British Journal of Anaesthesia 1997; 79: 301–305 Transient neurological symptoms after spinal anaesthesia with 4% mepivacaine and 0.5% bupivacaine A. HILLER AND P. H. ROSENBERG Summary those after hyperbaric lignocaine spinal anaesthesia should be expected. In this study, we examined the Several studies have reported transient neuro- occurrence of transient neurological symptoms logical symptoms after spinal anaesthesia with 5% after spinal anaesthesia with either 4% hyperbaric lignocaine. In order to evaluate the role of con- mepivacaine or hyperbaric 0.5% bupivacaine. centrated solutions of local anaesthetic in the development of transient neurological symptoms, 200 ASA I or II patients undergoing minor Patients and methods orthopaedic or rectal surgery under spinal anaes- Two hundred ASA I or II patients undergoing minor thesia were allocated randomly to receive 4% orthopaedic, varicose vein, rectal or gynaecological mepivacaine 80 mg or hyperbaric 0.5% bupi- operations were studied in a randomized, double- vacaine 10 mg. All patients were interviewed by an blind manner (table 1). Patients with a pre-existing anaesthetist approximately 24 h after spinal neurological disease or diabetes mellitus were anaesthesia, and after 1 week patients were asked excluded. The study was approved by the Ethics to return a written questionnaire. The incidence Committee of the hospital, and informed consent of transient neurological symptoms consisting of was obtained from the patients. pain in the buttocks or pain radiating symmetri- All patients were premedicated with diazepam cally to the lower extremities differed (P:0.001) 5–15 mg orally. Patients were allocated randomly by between patients receiving mepivacaine (30%) and sealed envelope to receive 4% mepivacaine 80 mg those receiving bupivacaine (3%). Hyperbaric 0.5% with glucose 95 mg ml91 (Scandicain 40 mg ml91, bupivacaine can be recommended for minor Astra, Wedel, Germany) or 0.5% hyperbaric bupi- operations on the lower abdomen or lower vacaine 10 mg with glucose 80 mg ml91 (Marcain extremities. (Br. J. Anaesth. 1997; 79: 301–305). spinal 5 mg ml91, Tung, Astra, Södertälje, Sweden). An identical volume of 2 ml was drawn into a syringe Key words by an independent anaesthesia nurse so that the Anaesthetic techniques, subarachnoid. Anaesthetics anaesthetist (A. H.) performing the block was local, mepivacaine. Anaesthetics local, bupivacaine. unaware of which drug was given. Although the Complications, neurological. doses are not equipotent from a theoretical point of view, similar spread and duration of spinal anaesthesia have been observed after a dose of 10 mg The first report of transient neurological symptoms, of 0.5 % hyperbaric bupivacaine and 80 mg of termed initially transient neurological impairment or hyperbaric mepivacaine.13 14 transient radicular irritation, after spinal anaesthesia A peripheral i.v. infusion with acetated Ringer’s with hyperbaric 5% lignocaine by Schneider and solution was started before operation. Thereafter colleagues in 19931 was confirmed later by several spinal anaesthesia was performed at the L3–4 inter- other studies.2–6 It is thought that a localized local space with the patient in the lateral position using a anaesthetic toxic effect may be an important 27-gauge Quincke needle. However, if the puncture contributing factor in the development of transient was considered difficult, a higher interspace, larger neurological symptoms after spinal anaesthesia needle or the sitting position was chosen to perform with concentrated solutions.7 8 The occurrence of spinal anaesthesia. Free flow of cerebrospinal fluid this complication is rare after the use of 0.5% was verified before and after injection of the local bupivacaine for spinal anaesthesia.5 9 10 anaesthetic. Immediately after spinal puncture, the Mepivacaine