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• W1561588392 abstract "A healthy, 55 kg, 12-year-old girl had a general anaesthetic to remove a Rice Crispy-sized rudimentary tooth and fit a brace. Her general health was good and she took no medication. There was no family history of movement disorders and specifically Huntington's disease, Wilson's disease, chorea or congenital heart disease. Anaesthesia was performed at another hospital using propofol, nitrous oxide, enflurane and oxygen. The report from this hospital describes anaesthesia and recovery as uneventful. When she recovered, she noticed that her body involuntarily jerked. ‘At first it was about once every three minutes.’ The jerks were single, involving her left upper arm more than the right. ‘If I’m woken up in the morning, I fling out my arms a couple of times.' They increased in frequency: ‘if I think about blood, or about them’. Also when she was exposed to a draught of cold air. They were not painful. She remained healthy, attended school and her teachers did not notice any behavioural or academic problems. Her neurological examination and investigations were normal. Her cortical reflex myoclonus decreased in frequency and severity over the next month, disappearing completely 4 months later, and needing no treatment. The child had blood taken for bacterial and viral studies, thyroid and liver function tests, as well as an electrocardiogram and echocardiogram. These were normal and she remains well 2 years later. The manufacturers were contacted for information of side-effects of each drug used during anaesthesia. Two convulsions have been described in 8 000 000 anaesthetics using enflurane; myoclonus has not been reported. The manufacturer of propofol helpfully pointed out that propofol was not licensed for dental anaesthesia. They also mentioned that myoclonus had been described. Propofol (Diprivan: 2,6 di-isopropyl phenol) is a general anaesthetic licensed for children over the age of 3 years. One site of action is the striatopallidal pathways, possibly involving a dopamine D2 receptor block. Propofol causes a wide range of movement disorders in 30–70% of children [1] at the time of anaesthesia and usually as the anaesthetic wears off. The commonest is choreoathetosis [2]. However, the manufacturer, AstraZeneca, does recognise myoclonus as a rare complication, occurring at a rate of less than 1 in 1000–10 000 patients. The company felt that the myoclonus is ‘almost always self limiting and short lived with no treatment needed. Although in various patients benzodiazepines have been given’[3]. However, drug-induced dystonias are much commoner in children than adults [4]. Unlike children, in adults there may be an underlying movement disorder. This case is unusual in that the teenager developed myoclonus, and that it lasted for as long as 4 months. Myoclonus is defined as a brief involuntary contraction of a muscle or group of muscles [5]. Myoclonus is rare, and excluding epilepsy, it accounts for only 2% of primary manifestations in a paediatric movement disorder clinic [6]. Although there are numerous causes (Table 2), drugs account for the majority of cases. Clinically, myoclonus can be divided into three groups. Cortical myoclonus is usually focal, effects distal muscles, and can be provoked by a variety ofmotor or sensory stimuli, hence cortical reflex myoclonus. Or a cortical discharge arises de novo as in the myoclonic epilepsies. The myoclonus in our case was worsened by various stimuli and so we classify it as cortical reflex myoclonus. Subcortical myoclonus can also be provoked, usually by rapid voluntary movements. However, it is generalised and involves the face and eye muscles as well as the limbs. Finally, segmental myoclonus involves muscle groups innervated by contiguous segments of the brainstem or spinal cord. The difference between chorea and myoclonus is obviously important here, given the proximity of the dental operation. The research group on extrapyramidal disorders of the world federation of neurology defined chorea as ‘a state of excessive, spontaneous movement, irregularly timed, non-repetitive, randomly distributed and abrupt in character’[7]. In our opinion, her movements were not choreo-athetotic. In addition, all her acute phase reactants, blood cultures, antistreptolysin titres, as well as an electrocardiogram and echocardiogram, were normal, and there was no sign at all of streptococcal infection in our case. Various investigations were done that excluded congenital or other obvious physical cause for the child's myoclonus. The manufacturer of propofol pointed out that myoclonus has been described, but in the experience of one author these are limited to a few twitches on induction. We conclude that the cause of the child's prolonged myoclonus was a very severe variant of this already described side-effect. If the child is assessed by general physicians or paediatricians, this rare complication of an anaesthetic drug may be overlooked in the history, in which case the child could be subjected to a large number of invasive and painful investigations which are in fact not needed." @default.
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• W1561588392 date "2002-07-18" @default.
• W1561588392 modified "2023-10-18" @default.
• W1561588392 title "Cortical reflex myoclonus after propofol anaesthesia" @default.
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• W1561588392 doi "https://doi.org/10.1046/j.1365-2044.2002.02752_20.x" @default.
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