[Acute exacerbation of restless legs syndrome during perioperative procedures: case reports and suggested management]

Restless legs syndrome, or Ekbom syndrome, is a common (yet poorly recognized) neurological condition, with sensitive and motor symptoms and a probable genetic vulnerability. The subjects experience an imperious urge to move their legs at rest, possibly associated with paresthesia and pain, which occurs mostly in the evening and night, and is transiently relieved by movements and walking. Severe cases suffer from involuntary leg jerks during quiet wake and severe insomnia. The syndrome is more frequent in middle-aged subjects, in women, and in iron deficient subjects (renal insufficiency, pregnancy, multiparous mothers). We report a series of patients with a severe restless legs syndrome, adequately treated with small doses of dopamine agonist in the evening. They experienced a perioperative, acute exacerbation of their syndrome. The inability to stay still with involuntary jerks in the operating room, the generalized pain followed by suicidal thoughts, and the agitation with akathisia in the recovery room, complicated the surgery procedures and their follow-ups. The prevention of restless legs exacerbation includes: (i) contra-indicating hydroxyzine, droperidol and any other drug blocking the central dopamine transmission before and during anaesthesia; (ii) using intravenous or subcutaneous opioids, and benzodiazepines during and after the surgery procedure; (iii) temporary increasing the dosage of dopamine agents after surgery; (iv) monitoring (and compensating if low) the iron stores after surgery.