Transient neurological symptoms by fjhuangjun


									British Journal of Anaesthesia 1997; 79: 301–305

Transient neurological symptoms after spinal anaesthesia with 4%
mepivacaine and 0.5% bupivacaine


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,
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

        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
          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.

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