has been used for spinal anaesthesia patient was turned to the supine position with the since the beginning of the 1960s.11 In the first operating table in a slight head-up tilt position. large-scale report of 20 000 mepivacaine spinal anaesthetics, outcome was favourable and no neuro- A. HILLER, MD, PHD, Department of Anaesthesia, Kuusankoski logical complications were noted.12 However, as District Hospital, FIN-45750 Sairaalamäki, Finland. P. H. ROSENBERG, MD, PHD, Department of Anaesthesiology, Helsinki with 5% hyperbaric lignocaine, the hyperbaric spinal University Central Hospital, FIN-00290 Helsinki, Finland. anaesthetic solution of mepivacaine is also quite con- Accepted for publication: April 10, 1997. centrated (4%) and post-spinal sequelae similar to Correspondence to A. H. 302 British Journal of Anaesthesia Patients were monitored with electrocardiography, Results automated arterial pressure and pulse oximetry. Hypotension (systolic arterial pressure :90 mm Hg The characteristics of the patients and details of the or 930% decrease from baseline) was treated with operations and spinal anaesthetic procedures are 5-mg increments of ephedrine or 200- g increments summarized in tables 1 and 2. Motor block was of phenylephrine. Bradycardia (heart rate :50 complete in 96% of patients in the mepivacaine beat min91 was treated with atropine 0.5 mg or group and in 81% of patients in the bupivacaine glycopyrronium 0.2 mg. group (P:0.001). Details of motor block are pre- Testing of pinprick analgesia and motor block was sented in table 3. In one case, bupivacaine provided performed at 5, 10, 15, 60 min, and thereafter at inadequate surgical anaesthesia although free flow of 30-min intervals. A modified Bromage scale was cerebrospinal fluid was verified before and after used for testing motor block: 0:no paralysis (full injection of the drug. flexion of the knees and feet), 1:inability to flex Eighty-nine of 99 (90%) patients in the the extended leg (just able to move the knees), 2: mepivacaine group and 88 of 99 (89%) patients in inability to flex the knee (able to move the feet only), the bupivacaine group returned the questionnaire. 3:inability to flex the ankle joint (unable to move Twelve patients in the mepivacaine group and two the feet or knees). Patients were discharged from the patients in the bupivacaine group were not satisfied recovery room when recovery of motor block was with their spinal anaesthesia (P:0.05). Two patients complete. Nurses on the ward recorded the time who had received mepivacaine spinal anaesthesia when patients reported that they had normal had headache at home, one for 3 days and the other sensation in the buttocks and feet. for 1 week. Neither needed an extradural blood All patients were interviewed by the investigator patch. Two patients who had received bupivacaine on the first postoperative morning. They were asked spinal anaesthesia reported transient deterioration in if they had experienced any of the symptoms on the hearing. following standardized symptom checklist: head- The incidence of transient neurological symptoms ache, backache, pain not associated with surgery, differed (P:0.001) between patients who received sensory disturbances, change in muscle strength, or difficulties in voiding or in hearing. Special attention Table 1 Characteristics of patients and variables of spinal was paid to lower extremity symptoms, type of pain anaesthesia (median (range) or number) and radiation of pain.3 One week after spinal anaesthesia, patients were Characteristic/variable 4% Mepivacaine 0.5% Bupivacaine asked to return a mailed questionnaire. They were n 100 100 asked to mention symptoms which they particularly Sex (M/F) 45/55 47/53 associated with spinal anaesthesia. Enquiries con- Age (yr) 41 (21–68) 44 (20–70) cerning symptoms and their duration included Height (cm) 170 (148–191) 171 (150–193) headache, backache, pain in the operation area and Weight (kg) 76 (49–115) 75 (50–116) Needle size pain in the thighs, buttocks, calves or elsewhere. 