Spinal nerve function in five volunteers experiencing transient neurologic symptoms after lidocaine subarachnoid anesthesia

Transient neurological symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics in adult surgical patients: a network meta-analysis

BACKGROUND

Spinal anaesthesia has been implicated as one of the possible causes of neurological complications following surgical procedures. This painful condition, occurring during the immediate postoperative period, is termed transient neurological symptoms (TNS) and is typically observed after the use of spinal lidocaine. Alternatives to lidocaine that can provide high-quality anaesthesia without TNS development are needed. This review was originally published in 2005, and last updated in 2009.

OBJECTIVES

To determine the frequency of TNS after spinal anaesthesia with lidocaine and compare it with other types of local anaesthetics by performing a meta-analysis for all pair-wise comparisons, and conducting network meta-analysis (NMA) to rank interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Elsevier Embase, and LILACS on 25 November 2018. We searched clinical trial registries and handsearched the reference lists of trials and review articles.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing the frequency of TNS after spinal anaesthesia with lidocaine to other local anaesthetics. Studies had to have two or more arms that used distinct local anaesthetics (irrespective of the concentration and baricity of the solution) for spinal anaesthesia in preparation for surgery. We included adults who received spinal anaesthesia and considered all pregnant participants as a subgroup. The follow-up period for TNS was at least 24 hours.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed studies for inclusion. Three review authors independently evaluated the quality of the relevant studies and extracted the data from the included studies. We performed meta-analysis for all pair-wise comparisons of local anaesthetics, as well as NMA. We used an inverse variance weighting for summary statistics and a random-effects model as we expected methodological and clinical heterogeneity across the included studies resulting in varying effect sizes between studies of pair-wise comparisons. The NMA used all included studies based on a graph theoretical approach within a frequentist framework. Finally, we ranked the competing treatments by P scores.

MAIN RESULTS

The analysis included 24 trials reporting on 2226 participants of whom 239 developed TNS. Two studies are awaiting classification and one is ongoing. Included studies mostly had unclear to high risk of bias. The NMA included 24 studies and eight different local anaesthetics; the number of pair-wise comparisons was 32 and the number of different pair-wise comparisons was 11. This analysis showed that, compared to lidocaine, the risk ratio (RR) of TNS was lower for bupivacaine, levobupivacaine, prilocaine, procaine, and ropivacaine with RRs in the range of 0.10 to 0.23 while 2-chloroprocaine and mepivacaine did not differ in terms of RR of TNS development compared to lidocaine. Pair-wise meta-analysis showed that compared with lidocaine, most local anaesthetics were associated with a reduced risk of TNS development (except 2-chloroprocaine and mepivacaine) (bupivacaine: RR 0.16, 95% confidence interval (CI) 0.09 to 0.28; 12 studies; moderate-quality evidence; 2-chloroprocaine: RR 0.09, 95% CI 0.01 to 1.51; 2 studies; low-quality evidence; levobupivacaine: RR 0.13, 95% CI 0.02 to 0.69; 2 studies; low-quality evidence; mepivacaine: RR 1.01, 95% CI 0.18 to 5.82; 4 studies; very low-quality evidence; prilocaine: RR 0.18, 95% CI 0.07 to 0.49; 4 studies; moderate-quality evidence; procaine: RR 0.14, 95% CI 0.04 to 0.52; 2 studies; moderate-quality evidence; ropivacaine: RR 0.10, 95% CI 0.01 to 0.78; 2 studies; low-quality evidence). We were unable to perform any of our planned subgroup analyses due to the low number of TNS events.

