Postoperative Backache Research Articles

The Efficacy of Intraoperative Freehand Erector Spinae Plane Block in Lumbar Spondylolisthesis: A Randomized Controlled Study.

Prospective randomized comparative (controlled) study. Management of the severe postoperative back pain followed the major spinal surgeries remains a challenge. The search is going on to find simple, efficient, and reliable perioperative analgesia with low side effects. We aimed to investigate the efficacy of intraoperative freehand erector spinae plane block (ESBP) after spinal surgeries. A few case reports and randomized controlled studies demonstrated the analgesic efficacy of ESPB in spinal surgeries. Up-to-date, no randomized controlled studies investigated the effectiveness of ESPB on spinal instrumentation surgeries. We randomly divided 56 consecutive adult patients who underwent posterior spinal instrumentation and fusion for spondylolisthesis into two groups. The study (ESPB) group (n = 28) received intraoperative freehand bilateral ESPB with a 20-mL mixture solution of 0.25% bupivacaine and 1.0% lidocaine equally divided into all operating levels. In the control group (n = 28), 20 mL physiological saline was injected. Postoperatively, we ordered 1 g paracetamol thrice/day, besides patient-controlled analgesia pumps with morphine. We performed a postoperative evaluation with a visual analog scale (VAS), morphine consumption, ESPB-related adverse effects, and postoperative length of hospital stay (PLOS). Morphine consumption was significantly higher in the controls within the first postoperative 24-hour 44.75 ± 12.3 mg versus 33.75 ± 6.81 mg in the ESPB participants (P < 0.001). Except for postoperative 24th-hour VAS (P = 0.127), all postoperative VAS scores recorded at all time-points were significantly higher in the controls (P < 0.05). In control individuals, the first analgesic demand time was shorter, and PLOS was longer (P < 0.001). Patient satisfaction was significantly higher in the ESPB group. We observed no significant difference regarding postoperative complications. Intraoperative ESPB as a part of multimodal analgesia was effective. For posterior instrumented patients with spondylolisthesis, it can relieve postoperative backache and reduce opioid consumption.Level of Evidence: 1.

Randomized Control Study for Evaluation of Effectiveness of Topical NSAIDS Patches to Prevent Backache Following Spinal Anesthesia in Caesarean Section

Background: Women who had caesarean section (CS) with spinal anaesthesia had more chances to develop low back pain. Controlled studies evaluating the prevention of back pain after neuraxial anaesthesia involved mostly the use of an anti-inflammatory medication or steroid, given epidurally or as part of the intradermal injectate. The purpose of this study is to determine the effect of topical Nonsteroidal Anti-inflammatory drugs (NSAIDS) patch on decreasing the incidence of post-operative backache following spinal anaesthesia for caesarean section. Patients and methods: One hundred thirty parturients aged 19 - 40 years, American society of Anaesthesiology class I & II scheduled for elective caesarean section with spinal anaesthesia were divided randomly into two equal Groups (65 patients each): ketoprofen group (TDK) received 30 mg ketoprofen transdermal patch at site of puncture for 24 hours and control group (TDC) received a placebo transdermal patch at site of puncture for 24 hours. In the Postoperative period 24 hours after the spinal procedure, the transdermal patch was removed in both groups then symptoms of back pain have been determined by visual numerical scale (VNS). Results: regard incidence of occurrence and severity of back pain (VNS > 3) the results showed that the back pain was less in the TDK group than in the TDC group at 24 hours post spinal interval (4.6% vs 15.4%) respectively. On the other hand there was no statistical significant difference at 48 hours and 2 weeks post spinal interval. Conclusion: Prophylactic application of topical NSAIDS patch may reduce the incidence and the severity of short term backache after spinal anaesthesia in CS with negligible complications.

SATISFACTION OUTCOMESAFTER SPINAL ANESTHESIA FOR CAESAREAN SECTION IN KAUH IN JEDDAH AND IN MCH IN MAKKAH.

