• Joseph M Neal, Sandra L Kopp, Jeffrey J Pasternak, William L Lanier, and James P Rathmell.
• From the *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA; †Mayo Clinic College of Medicine, Rochester, MN; and ‡Harvard Medical School, Boston, MA.
• Reg Anesth Pain Med. 2015 Sep 1; 40 (5): 506-25.

Background And ObjectivesIn March 2012, the American Society of Regional Anesthesia and Pain Medicine convened its second Practice Advisory on Neurological Complications in Regional Anesthesia and Pain Medicine. This update is based on the proceedings of that conference and relevant information published since its conclusion. This article updates previously described information on the pathophysiology of spinal cord injury and adds new material on spinal stenosis, blood pressure control during neuraxial blockade, neuraxial injury subsequent to transforaminal procedures, cauda equina syndrome/local anesthetic neurotoxicity/arachnoiditis, and performing regional anesthetic or pain medicine procedures in patients concomitantly receiving general anesthesia or deep sedation.MethodsRecommendations are based on extensive review of research on humans or employing animal models, case reports, pathophysiology research, and expert opinion.ResultsThe pathophysiology of spinal cord injury associated with regional anesthetic techniques is reviewed in depth, including that related to mechanical trauma from direct needle/catheter injury or mass lesions, spinal cord ischemia or vascular injury from direct needle/catheter trauma, and neurotoxicity from local anesthetics, adjuvants, or antiseptics. Specific recommendations are offered that may reduce the likelihood of spinal cord injury associated with regional anesthetic or interventional pain medicine techniques.ConclusionsThe practice advisory's recommendations may, in select cases, reduce the likelihood of injury. However, many of the described injuries are neither predictable nor preventable based on our current state of knowledge.What's NewSince publication of initial recommendations in 2008, new information has enhanced our understanding of 5 specific entities: spinal stenosis, blood pressure control during neuraxial anesthesia, neuraxial injury subsequent to transforaminal techniques, cauda equina syndrome/local anesthetic neurotoxicity/arachnoiditis, and performing regional anesthetic or pain procedures in patients concomitantly receiving general anesthesia or deep sedation.

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