AUTHORS' CONCLUSIONS

Results from both NMA and pair-wise meta-analysis indicate that the risk of developing TNS after spinal anaesthesia is lower when bupivacaine, levobupivacaine, prilocaine, procaine, and ropivacaine are used compared to lidocaine. The use of 2-chloroprocaine and mepivacaine had a similar risk to lidocaine in terms of TNS development after spinal anaesthesia. Patients should be informed of TNS as a possible adverse effect of local anaesthesia with lidocaine and the choice of anaesthetic agent should be based on the specific clinical context and parameters such as the expected duration of the procedure and the quality of anaesthesia. Due to the very low- to moderate-quality evidence (GRADE), future research efforts in this field are required to assess alternatives to lidocaine that would be able to provide high-quality anaesthesia without TNS development. The two studies awaiting classification and one ongoing study may alter the conclusions of the review once assessed.

Spinal blocks

Every anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single-injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow-up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.

Continuous spinal anesthesia with high dose of local anesthetics

BACKGROUND AND OBJECTIVES

Better control of the level, intensity, and duration of spinal analgesia represents the greatest advantages of continuous spinal anesthesia. With the advent of intermediate catheters (over-the-needle catheter) and its low incidence of headaches and neurological symptoms, the technique has been gaining credibility. The objective of this paper is to report the possible safety of the new catheter with a large dose of hyperbaric 0.5% bupivacaine with 1.6% glucose associated with hyperbaric 2% lidocaine with 1.6% glucose.

CASE REPORT

Male patient, 78 years old, 85 kg, 168 cm, physical status ASA III, with hypertension, coronary artery disease, and chronic renal failure. The patient was candidate for surgery for huge bilateral inguinal and umbilical hernias, being submitted to preoperative pneumoperitoneum for one week to stretch abdominal cavity. After venoclysis with an 18G catheter, he was monitored with cardioscope, non-invasive blood pressure, and pulse oximetry; he was sedated with 1 mg of midazolam and 100 μg of fentanyl intravenously, and placed in left lateral decubitus. He underwent continuous spinal anesthesia by a median puncture in L₃-L₄ with a set with a 27G cut-bevel needle and 22G catheter. The total dose of anesthetic used was 25mg of 0.5% bupivacaine (hyperbaric, with 1.6% glucose), 160 mg of 2% lidocaine (hyperbaric, with 1.6% glucose), and morphine (100 μg). The patient was followed-up until the 30th postoperative day without neurological complaints.

CONCLUSIONS

Recently, the poor distribution of the local anesthetic through the microcatheter was attributed as the cause of cauda equina syndrome. This case report showed that, with the administration of high doses of hyperbaric anesthetics through the new catheter, poor distribution or risk of cauda equina syndrome were not observed.

Neurological adverse events following regional anesthesia administration

Regional anesthesia and analgesia have been associated with improved analgesia, decreased postoperative nausea and vomiting, and increased patient satisfaction for many types of surgical procedures. In obstetric anesthesia care, it has also been associated with improved maternal mortality and major morbidity. The majority of neurological adverse events following regional anesthesia administration result in temporary sensory symptoms; long-term or permanent disabling motor and sensory problems are very rare. Infection and hemorrhagic complications, particularly with neuraxial blocks, can cause neurological adverse events. More commonly, however, there are no associated secondary factors and some combination of needle trauma, intraneural injection, and/or local anesthetic toxicity may be associated, but their individual contributions to any event are difficult to define.

Transient neurological symptoms after spinal anaesthesia with levobupivacaine 5 mg/ml or lidocaine 20 mg/ml

BACKGROUND

Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine.

METHODS

Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs.

RESULTS

In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade.

CONCLUSION

After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

BACKGROUND

Spinal anaesthesia has been in use since 1898. During the last decade there has been an increase in the number of reports implicating lidocaine as a possible cause of temporary and permanent neurologic complications after spinal anaesthesia. Follow up of patients who received uncomplicated spinal anaesthesia revealed that some of them developed pain in the lower extremities after an initial full recovery. This painful condition that occurs in the immediate postoperative period was named 'transient neurologic symptoms' (TNS).

OBJECTIVES

To study the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine compared to other local anaesthetics.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library, Issue 4, 2008); MEDLINE (1966 to August 2008); EMBASE (1980 to week 35, 2008); LILACS (August 2008); and handsearched the reference lists of trials and review articles.