31Aug 2016 SATISFACTION OUTCOMESAFTER SPINAL ANESTHESIA FOR CAESAREAN SECTION IN KAUH IN JEDDAH AND IN MCH IN MAKKAH. Ahmad A. Saifuddin , Abdullah T. Salem , *Ahmed H. Alhasan , Faisal T. Sugati , Raghad M. Namnqani and Safaa M. Al-Hasani. Aim:To determine the level of the satisfaction in terms of intra-operative pain and postoperative nausea, vomiting, headache, backache among patients receiving spinal anesthesia for caesarean section.Methodology:Cross-sectional survey conducted in maternity and children hospital in Makkah from January 2014 to December 2015. A total of 200 pregnant patients undergoing caesarean section under spinal anesthesia were surveyed. A questionnaire was given to patients to score their satisfaction on a four-point visual analogue scale regarding:1-Pain during surgery, 2-Postoperative Nausea, and Vomiting (PONV), and 3-postoperative headache. The average of responses to questionnaire questions in each of the three areas was taken as the “FundamentalArea Score"(FAS) and the average of these individual (FAS) scores was taken as the Patient Satisfaction score(PSS).Results: There was a high satisfaction score for PONV (90%); but satisfaction regarding intra-operative pain/discomfort, postoperative backache and headache has a lower satisfaction score plotted, as (88%, 87% and 55% respectively).Patient’s overall level of satisfaction with spinal anesthesia was 90%.Conclusion: Most of the patients in the study were satisfied with their experience with spinal anesthesia although there was a high frequency of postoperative backache.

Effectiveness of Inflatable Lumbar Support (ILS) for the Prevention of Short Term Backache among Post-operative Female Patients Undergoing Lower Abdominal Surgery Under Spinal Anesthesia

Introduction:Backache strikes nearly 85% of the population at some time of their life. Majority of the backache is due to stress and strain of back muscles, ligaments and tendons. Today the incidence of post-operative backache is increasing and positioning the patient as well as the anesthetic technique of surgery places an important role to develop post- operative backache.1 Objectives:To analyze the effectiveness of lumbar support in preventing post- operative backache as measured by Verbal Descriptive Scale (VDS) and also to find its association between post-operative backache and age, occupation, BMI, type of surgery, position during surgery and also the duration. Method and material:A 10 point Verbal Descriptive Scale pain scale was used to evaluate the post operative backache of both experimental (30) and control group (30). Result:The median of 2nd and 5th day VDS pain score between both the groups were significantly different (Z value is -5.070 in experimental group and - 4.217 in the control group). The median reduction in the VDS pain score between the two groups is statistically significant (Z=-5.028) at p<.05. Conclusion:This study provides empirical evidence to the effectiveness of inflatable lumbar support for the prevention of post-operative backache and is found to have association with BMI.

Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia

Background:Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one.Objectives:We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT).Methods:After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared.Results:SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups.Conclusion:SDT is an acceptable alternative to DST and SST.

Factors in patient dissatisfaction and refusal regarding spinal anesthesia.

BackgroundSpinal anesthesia is the most common regional anesthesia conducted for many surgical procedures. Multiple factors can affect the success, the side effects, and patient satisfaction with the procedure. This study was undertaken prospectively to discover factors affecting dissatisfaction and refusal of spinal anesthesia.MethodsStarting in December 2007, patients who underwent spinal anesthesia in the operating rooms of our hospital were surveyed over a period of a year. Before attempting the procedure, patient characteristics and previous history of anesthesia were recorded. Spinal anesthesia was administered with 0.5% heavy bupivacaine combined with fentanyl 0-20 µg. Intraoperative data and postoperative data on the day after surgery were collected. The patients were also asked about their general satisfaction with spinal anesthesia, causes of dissatisfaction with the procedure, and causes of their refusal to have spinal anesthesia again.ResultsSix patients among 1,197 cases were excluded from the study because of spinal anesthesia failure. The dissatisfaction rate of spinal anesthesia was 3.7%, and its risk factors were more than three puncture attempts, paresthesia at puncture, postoperative nausea and vomiting, and postoperative backache. The refusal rate to have spinal anesthesia again was 3.2%, and its risk factors were postoperative backache and dissatisfaction.ConclusionsAlthough spinal anesthesia was conducted safely during the study and revealed a high rate of patient satisfaction (96.3%), side effects still occurred. Therefore, attending anesthesiologists must perform the procedure carefully and always pay attention to patients under spinal anesthesia.

