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Spinal myoclonus under regional anaesthesia necessitates awareness about its manifestation with a framework for immediate plan of action. Case: A 52 year old male patient posted for open reduction and internal fixation with Interlocking nail for both bone leg fracture lower limbs. Combined spinal and epidural anesthesia (CSE) was administered. He developed abnormal movements in lower limb after 2hrs of subarachnoid block. These uncoordinated movements initially thought to be due to weaning of the effect of spinal anesthesia were later found to be spinal myoclonus which resolved over a period of three hours after giving GABA agonists. Conclusion: Spinal myoclonus, a rare disorder requires high clinical suspicion of the entity for diagnosis and can be managed successfully with GABA agonist drugs. Introduction Spinal myoclonus is an uncommon disorder characterized by sudden onset myoclonic jerks involving a group of muscles supplied by a few contiguous segments of the spinal cord. Spinal myoclonus may be due to trauma, tumor, infection, spinal cord compression, demyelinating diseases, vascular lesions. Drugs used for spinal anesthesia, subarachnoid catheter in-situ and contrast material may also cause such type of spinalclonus. We present the case report of spinal myoclonus following Combined spinal and epidural anesthesia (CSE) which was managed successfully. Case Report A 52 year old male patient presented to PAC for open reduction internal fixation with Interlocking nail in a case of both bone leg fracture in left lower limb. Patient gave history of road traffic accident 10 days before. There was no history of loss of consciousness, ENT bleed, seizures, vomiting or head injury. Patient was a known case of hypertension since 3 years. He was on Tab. Amlodipine 5mg once a day, Tab. Ecosprin 75 mg once a day, Tab. Atorvastatin 20 mg once a day. Exercise tolerance was good with no history of chest pain, syncope, breathlessness, palpitation or seizure disorder. All the investigations were within normal limits. Patient was planned to be taken under combined Spinal & Epidural anaesthesia. Patient was premedicated with Tab. Alprazolam 0.25 mg night before surgery and Tab. Amlodipine 5mg on the morning of surgery with sips of water. Patient was transferred to Operation Theater and standard monitors applied which showed Pulse80/min, B.P130/80 mmHg, room air saturation 99%. In sitting position, epidural catheter was placed aseptically in L2-L3 epidural space. Catheter fixed at 9cm. Subarachnoid block was given in L3L4 spinal space with 25G Quincke Babcock spinal needle. 2.4 ml of 0.5% Bupivacaine (heavy) was given. Sensory level up to T8 was achieved. Surgery was started on left lower limb with tourniquet placed. Surgery was uneventful until 2hrs when patient developed involuntary abnormal movements of both the lower limbs every 5 to 10 minutes. Sensory and motor blockade appeared to be adequate with normal vital parameters. Patient was conscious, oriented but had no control on those involuntary movements. 5 ml of 0.5% bupivacaine was given through epidural catheter in view of suspected weaning of spinal block. However, Myoclonic movements persisted even after 15 minutes of epidural top-up. Inj. Midazolam 1 mg intravenously given which decreased the frequency of myoclonus. Patient remained hemodynamically stable. Blood sample of the patient was sent for serum electrolytes and blood sugar, which came out to be in normal limits. Post-surgery patient was shifted to ICU for monitoring. EEG and CT scan of brain done and were found to be normal. Neurology advice was sought. No definitive diagnosis could be established and thus these movements were clinically attributed to Spinal myoclonus. Inj. Midazolam 1 mg and Tab. Clonazepam o.5 mg given in ICU in consultation with neurologist. Finally, myoclonic movements stopped after 3 hours of its first onset. Patient was discharged one week after surgery. Article Info Received: 7th July, 2019 Accepted: 22nd July, 2019 Published Online: 22nd August, 2019

Spinal myoclonus following combined spinal and epidural anesthesia: An unusual complication