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ARTICLES: B. Högl, B. Frauscher, K. Seppi, H. Ulmer, and W. Poewe Transient restless legs syndrome after spinal anesthesia: A prospective study Neurology 2002; 59: 1705-1707 [Abstract] [Full text] [PDF]

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Reply to Letter to the Editor

Werner Poewe   (7 February 2003)

Transient restless legs syndrome after spinal anesthesia: A prospective study

Paul J. Zetlaoui, Julie Cosserat   (7 February 2003)

Reply to Letter to the Editor 7 February 2003
Werner Poewe Department of Neurology Innsbruck Austria Send Correspondence to journal: Re: Reply to Letter to the Editor werner.poewe{at}uibk.ac.at Werner Poewe	In response to the correspondence regarding our study on transitory restless legs syndrome (RLS) after spinal anesthesia, we are grateful to Drs. Zetlaoui and Cosserat for having spotted the error regarding concentrations of the local anesthetic used in our study: The concentrations should read 0.5% for bupivacaine and 4% for mepivacaine and not the way it was stated in the manuscript. The 22-gauge sharp needle was only used in a minority of patients when degenerative changes of the lumbar spine impeded puncture with non- cutting needles. Therefore, there is no reason to believe that transitory RLS symptoms were related to this particular needle type. Similarly there is no reason to believe that persistency of CSF leakage was involved in the pathophysiology of spinal anesthesia related RLS seen in our study. Symptoms of post lumbar puncture CSF leakage are well defined and, as stated in the Results section, post lumbar puncture headache was found in 6.9% of our cases with no association between this complication and the occurrence of transient RLS. It is correct that our study did not aim to investigate a possible relationship between lumbar puncture alone and RLS. Indeed we do not think there is a strong rationale to perform such an investigation. We were certainly aware of TNS as a complication of spinal anesthesia. We would encourage Drs. Zetlaoui and Cosserat to review the literature on TNS in order to recognize that these reports describe transient and sometimes persistent radicular symptoms as well as other neurologic symptoms related to spinal cord dysfunction but we did not find mention of transient RLS in any of those papers." Our study certainly does support a relationship between spinal anesthesia and transient RLS and their comments do not provide any strong argument to the contrary.
Transient restless legs syndrome after spinal anesthesia: A prospective study 7 February 2003
Paul J. Zetlaoui Hopital Bicetre Universite Paris Sud, France, Julie Cosserat Send Correspondence to journal: Re: Transient restless legs syndrome after spinal anesthesia: A prospective study paul.zetlaoui{at}free.fr Paul J. Zetlaoui, et al.	I read with great interest the paper by Högl et al. [1] about new onset of restless legs syndrome (noRLS) after spinal anesthesia. Obviously this paper opens a new window in the field of nosocomial disease. However, some problems appear reading this paper: First of all, there is confusion in the dosage of the drugs injected during spinal anesthesia; anesthesiologists use 0.5% bupivacaine or 4% mepivacaine. In the paper there is an inversion in drug concentrations. Second, I am very surprise that Austrian anesthesiologists still use 22-gauge cutting-bevel spinal needle. These needles are used by non- anesthesiologist for lumbar puncture. In obstetrics (37% of the sample), Anesthesiologists perform spinal anesthesia with 26 or 27 gauge non- cutting bevel needles. It should be interesting to look for a relation between noRLS and the actual gauge of the needle used. Third, I am surprise that authors do not report the effect of spinal puncture alone, without local anesthetic (LA) injection, on the incidence of noRLS. Doing so, lead to the conclusion that only LA is involved in this problem. It should be useful to know if lumbar punctures, performed with 22 gauge Quincke needles can be responsible of noRLS. Neurologists should easily perform such a study. Four, authors seems not to be aware about TNS. In 1993, Schneider et al. has described a new potential complication of spinal anesthesia, and more than 50 international papers have been published. From laboratory studies, it is possible to suspect LA responsibility in TNS; however definitive proof is lacking. Clinically, bupivacaine is very rarely responsible for TNS, but mepivacaine is more often implicated in TNS. Is there any difference in the incidence of noRLS between bupivacaine and mepivacaine, as all local anesthetics are not created equal? Perhaps, authors have to look for a link between TNS and noRLS. Obviously authors have reported a new nosocomial complication following spinal puncture and local anesthetic injection. Obviously, this study does not support the conclusion that this is a spinal anesthesia related complication. Obviously, complications of persistent CSF leakage are underestimated, as we know patients suffering for months from lumbar puncture headache, hypoacousia or other complication [3]. The fact that some cases of new onset RLS were still present after 2 months is a clue allowing facing this problem as a complication of persistent CSF leakage. Obviously, controlled studies are warranted before conclusive propositions. References: 1. Hogl B, Frauscher B, Seppi K, Ulmer H, Poewe W. Transient restless legs syndrome after spinal anesthesia: A prospective study. Neurology 200210;59:1705-1707 2. Schneider M, Ettlin T, Kaufmann M, Schumacher P, Urwyler A, Hampl K, von Hochstetter A. Transient neurologic toxicity after hyperbaric subarachnoid anesthesia with 5% lidocaine. Anesth Analg 1993;76:1154-1157. 3. Narchi P, Veyrac P, Viale M, Benhamou D. Long-term postdural puncture auditory symptoms: effective relief after epidural blood patch. Anesth Analg 1996;82:1303.