Spinal anesthesia: how can we improve patient satisfaction?

Since spinal anesthesia was introduced in clinics about 100 years ago, many studies have examined whether spinal anesthesia decreases operating time, mortality, cardiovascular morbidity, number of patients requiring a blood transfusion, deep vein thrombosis and pulmonary embolism, pain, opioid-related adverse effects, and the length of hospital stay when compared with general anesthesia. Macfarlane et al. [1] performed a systemic review of the contemporary literature comparing general anesthesia and/or systemic analgesia with regional anesthesia for total knee arthroplasty. They did not suggest a difference in blood loss or duration of surgery. However, regional anesthesia reduced postoperative pain and opioid-related adverse effects in patients undergoing total knee arthroplasty. Length of hospital stay may also be reduced and rehabilitation facilitated by regional anesthesia compared with general anesthesia. They found insufficient evidence from randomized, controlled trials alone to conclude whether anesthetic technique influenced mortality, cardiovascular morbidity other than postoperative hypotension, or the incidence of deep vein thrombosis and pulmonary embolism in the setting of routine thromboprophylaxis. In this issue of the journal, Rhee et al. [2] prospectively evaluated factors affecting dissatisfaction and refusal of spinal anesthesia. Anesthesiologists have a duty to inform patients about risks and alternatives to anesthetic methods. It is the basic spirit of medical ethics to allow patients to choose an anesthesia method. Anesthesiologists frequently hold a biased view when they choose the anesthetic method rather than obtain the opinion of patients, and they have a variety of reasons for choosing a given anesthetic technique. A technique may be chosen simply because we know it; it may be a favorite technique or a less familiar technique chosen to maintain competence/experience or to teach. Other reasons are a request from patients or surgeons [3]. If anesthesiologist allow patients to decide the anesthetic method, in many cases the patients say don't know. It's up to you; Is spinal anesthesia painful?, don't want to awaken during the Will I feel pain after the operation?, or Does spinal anesthesia cause back pain?. Therefore, the anesthesiologists must explain fully about the applicable anesthesia method and help patients to decide the procedure by their own volition. If a patient can not decide their anesthetic method, anesthesiologists must choose it considering the patient's situation. In a study by Rhee et al. [2] 44/1,191 patients (3.7%) revealed dissatisfaction with spinal anesthesia. The reasons for the dissatisfaction were backache (29.5%), postoperative nausea and vomiting (PONV; 20.4%), pain at the puncture site (15.9%), inadequate analgesia (13.6%), consciousness during the operation (6.8%), postdural puncture headache (4.5%), transient neurologic symptoms (4.5%), and urinary retention (4.5%). In that study, postoperative backache was the most common cause of dissatisfaction. However, back pain may not be directly related to spinal anesthesia and is almost always associated with pre-existing back pain [4,5]. Backache after spinal anesthesia is almost always associated with positions during the operation, surgical trauma, operation time, age, pregnancy, needle type, the number of punctures, a different bed, or long bed rest other than preadmission to the hospital [4,6]. Therefore, if the anesthesiologist had explained to the patient that back pain was not directly related to the spinal anesthesia, in most cases, the results of their study would change. PONV after spinal anesthesia is often due to fentanyl administered with local anesthetics. It is difficult to say that PONV is a side effect of spinal anesthesia. It can increase the satisfaction rate not to mix opioids with local anesthetics when it is known that PONV will cause a problem to patients. Rhee et al. [2] reported that the dissatisfaction rate from spinal anesthesia was 3.7%. Other studies have demonstrated higher rates such as 3.8-17% [7,8]. A patient's satisfaction is associated with multiple factors including the methods and attitudes of the investigators, social circumstances, and the relationship between the patient and doctor. I think that the patient-doctor relationship is the most important factor when physicians care for their patients, and good rapport can affect patient satisfaction. Paresthesia and pain at the puncture site are dependent on the skillfulness of the physician, the number of punctures, and age and gender of the patient. Sedation during an operation with spinal anesthesia is frequently required and is an important factor to increase satisfaction rate. Midazolam, propofol, and dexmedetomidine are used for this purpose. The main uses for sedation in regional anesthesia are to reduce anxiety and improve patient comfort and cooperation [9]. In conclusion, some factors increase the satisfaction rate of patients who are undergoing an operation with spinal anesthesia. First, a patient's opinion is very important when deciding the anesthetic method. Secondly, the anesthesiologists must fully explain about spinal anesthesia before surgery. Thirdly, the anesthesiologists should have good rapport with their patients. Finally, the anesthesiologist should manipulate the patient skillfully and sedate the patients if they want.

