The knee-jerk reflex (patellar reflex) is an example of a stretch reflex (myotatic reflex). Stretch reflexes are monosynaptic reflexes happening in the spinal cord without involvement of the brain.

Does it mean that this reflex will continue to function in an unconscious person, e.g. under general anaesthesia? Does it depend on the "deepness" of anaesthesia? Does it depend on a specific drug? I would also be interested to know if spinal reflexes keep working in unconscious states such as e.g. alcohol poisoning or a knockout.


The issue is complicated. In general it depends on the specific spinal reflex and on the specific anaesthetic. But it seems that the modern general anaesthetics usually do NOT block monosynaptic spinal reflexes (such as knee-jerk).

Here are two figures from Baars et al. 2009 that show that propofol and sevoflurane strongly inhibit withdrawal reflex (spinal two-synaptic reflex) but have almost no effect on the H-reflex (spinal monosynaptic reflex closely connected to the stretch reflex):

Effect of propofol and seveflurane on withdrawal and stretch reflexes

See below for many more details. Disclaimer: I know very little about anaesthesia and am simply writing down what I found after a couple of days searching and reading.

Withdrawal reflex

As @AliceD wrote, withdrawal reflex (a two-synaptic spinal cord reflex) usually disappears under any anaesthesia and this disappearance is used as a clinical sign of anaesthesia being deep enough for the surgery. As an example, this handout on monitoring anaesthetic depth in rodents has the following entry on the list of criteria for surgical anesthesia:

Withdrawal reflexes are absent! Try at least 2 toes and the ears so that you are sure that this reflex is absent.

Knee-jerk reflex: early history

On the other hand, it is known from the XIX century that stretch reflexes such as knee-jerk (note that they are monosynaptic) are very persistent. They can be abolished under some drugs (such as e.g. chloroform and ether) that act directly on the spine, but keep working under others. I am quoting from three old papers on the topic (here and below emphasis is mine).

Horsley, 1883, Note on the patellar knee-jerk:

In 1881, while experimenting (on myself) with this gas [nitrous oxide] for a different purpose, it occurred to me to contrast the conditions of the superficial and deep "reflexes," taking the plantar reflex as an example of the former, and the patellar phenomenon to illustrate the latter. Being aware of the fact that deep chloroform-narcosis abolishes all the "reflexes," superficial and deep, and yet that with ether-narcosis, however deep, ankle-clonus frequently, appears, I was scarcely surprised to find that the knee-jerk persisted in the deepest anaesthesia from nitrous oxide, while the superficial reflexes all disappeared.

Sherrington, 1892, Notes on the arrangement of some motor fibres in the lumbo-sacral plexus (p 671):

With regard to the effect of anaesthetics on the "jerk," a better proof of the action of chloroform being rapid and direct on the nervous mechanisms of the cord itself could hardly be found than in the speedy abolition of the "jerk" by chloroform inhalation when the cord has been previously divided in the thoracic region.

Simpson & Herring, 1905, The effect of cold narcosis on reflex action in warm-blooded animals:

The knee-jerk is a very persistent phenomenon. It is known to disappear in deep anesthesia produced by ether or chloroform [Sherrington 1892]. [...] The knee-jerk is as a rule easily elicited, and we find it present when all the reflexes have disappeared. [...] The lower the temperature the smaller the jerk. [...] In several animals that died at a low temperature the disappearance of the knee-jerk was simultaneous with death [...] The lowest temperature at which we found the knee-jerk present was 15° C., and this was also the lowest temperature at which any of our animals were still alive. [...] Pinching the skin does not provoke any response till the temperature is 25° C. [...] We have compared these results with similar ones obtained from cats in recovery from deep ether anesthesia and find that the order of reappearance agrees very closely.

Modern studies in animals

Hara & Harris, 2002, The Anesthetic Mechanism of Urethane: The Effects on Neurotransmitter-Gated Ion Channels mention in the abstract that

Urethane is widely used as an anesthetic for animal studies because of its minimal effects on cardiovascular and respiratory systems and maintenance of spinal reflexes.