SELECTION CRITERIA

We included all randomized and quasi-randomized studies comparing the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine as compared to other local anaesthetics.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the quality of the relevant studies and extracted the data from the included studies.

MAIN RESULTS

Sixteen trials reporting on 1467 patients, 125 of whom developed TNS, were included in the analysis. The use of lidocaine for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology; the symptoms disappeared spontaneously by the fifth postoperative day. The relative risk (RR) for developing TNS after spinal anaesthesia with lidocaine as compared to other local anaesthetics (bupivacaine, prilocaine, procaine, levobupivacaine, ropivacaine, and 2-chloroprocaine) was 7.31 (95% confidence interval (CI) 4.16 to 12.86). Mepivacaine was found to give similar results as lidocaine and was therefor omitted from the overall comparison to diminish the heterogeneity.

AUTHORS' CONCLUSIONS

The risk of developing TNS after spinal anaesthesia with lidocaine was significantly higher than when bupivacaine, prilocaine, or procaine were used. The term 'transient neurological symptoms' implies neurologic pathology. Failing identification of the pathogenesis of TNS, consideration should be given to choosing a neutral descriptive term which does not imply a particular causation. One study about the impact of TNS on patient satisfaction and functional impairment demonstrated that non-TNS patients were more satisfied and had less functional impairment after surgery than TNS patients, but this did not influence their willingness to recommend spinal anaesthesia.

Intrathecal ropivacaine 5 mg/ml for outpatient knee arthroscopy: a comparison with lidocaine 10 mg/ml

PURPOSE

The aim of this prospective, randomised, blind study was to compare the evolution of spinal block produced with 50 mg lidocaine 10 mg/ml and 10 mg ropivacaine 5 mg/ml for outpatient knee arthroscopy.

METHODS

Thirty outpatients undergoing knee arthroscopy received 50 mg of lidocaine 10 mg/ml (n=15) or 10 mg of ropivacaine 5 mg/ml (n=15) intrathecally. The evolution of spinal block was recorded until home discharge, while the occurrence of transient neurologic symptoms (TNS) was evaluated through phone-call follow-ups.

RESULTS

The median onset time was 15 (10-21) min with lidocaine and 24 (11-37) min with ropivacaine (P=0.109). Spinal lidocaine resulted in a faster resolution of sensory block [148 (130-167) min vs. 188 (146-231) (P=0.022)], unassisted ambulation with crutches [176 (144-208) min vs. 240 (179-302) min (P=0.014)], and voiding [208 (163-254) min vs. 293 (242-343) min (P=0.001)] than ropivacaine. Recovery of motor function required 113 (95-131) min with lidocaine and 135 (87-183) with ropivacaine (P=0.219). Six lidocaine patients reported TNS (40%) as compared with no patient receiving ropivacaine (0%) (P=0.005).

CONCLUSIONS

Spinal block produced with 10 mg ropivacaine 5 mg/ml is as effective as that produced by 50 mg of lidocaine 10 mg/ml. Recovery of unassisted ambulation and spontaneous voiding occurred earlier with lidocaine, but this was associated with a markedly higher incidence of TNS.

Low dose of lidocaine: comparison of 15 with 20 mg/ml with dextrose for spinal anesthesia in lithotomy position and ambulatory surgery

BACKGROUND

Spinal anesthesia with the local anesthetic lidocaine has come under scrutiny because it is associated with transient neurologic symptoms (TNS). Although TNS is not associated with either lidocaine concentration or dose, its incidence has never been examined with very small doses of hyperbaric spinal lidocaine in patients in the lithotomy position. We designed this study prospectively to compare the efficacy of low-dose 15 mg/ml with low-dose 20 mg/ml hyperbaric lidocaine in patients undergoing elective outpatient surgery in the lithotomy position.