Maternal satisfaction after spinal anaesthesia for caesarean deliveries.

To determine the level of satisfaction in terms of intra-operative pain and postoperative nausea, vomiting and backache among patients receiving spinal anaesthesia for caesarean section. Cross-sectional survey. Department of Anaesthesia and Intensive Care at the Combined Military Hospital, Bahawalpur, from August 2005 to June 2007. A total of 246 pregnant patients undergoing caesarean section under spinal anaesthesia were surveyed. Postoperatively, a questionnaire was given to the patients to score their satisfaction on a four-point visual analogue scale regarding pain during surgery, Postoperative Nausea and Vomiting (PONV), and postoperative backache. The average of response to the questions in each of these three areas was taken as the Fundamental Area Score (FAS) and the average of all these individual area scores was taken as the Patient Satisfaction Score (PSS). There was high satisfaction score for PONV (98.17%); but the satisfaction regarding intra-operative pain / discomfort and postoperative backache was low as shown by a decrease in satisfaction score in these areas (74.09% and 76.83%). Patient's overall level of satisfaction with spinal anaesthesia was 81.40%. Patients (53.66%) would opt for spinal anaesthesia in future, if required, 90 (36.59%) would not and 8 patients (9.8%) were not sure. Most of the patients were satisfied with their experience with spinal anaesthesia although there was a higher frequency of postoperative backache.

Roderick B. Salisbury and Dustin Keeler, eds, Space – Archaeology's Final Frontier? An Intercontinental Approach (Newcastle: Cambridge Scholars Publishing, 2007, 316 pp., 90 figs, pbk, ISBN 978 1 84 7182784)

Roderick B. Salisbury and Dustin Keeler, eds, Space – Archaeology's Final Frontier? An Intercontinental Approach (Newcastle: Cambridge Scholars Publishing, 2007, 316 pp., 90 figs, pbk, ISBN 978 1 84 7182784) - Volume 12 Issue 1-3

Local application of low-dose Depo-Medrol is effective in reducing immediate postoperative back pain

This prospective, randomised case-control study was made to determine effectiveness of low-dose Depo-Medrol applied to the affected nerve root after discectomy. Fifty seven patients with L4-5 or L5-S1 single level disc herniation with unilateral leg pain were selected for the study and were divided in two groups. Twenty eight patients were in the control group and 29 in the steroid group. Discectomy was done after flavotomy in all patients. In the steroid group low-dose 40 mg Depo-Medrol soaked Gelfoam was applied over the affected nerve root after discectomy while in the control group neither saline nor plain Gelfoam was applied to affected root. Postoperatively, patients were asked to evaluate backache using VAS which was compared statistically using the unpaired t test. Statistical difference was significant (p < 0.0001) regarding postoperative VAS during the first month and then it became insignificant. Results show that local application of low-dose Depo-Medrol is helpful in reducing immediate postoperative backache after discectomy, but it is not effective in the long-term.