(they don't specify which reflexes specifically).

Ho & Waite, 2002, Effects of Different Anesthetics on the Paired-Pulse Depression of the H Reflex in Adult Rat study the effect of five different anaesthetics (ketamine, halothane, etomidate, saffan, and nembutal) on the Hoffman reflex (H-reflex), a monosynaptic reflex similar to the stretch reflex. They report that it keeps working under all five drugs, but the drugs modulate the decrease of the reflex under repeated stimulation (this decrease depends on the descending controls and is affected differently by different drugs):

The results suggest a preferential action of some anesthetics on descending pathways involved in reflex modulation [...]

Strangely, Ho & Waite do not describe how anaesthesia affects the reflex strength following an unrepeated stimulation, but in any case it is clear the the reflex keeps functioning.

Propofol etc.

What about the anaesthetics widely used in humans, such as e.g. propofol? Matute et al., 2004, Effects of propofol and sevoflurane on the excitability of rat spinal motoneurones and nociceptive reflexes in vitro:

We used an isolated spinal cord in vitro preparation from rat pups and superfused the anaesthetics at known concentrations. [...] Applied at anaesthetic concentrations, [...] sevoflurane produced a large depressant effect on the monosynaptic reflex whereas propofol was ineffective. [...] Sevoflurane produces large inhibitory effects on nociceptive and non-nociceptive reflexes which are likely to contribute to immobility during surgery. Compared with sevoflurane, propofol appears to have much weaker effects on spinal reflexes such as those recorded in an isolated preparation.

Kerz et al., 2001, Effects of Propofol on H-reflex in Humans:

Previous studies of motoneuron excitability using H-reflexes or F-waves during general anesthesia found significant depression after administration of halothane, enflurane, isoflurane, desflurane, or nitrous oxide. [...]

Recommended propofol doses for induction and maintenance only had a transient effect on the H-reflex and were no longer demonstrable after 10 min of propofol anesthesia. [...] Immobility during propofol anesthesia [...] does not seem to be caused by a depression of spinal motoneuron circuit excitability.

So why is then the withdrawal reflex so easily abolished and the stretch reflex is so persistent (e.g. under propofol)? This does not seem to be well understood. Baars et al., 2009, Effects of Sevoflurane and Propofol on the Nociceptive Withdrawal Reflex and on the H Reflex write

Both H reflex and nociceptive withdrawal reflexes are reduced dose-dependently by propofol and sevoflurane in humans. [...] We have shown a striking difference of the degree to which both reflexes are reduced by the two anesthetics. The relative reduction of the polysynaptic RIII reflex amplitude was more than four times higher than that of the H reflex. This difference can probably be attributed to the higher number of neurons interposed in the RIII reflex pathway in comparison to the H reflex.

Note that the last sentence is very vague; it says that the difference is "probably" due to monosynaptic vs. polysynaptic mechanisms of these two reflexes but does not offer any explanation. Withdrawal reflex is mediated by an excitatory interneuron and propofol acts on GABA (which is inhibitory transmitter), so it remains unclear. This study is from 2009 and I did not find anything relevant in the papers that cite it.


From an animal-experimentation perspective, the absence of functional reflex arches are often used to assess adequate anesthetic depth. For example, in rodents a toe-pinch is often used to assess whether the animal is sufficiently anesthetized to commence surgery. The absence of a withdrawal reflex marks the point to proceed after initiation of general anesthesia. Hence, in these cases, pain-induced muscle reflex arches are suppressed. Note it is a two-synaptic process (nociceptor to spinal chord, spinal chord to muscle).