25-gauge 16 17 Patients were also asked to assess the degree of 27-gauge 84 83 satisfaction with their spinal anaesthesia. Patient position during injection Transient neurological symptoms were defined as Sitting 4 3 Lateral 96 97 symmetrical bilateral pain in the back or buttocks or Duration of operation pain radiating to the lower extremities after recovery (min) 32 (9–115) 32 (7–87) from spinal anaesthesia. Patient position during operation Student’s t test and Fisher’s exact test were used Supine 95 94 to compare differences. P:0.05 was considered Lithotomy 2 4 Prone 3 2 significant. Table 2 Details of the spinal anaesthetic procedures. ***P<0.001 Patients with transient neurological All patients symptoms 4% Mepivacaine 0.5% Bupivacaine 4% Mepivacaine 0.5% Bupivacaine n 100 100 30*** 3 Sex (M/F) 45/55 47/53 14/16 1/2 Surgery Arthroscopy of knee 67 58 22 2 Other orthopaedic 17 21 3 1 Varicose veins 13 15 3 0 Rectal or gynaecological 3 6 2 0 Attempts at dural puncture 1 88 86 25 2 2–3 5 8 4 1 >3 7 6 1 0 Paraesthesia during dural puncture 6 5 2 0 Median maximum height of block (range) T6 (T3–12) T7 (T3–L4) T6 (T3–12) T8 (T8–12) Neurological symptoms after hyperbaric spinal anaesthesia 303 Table 3 Characteristics of the motor block (median (range)). Motor block 3:unable to move the feet or knees, 2:able to move the feet only, 1:just able to move the knees. ***P<0.001 Patients with transient neurological All patients symptoms 4% Mepivacaine 0.5% Bupivacaine 4% Mepivacaine 0.5% Bupivacaine n 100 100 30*** 3 Motor block 3 96*** 81 29 3 2 3 14 1 0 1 0 1 0 0 No paralysis 1 4 0 0 Time to maximum motor block (min) 8 (5–60)*** 17 (5–60) 8 (5–60) 13 (5–60) Time to total recovery of motor block (min) 135 (90–210) 127 (60–240) 130 (90–210) 100 (60–120) Table 4 Nature of pain and analgesic requirement in patients 14 patients in the mepivacaine group and in one with transient neurological symptoms (NSAID:non-steroidal patient in the bupivacaine group, pain was relieved anti-inflammatory drug). ***P:0.001 by non-steroidal anti-inflammatory drugs; nine 4% Mepivacaine 0.5% Bupivacaine patients also needed opioids. Five patients reported that the pain was worse in the supine position and it n 30*** 3 Location of pain was relieved when they stood up and started to walk Buttocks 13 0 (table 4). Buttocks and thighs 13 1 No patient had sensory disturbances, change in Thighs 0 1 muscle strength or difficulties in voiding on the first Buttocks, thighs and legs 4 1 postoperative morning. Severity of pain Mild or moderate 20 3 Three patients who had transient neurological Severe 10 0 symptoms after mepivacaine spinal anaesthesia had Onset of pain after recovery of block (h) experienced similar symptoms before, one after 5% 1–6 16 1 hyperbaric lignocaine spinal anaesthesia and two 6–12 8 1 12–24 2 1 after 4% hyperbaric mepivacaine anaesthesia. All 24–48 4 0 three patients who had transient neurological Duration of pain (h) symptoms in the bupivacaine group returned the <12 11 3 questionnaire and were satisfied with the spinal 12–24 9 0 anaesthesia. In the mepivacaine group, 27 of 30 24–72 9 0 120 1 0 patients returned the questionnaire and 20% were Needed analgesia not satisfied with spinal anaesthesia; four because Yes 23 2 of transient neurological symptoms, one because NSAID 14 1 of painful puncture and one patient complained of Opioids 1 0 Both NSAID and opioids 8 1 difficulty in breathing because of the maximum No 7 1 height of block (T4) during operation. All complaints were transient and had disappeared by the time the patients mailed the questionnaire. mepivacaine (30%) and those who had received bupivacaine (3%). The mean age of patients with transient neurological symptoms in the mepivacaine Discussion group was 44 (range 21–68) yr and in the bupi- In this study, transient neurological symptoms vacaine group 51 (47–54) yr. Mean weight was 77 occurred in 30% of patients who received spinal (56–105) kg in the mepivacaine group and 77 anaesthesia with mepivacaine but also in 3% of (75–80) kg in the bupivacaine group. There was no patients who received spinal anaesthesia with hyper- association between the incidence of transient baric bupivacaine. However, duration of symptoms neurological symptoms and patient sex, weight or after bupivacaine spinal anaesthesia was less than age. All patients who experienced transient neuro- 12 h compared with 12–120 h after mepivacaine logical symptoms had been in the supine position spinal anaesthesia. during operation, except for one who was in the In 1993, Schneider and colleagues published the lithotomy position. Furthermore, in all patients with first case reports of transient neurological symptoms transient neurological symptoms the spinal puncture after spinal anaesthesia with 5% hyperbaric had been performed in the lateral position. There lignocaine.1 Other later studies have shown similar was no association between transient neurological symptoms, termed transient radicular irritation symptoms and difficulty of block placement or (TRI) after 5% hyperbaric lignocaine spinal anaes- paraesthesia. In all three patients in the bupivacaine thesia in 10–37% of patients.2–5 Thus the incidence group and in 26 of 30 patients with symptoms in the of transient neurological symptoms or TRI after mepivacaine group, pain occurred within the first concentrated solutions of 4% mepivacaine and 5% 24 h. In one patient who had both pain and dysaes- lignocaine is similar. In the study of Pollock and thesia in the buttocks, symptoms lasted for 5 days. In colleagues the incidence of TRI was 16% after both 304 British Journal of Anaesthesia 5% hyperbaric lignocaine and 2% lignocaine without vulnerability to injury. In our study, four patients in glucose, but 0% after 0.75% hyperbaric bupi- the bupivacaine group and two in the mepivacaine vacaine.5 In the study by Tarkkila, Huhtala and group were in the lithotomy position during surgery. Tuominen, only one of 110 patients had TRI after Only one patient in the mepivacaine group had 0.5% hyperbaric bupivacaine.10 The neurotoxic transient neurological symptoms starting 24–48 h potential of 5% hyperbaric lignocaine and 0.75% after anaesthesia. However, transient neurological bupivacaine has been evaluated.7 Exposure of symptoms occurred in 22 patients undergoing amphibian nerves to 0.75% isobaric bupivacaine arthroscopy of the knee. In our hospital, arthroscopy produced partially reversible conduction block, patients have both legs straight at the hip, and flexed whereas 5% lignocaine with or without glucose 90 at the knee. The operative leg position is varied caused irreversible block of impulses.7 Furthermore, throughout surgery. The position and manipulation it has been shown in an in vitro study that lignocaine may contribute to neural stretching and thus to the 80 mmol, which is equivalent to a concentration of development of transient neurological symptoms. 