METHODS

A total of 100 patients were randomized to receive either 30 mg of 15 mg/ml or the same dose of 20 mg/ml hyperbaric lidocaine. Lidocaine density at 37 degrees C is 1.0241 g/ml for the 15 mg/ml and 1.0260 g/ml for the 20 mg/ml solution. Patients were examined for motor block, sensory block, and block duration. Patients were contacted at 24, 48 and 72 h and questioned about their perceptions of pain after the spinal anesthesia with specific questions designed to diagnose TNS.

RESULTS

The spread of analgesia was the same with both solutions of lidocaine. Motor block was incomplete in all patients in both groups. TNS were not observed when low doses of both solutions of lidocaine with dextrose were used in these ambulatory patients in the lithotomy position.

CONCLUSION

Hyperbaric lidocaine results in rapid recovery from sensory block and motor blockade. It may have advantages for patients in a day-case setting. No patients complained of TNS after discharge.

Neuraxial drug administration: a review of treatment options for anaesthesia and analgesia

Neuraxial drug administration describes techniques that deliver drugs in close proximity to the spinal cord, i.e. intrathecally into the CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion. This approach was initially developed in the form of spinal anaesthesia over 100 years ago. Since then, neuraxial drug administration has evolved and now includes a wide range of techniques to administer a large number of different drugs to provide anaesthesia, but also analgesia and treatment of spasticity in a variety of acute and chronic settings. This review concentrates on the pharmacological agents used and the clinical basis behind currently utilised approaches to neuraxial drug administration. With regard to local anaesthetics, the main focus is on the development of the enantiomer-specific compounds ropivacaine and levobupivacaine, which provide similar efficacy to bupivacaine with a reduced risk of severe cardiotoxicity. Opioids are the other group of drugs widely used neuraxially, in particular to provide analgesia alone or more commonly in combination with other agents. The physicochemical properties of the various opioids explain the main differences in efficacy and safety between these drugs when used intrathecally, of which morphine, fentanyl and sufentanil are most commonly used. Another group of drugs including clonidine, dexmedetomidine and epinephrine (adrenaline) provide neuraxial analgesia via alpha-adrenergic receptors and are used mainly as adjuvants to local anaesthetics and opioids. Furthermore, intrathecal baclofen is in routine clinical use to treat spasticity in a number of neurological conditions. Beside these established approaches, a wide range of other drugs have been assessed for neuraxial administration to provide analgesia; however, most are in various early stages of investigation and are not used routinely. These drugs include neostigmine, ketamine, midazolam and adenosine, and the conotoxin ziconotide. The latter is possibly the most unusual compound here; it has recently gained registration for intrathecal use in specific chronic pain conditions.

Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

BACKGROUND

Spinal anaesthesia has been in use since the turn of the late nineteenth century. During the last decade there has been an increase in the number of reports implicating lidocaine as a possible cause of temporary and permanent neurologic complications after spinal anaesthesia. Follow-up of patients who received uncomplicated spinal anaesthesia revealed that some of them developed pain in the lower extremities after an initial full recovery. This painful condition that occurs in the immediate postoperative period was named "transient neurologic symptoms" (TNS).

OBJECTIVES

To study the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine, compared to other local anaesthetics.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (CENTRAL), (The Cochrane Library, Issue 1, 2005); MEDLINE (1966 to January 2005); EMBASE (1980 to week 6, 2005); LILACS (March 2005); and handsearched the reference lists of trials and review articles.

SELECTION CRITERIA

We included all randomized and pseudo-randomized studies comparing the frequency of TNS and of neurologic complications after spinal anaesthesia with lidocaine as compared to other local anaesthetics.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the quality of the relevant studies and extracted the data from the included studies.

MAIN RESULTS

Fifteen trials, reporting 1437 patients, 120 of whom developed transient neurologic symptoms, were included in the analysis. The use of lidocaine for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology; the symptoms disappeared spontaneously by the fifth postoperative day. The relative risk (RR) for developing TNS after spinal anaesthesia with lidocaine as compared to other local anaesthetics (bupivacaine, prilocaine, procaine, levobupivacaine and ropivacaine) was 7.16 (95% confidence interval (CI) 4.02, 12.75).