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    $\begingroup$ Thanks, Alice! +1. This is interesting; withdrawal reflex is polysynaptic, but nevertheless a spinal reflex. So what is your intuition then: would a knee-jerk also disappear under similar anesthesia? By the way, by now I think that the answer might depend on the specific drug and dosage, but I am actually not interested in anesthesia per se. I will now update my question to specify that I am rather asking about any "unconscious" state, such as e.g. after an alcohol intoxication or after being knocked out. $\endgroup$ – amoeba Sep 17 '15 at 13:48
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    $\begingroup$ My intuition is that these reflexes will be absent. I will try to ping @anongoodnurse here in the hopes she can shed light on this. After your edits it is outside the realm of my expertise. Note that alcohol, being quite related to ether, may be considered a general anesthetic, in a way. I think that the question is becoming quite broad as of now and I'll not attempt another answer. Good luck and nice question nonetheless, +1'd. $\endgroup$ – AliceD Sep 17 '15 at 14:02
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    $\begingroup$ I guess you are right to say that the question becomes quite broad because "unconscious states" can (I presume) be quite different and can have distinct properties. I am not asking for a lot of details here and would be happy to accept any answer that gives a short overview. Also, I have just updated my question with some quotes from several XIX - early XX century papers that I found on the topic, I think you might like them. $\endgroup$ – amoeba Sep 17 '15 at 15:20
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    $\begingroup$ I have posted my own answer with a lot of citations; it seems that modern anaesthetics such as e.g. propofol do eliminate the withdrawal (as you say) but do NOT affect the stretch reflex (contrary to your intuition). Even though the effect seems to depend strongly on the specific drug. I have no idea at all why the withdrawal is so much more susceptible than the stretch. Neither can I make any general claim across various anaesthetics, because I only found some isolated information about several specific ones. $\endgroup$ – amoeba Sep 18 '15 at 22:53

I am not a surgeon. However, I might have some insight:

  • General anesthesia often (most of the time ?) include curare derivated drugs (such as pancuronium) that will effectively block any muscular response (by interfering in the neuromuscular junction: they block nicotinic Acetylcholine receptors). So this will effectively inhibate any reflex by blocking the final effector.

  • Spinal anesthesia might also inhibit reflex arc, for the same reasons, but only for a specific zone.

  • Other kind of anesthesia might be conservative regarding reflex arc.

You will find informations on wikipedia:



If you want me to give you a more elaborate answer, just say so, I will try to improve a little bit.

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    $\begingroup$ Thank you for your answer! +1. As far as I understood, neuromuscular blockers such as pancuronium are often used in anaesthesia (to prevent possible movements) but do not have an anaesthetic effect themselves. I guess you are right, and neuromuscular blockers would block spinal reflexes too, but my question was rather about unconsciousness/anaesthesia without an additional muscle paralysis. Your third bullet suggests that spinal reflexes will be unaffected in this situation (and I agree that it sounds plausible) but I would like to have some direct evidence or reference. $\endgroup$ – amoeba Sep 16 '15 at 23:30
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    $\begingroup$ My intuition is that, if there is no neurological lesions, or muscular pathologies, and you're just in presence of a person that is under anesthesia, spinal involving reflex won't be affected. But I will ask to the folks at the hospital tomorrow, whether this is true or false and get back to you. $\endgroup$ – Y. Boursin Sep 17 '15 at 0:18
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    $\begingroup$ General anesthesia is not induced by muscle blockers. They are given to block muscle activity to enhance ease of operation. $\endgroup$ – AliceD Sep 17 '15 at 13:12
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    $\begingroup$ I cannot add commentaries for other posts, but inhibition of withdrawal reflexes is kinda logical speaking of anesthesia. You are aiming to block nociception signal and responses as well as to provoke unconsciousness. I think if you do not administer morphine, or any other kind of analgesic and only use propofol to knock someone down, this will not abolish reflexes. $\endgroup$ – Y. Boursin Sep 18 '15 at 20:55
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    $\begingroup$ So, I've looked a little bit on pubmed. Propofol acts by linking to GABAa receptors (so it tends to inhibit neuronal signals). In the case of a monosynaptic reflex, there is little to no regulation (this is purely hypothetical). In case of polysynaptic reflexes, regulation can occur. For withdrawal reflex, if there are inhibitory GABAergic neurons, these will be affected by Propofol and this inhibit the signal leading to reflex abolition. $\endgroup$ – Y. Boursin Sep 20 '15 at 19:00

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