2% lignocaine, caused complete ablation of impulse Also, Pollock and colleagues found a higher activity.8 In clinical studies, decreasing the concen- incidence of transient neurological symptoms in tration of lignocaine from 5% to 2% did not prevent patients undergoing arthroscopy than in those the development of TRI.5 15 having inguinal hernia repair.5 The doses of mepivacaine and bupivacaine in our Individual physical characteristics of patients may study were based on the clinical study of Pitkänen, predispose to the development of transient neuro- Kalso and Rosenberg, where 80 mg (2 ml) of 4% logical symptoms after spinal anaesthesia. hyperbaric mepivacaine resulted in spinal anaes- Interestingly, in this study three patients who had thesia similar to that after a dose of 0.5% hyperbaric transient neurological symptoms after mepivacaine bupivacaine 10 mg (2 ml) or 0.5% hyperbaric ligno- spinal anaesthesia had experienced similar caine 100 mg (2 ml).14 Also, spinal anaesthesia with symptoms before, one after 5% hyperbaric ligno- mepivacaine 60 mg produced analgesia and motor caine and two after 4% hyperbaric mepivacaine block of good quality but of short duration com- spinal anaesthesia. It has been shown that the pared with spinal anaesthesia with 0.5% hyperbaric anatomical configuration of the spinal column bupivacaine 15 mg.16 Decreasing the dose of mepi- affects the spread of subarachnoid anaesthetic vacaine from 80 to 60 mg may diminish the develop- solutions that move under the influence of ment of transient neurological symptoms and still gravity.19 20 Both lumbar lordosis and thoracic provide adequate anaesthesia for operations on the kyphosis differ between individuals, particularly with lower extremities. respect to the lowest point of the thoracic spinal Lambert, Lambert and Strichartz demonstrated canal.21 Musculoskeletal disturbances in the back synergistic neurotoxic effects of lignocaine and and leg symptoms cannot be totally excluded. glucose in vitro, in frog sciatic nerve.7 The loss of We speculate that profound relaxation of the neural activity was not found to correlate with the supportive muscles of the lumbar spine may result glucose concentration and inhibition could not be in straightening of the lordotic curve, and even induced without local anaesthetic. The hyperbaric transient spondylolisthesis, when the patient is lying mepivacaine solution has a higher concentration of on the operating table. This may be responsible in glucose (95 mg ml91) compared with hyperbaric part for the radiating back symptoms which occurred lignocaine (62.5 mg ml91) or hyperbaric bupivacaine after the intense motor block, observed during (80 mg ml91). The greater the baricity of the mepivacaine spinal block in particular. solution the greater the chance of gravity- In summary, the incidence of transient neuro- determined spread restriction. This, together with logical symptoms was greater after spinal anaesthesia the use of small gauge pencil-point needles with one with 4% hyperbaric mepivacaine than after 0.5% side hole near the tip, could result in pooling of the hyperbaric bupivacaine. Patients were more satisfied concentrated local anaesthetic solution. Repeated with bupivacaine spinal anaesthesia. Except for a injections through thin intrathecal catheters may, greater number of complete motor blocks after therefore, result in cauda equina syndrome.17 mepivacaine, spinal anaesthesia and recovery were Beardsley and colleagues showed that sacral direc- similar after both agents. Therefore, hyperbaric tion of the needle orifice and a slow injection rate 0.5% bupivacaine 10 mg can be recommended for with a Whitacre needle may be predisposing factors minor operations on the lower extremities or lower to transient neurological complications with 5% abdomen lasting less than 90 min. hyperbaric lignocaine.18 However, other studies have failed to confirm this.3 10 In contrast, in this study we injected via Quincke-type needles (orifice at the References bevelled tip) and initial directional pooling of the 1. Schneider M, Ettlin T, Kaufmann M, Schumacher P, local anaesthetic in the sacral region was unlikely. Urwyler A, Hampl K, von Hochstetter A. Transient neuro- In addition to a toxic effect of the local anaes- logic toxicity after hyperbaric subarachnoid anesthesia with thetic, the lithotomy position during surgery has 5% lidocaine. Anesthesia and