine with left uterine displacement, and the cesarean delivery proceeded uneventfully.
Following completion of the surgery the patient was brought to the PACU, stable vital signs noted and full report given. Soon after, the patient reports mild involuntary, painless left leg twitching, and then involvement of her right leg in the recovery room (approximately 60 minutes from spinal placement). Symptoms progressively got worse within 30 minutes (left > right) of arrival to the PACU. The patient was alert and oriented without hemodynamic changes. On physical exam there was presence of irregular, bilateral myoclonic jerks of both legs, muscle strength and sensation intact, and 2+ bilateral dorsal pedis pulses.
Following a literature search the patient received 2 mg midazolam IV with complete resolution of twitching within 5 minutes. The patient was discharged to the postpartum floor without recurrence of myoclonic jerks for the remaining hospitalization. She was discharged home on postoperative day 3.
Myoclonus after neuraxial placement is an uncommon event. Myoclonus does not necessarily represent a pathological phenomenon; metabolic derangements and many types of medication can transiently cause myoclonus . There have been several cases describing myoclonic-like involuntary movements following spinal; fewer cases after an epidural placement . Medications such as sodium valproate, clonazepam, barbiturates and benzodiazepines may be utilized to stop the movements . In conclusion, it is important for anesthesiologists to be aware of the potential for myoclonus after neuraxial placement and the subsequent available treatments.
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