Chronic dystonic movements postoperatively are very rare, especially in a patient without a prior diagnosis of a movement disorder [1,2]. However, experiencing a transient movement disorder in the postoperative period that is associated with induction and emergence of anesthesia is relatively common [2]. Dystonic movements following surgery must be addressed quickly to navigate the differential of critical etiologies including local anesthetic system toxicity, serotonin syndrome, neuroleptic malignant syndrome, malignant hyperthermia, ketamine-mediated seizure activity, conversion disorder, and opioid-induced movement disorder [3].

Movement disorders are an adverse effect of many drugs [4]. During the perioperative period, patients are often on combinations of drugs that may cause more than one movement disorder, therefore making it challenging to identify the etiology of dystonic movements when they arise [4]. The diagnosis of a movement disorder required knowledge of the syndromes that can occur with different drug classes and their typical time course [4]. The therapeutic intervention for most drug-induced movement disorders is cessation of the offending drug, with or without supportive or other pharmacological treatment [4].

Propofol is a common anesthetic agent that has been implicated in causing movement disorders for over 30 years [5]. However, these instances have generally been documented in scenarios in which higher doses than normal were used or in patients with pre-existing movement disorders [5]. The mechanism for these movement disorders following surgery has not been well-defined but may involve the rapid change in cerebral concentration of propofol [5].

Case reports of dystonic reactions following propofol and specific anti-emetics have been published [2]. A 2012 case report documents the outpatient experience of a 10-year-old, otherwise healthy girl, undergoing foot surgery [1]. Around 2.5 hours following emergence from general anesthesia with propofol, the patient began to experience involuntary jerking movements of her arms and torso every time she slept [1]. General anesthesia had been maintained with sevoflurane, and she was given ondansetron for nausea after waking up from surgery [1]. Initially, the movements lasted for several seconds but, over the course of the day, turned into shaking, seizure-like movements lasting several minutes [1]. These movements lasted for several days before resolving completely [1].

A recent 2021 case report also details the occurrence of a movement disorder following surgery [3]. A 22-year-old man presented to the United States Naval Hospital for ankle surgery [3]. The patient underwent an unremarkable ankle surgery induced with propofol-induced anesthesia maintained with sevoflurane [3]. Shortly after emergence from anesthesia, he developed episodic involuntary whole-body muscle contractions that manifested in a relapsing-remitting fashion [3]. These dystonic muscle movements lasted between 20 to 40 seconds and occurred every 5 minutes [3]. In between episodes, his muscles were relaxed, and he appeared to breathe normally [3]. Eventually, the movements subsided, and the patient was discharged on postoperative day 4 [3].

References

1. Budde, A., Freestone-Bernd, M., & Vaida, S. (2012). Rhythmic movement disorder after general anesthesia. Journal of Anaesthesiology Clinical Pharmacology, 28(3), 371. doi:4103/0970-9185.98347
2. Allford, M. (2007). Prolonged myotonia and dystonia after general anaesthesia in a patient taking gabapentin. British Journal of Anaesthesia, 99(2), 218-220. doi:10.1093/bja/aem130
3. Chino, K., Carness, J., Claudio, O. et al. (2021). Unrecognized Postoperative Opioid-Induced Movement Disorder: A Case Report. A&A Practice, 15(5), e01448. doi:10.1213/XAA.0000000000001448
4. Duma, S., & Fung, V. (2019). Drug-induced movement disorders. Australian Prescriber, 42(2), 56. doi:18773/austprescr.2019.014
5. Brooks, D. (2008). Propofol-Induced Movement Disorders. Annals Of Emergency Medicine, 51(1), 111-112. doi:10.1016/j.annemergmed.2007.08.023