Analgesia 1993; 76: 1154–1157. been thought to be a possible cause of transient 2. Hampl KF, Schneider M, Drasner K, Stotz G, Drewe J. 5% neurological symptoms.1 4 10 The lithotomy position hyperbaric lidocaine: A risk factor for transient radicular irri- tation? Anesthesiology 1993; 79: 3A, A875. may contribute to transient neurological symptoms 3. Tarkkila P, Huhtala J, Tuominen M. Transient radicular by stretching the cauda equina and sciatic nerves, irritation after spinal anaesthesia with hyperbaric 5% thus decreasing the vascular supply and increasing lignocaine. British Journal of Anaesthesia 1995; 74: 328–329. Neurological symptoms after hyperbaric spinal anaesthesia 305 4. Salmela L, Aromaa U, Cozanitis DA. Leg and back pain after 13. Covino BG, Vassallo HG. Local Anesthetics: Mechanisms of spinal anaesthesia involving hyperbaric 5% lignocaine. Action and Clinical Use. New York: Grune and Stratton, Anaesthesia 1996; 51: 391–393. 1976; 49, 105. 5. Pollock JE, Neal JM, Stephenson CA, Wiley CE. Prospective 14. Pitkänen MT, Kalso EA, Rosenberg PH. Comparison of study of the incidence of transient radicular irritation in hyperbaric bupivacaine, lidocaine and mepivacaine in spinal patients undergoing spinal anesthesia. Anesthesiology 1966; anesthesia. Regional Anesthesia 1984; 9: 175–182. 84: 1361–1367. 15. Hampl KF, Schneider MC, Pargger H, Gut I, Drewe J, 6. Rodríquez-Chinchilla R, Rodríquez-Pont A, Pintanel T, Drasner K. A similar incidence of transient neurologic Vidal-López F. Bilateral severe pain at L3–4 after spinal symptoms after spinal anesthesia with 2% and 5% lidocaine. anaesthesia with hyperbaric 5% lignocaine. British Journal of Anesthesia and Analgesia 1996; 83: 1051–1054. Anaesthesia 1996; 76: 328–329. 16. Bengtsson M, Edström HH, Löfström JB. Spinal analgesia 7. Lambert LA, Lambert DH, Strichartz GR. Irreversible con- with bupivacaine, mepivacaine and tetracaine. Acta duction block in isolated nerve by high concentrations of Anaesthesiologica Scandinavica 1983; 27: 278–283. local anesthetics. Anesthesiology 1994; 80: 1082–1093. 17. Rigler ML, Drasner K, Krejcic TC, Yelich SJ, Schelnick FT, 8. Bainton C, Strichartz G. Concentration dependence of DeFontes J, Bohner D. Cauda equina syndrome after lidocaine-induced irreversible conduction loss in frog nerve. continuous spinal anesthesia. Anesthesia and Analgesia 1991; Anesthesiology 1994; 81: 657–667. 72: 275–281. 9. Hampl K, Schneider M, Ummenhofer W, Drewe J. 18. Beardsley D, Holman S, Gantt R, Robinson RA, Lindsey J, Transient neurologic symptoms after spinal anesthesia. Bazaral M, Stewart SFC. Transient neurologic deficit after Anesthesia and Analgesia 1993; 81: 1148–1149. spinal anesthesia: local anesthetic maldistribution with pencil 10. Tarkkila P, Huhtala J, Tuominen M. Transient radicular point needles? Anesthesia and Analgesia 1995; 81: 314–320. irritation after bupivacaine spinal anesthesia. Regional 19. Greene N. Distribution of local anesthetic solutions within Anesthesia 1996; 21: 26–29. the subarachnoid space. Anesthesia and Analgesia 1985; 64: 11. Knox PR, North WC, Stepher CS. Pharmacologic and 715–730. clinical observations with mepivacaine. Anesthesiology 1961; 20. Wildsmith J. Baricity and spinal anesthesia: What solution 22: 987–994. when? Anesthesiology Clinics of North America 1992; 10: 31–43. 12. El-Shirbing AM, Rasheed MH, Elmaghraby A, Motahew M. 21. Hirabayashi Y, Shimizu R, Saitoh K, Fukuda H, Furuse M. Experiences with carbocaine in spinal anaesthesia. Report of Anatomical configuration of the spinal column in the supine 20000 cases. Acta Anaesthesiologica Scandinavica 1966; 10 position. I. A study using magnetic resonance imaging. British (Suppl. 23): 442–448. Journal of Anaesthesia 1995; 75: 3–5.
Pages to are hidden for
"Transient neurological symptoms "Please download to view full document