AUTHORS' CONCLUSIONS

The risk of developing TNS after spinal anaesthesia with lidocaine was significantly higher than when bupivacaine, prilocaine and procaine were used. The term "TNS", which implies a positive neurologic finding, should not be used for this painful condition. One study about the impact of TNS on patient satisfaction and functional impairment demonstrated that non-TNS patients were more satisfied and had less functional impairment after surgery than TNS patients, but this did not influence their willingness to recommend spinal anaesthesia.

Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials

Lidocaine has been used for spinal anesthesia since 1948, seemingly without causing concern. However, during the last 10 years, a number of reports have appeared implicating lidocaine as a possible cause of neurologic complications after spinal anesthesia. Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities--transient neurologic symptoms (TNS). In this study, we sought to compare the frequency of 1) TNS and 2) neurologic complications after spinal anesthesia with lidocaine with that after other local anesthetics. Published trials were identified by computerized searches of The Cochrane Library, MEDLINE, LILAC, and EMBASE and by checking the reference lists of trials and review articles. The search identified 14 trials reporting 1347 patients, 117 of whom developed TNS. None of these patients showed signs of neurologic complications. The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine), i.e., 4.35 (95% confidence interval, 1.98-9.54). There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day.

Neurotoxicity of intrathecal local anaesthetics and transient neurological symptoms

Local anaesthetics have been placed in the intrathecal space for approximately 100 years. Currently used intrathecal local anaesthetics appear to be relatively benign on the basis of the low incidence of permanent neurological deficits. In large retrospective surveys of 4000-10 000 patients, the incidence of persistent neurological sequelae after subarachnoid anaesthesia varies between 0.01 and 0.7%. Since its introduction in 1948, hyperbaric 5% lidocaine has been used for millions of spinal anaesthetics. The predictable onset and limited duration of action have made lidocaine one of the most popular spinal anaesthetics currently available. Concern about the use of spinal lidocaine began in 1991 with published reports of cauda equina syndrome after continuous spinal anaesthesia. In 1993, Schneider published a case report of four patients undergoing spinal anaesthesia who postoperatively experienced aching and pain in the buttocks and lower extremities. This chapter reviews the neurotoxicity of spinal local anaesthetics, as well as the incidence, possible aetiology, and treatment of transient neurological symptoms after lidocaine spinal anaesthesia.

Spinal anaesthesia for outpatient surgery

Spinal anaesthesia in the outpatient is characterized by rapid onset and offset, easy administration, minimal expense, and minimal side effects or complications. Spinal anaesthesia offers advantages for outpatient lower extremity, perineal, and many abdominal and gynaecological procedures. Development of small-gauge, pencil-point needles are responsible for the success of outpatient spinal anaesthesia with acceptable rates (0-2%) of postdural puncture headache (PDPH). Compared with peripheral nerve blocks, spinal anaesthesia has a more predictable offset. There are many possible choices of local anaesthetics for outpatient spinal anaesthesia. These include lidocaine, prilocaine, mepivacaine and small doses of bupivacaine. Meperidine has local anaesthetic properties in addition to its opiate properties. It has been used as the sole intrathecal agent for spinal anaesthesia but has no real advantages over lidocaine. Mepivacaine and lidocaine have each been associated with transient neurological symptoms (TNS) following intrathecal administration. This has stimulated development of alternative agents, including combinations of local anaesthetics and opioids. Lidocaine remains the most useful agent for outpatient spinal anaesthesia. For longer procedures, mepivacaine is an excellent spinal anaesthetic agent. Attention to technique, reduction of dose and addition of fentanyl to lidocaine result in effective spinal anaesthesia with rapid recovery and a low incidence of significant side effects or complications.

Epidural analgesia in a child with sickle cell disease complicated by acute abdominal pain and priapism

We describe a case of a 9-yr-old child with sickle cell disease complicated by abdominal vaso-occlusive crisis and priapism. Both complications were successfully treated with a combination of epidural local anesthetics and morphine.