Back pain following general anaesthesia and surgery: Evaluation of risk factors and the effect of an inflatable lumbar support

Factors that contribute to postoperative lumbar back pain and the effect of an inflatable lumbar support on the incidence of postoperative backache were examined. The study consisted of two parts, a pilot study in which mathematical models for appropriate support pressures were produced and the main study to assess the role of an inflatable lumbar support. The use of a support reduced the incidence of back pain on the first postoperative day from 46 to 21 per cent (P = 0.007). The patient's sex, height, weight, and the presence or absence of obesity were not found to be significant factors in the incidence of postoperative back pain. Previous back pain or arthritis in any joint tended to be associated with an increase in the severity and incidence of postoperative back pain. Postoperative back pain was more severe after procedures lasting more than 40 min. Early mobilization reduced the amount of back pain. In conclusion, patients benefit from the use of an inflatable lumbar support if they have previously suffered from backache or if they are to be anaesthetized for more than 40 min.

Combined epidural/spinal anaesthesia: needle-through-needle or separate spaces?

This prospective, randomized and blinded study compared the performance of a new needle-through-needle (NTN) kit (Epistar; Medimex, Germany) with the double-space technique for providing combined spinal epidural anaesthesia during Caesarean section. Following local Ethics Committee approval and patient consent, 200 females were randomized to receive combined spinal epidural anaesthesia by the double-space (n = 100) or NTN (n = 100) technique. The frequency with which the intrathecal component could achieve a T5 block to touch for Caesarean section without the need for epidural augmentation or an alternative technique was determined. The time from start of procedure to achieving a block height to T5 was recorded. Pain and backache at insertion, and at 24 h follow-up were recorded using a visual analogue scale. To remove any bias due to posture, 50% of each group were further randomized to receive their block in the sitting or in the left lateral position. To evaluate improvement of performance over time the success in the first 100 study patients were compared to the success in the second 100. A successful block to T5 with the double-space and NTN techniques were 80 vs. 54, odds ratio 0.29. Failure to enter the intrathecal space once the epidural space had been located occurred in 29 patients in the NTN group. Time to readiness for surgery was 15 min (95% confidence interval (CI): 12.7-17.4) and 12.9 min (95% CI: 11.5-14.3) for the double-space and NTN techniques, respectively. The median (interquartile range) visual analogue scores for discomfort at insertion were 30 (12.5-51.5) and 32 (12.75-60) and for postoperative backache 0 (0-10) and 0 (0-10.75) in the double-space and NTN groups, respectively. The number of epidural augmentations was similar in both the groups and posture made no difference. There was a tendency to increased success in the second half of the study. The double-space technique had a greater success rate than the NTN technique.

Combined epidural/spinal anaesthesia: needle-through-needle or separate spaces?

Background and objective: This prospective, randomized and blinded study compared the performance of a new needle-through-needle (NTN) kit (Epistar®; Medimex, Germany) with the double-space technique for providing combined spinal epidural anaesthesia during Caesarean section. Methods: Following local Ethics Committee approval and patient consent, 200 females were randomized to receive combined spinal epidural anaesthesia by the double-space (n = 100) or NTN (n = 100) technique. The frequency with which the intrathecal component could achieve a T5 block to touch for Caesarean section without the need for epidural augmentation or an alternative technique was determined. The time from start of procedure to achieving a block height to T5 was recorded. Pain and backache at insertion, and at 24 h follow-up were recorded using a visual analogue scale. To remove any bias due to posture, 50% of each group were further randomized to receive their block in the sitting or in the left lateral position. To evaluate improvement of performance over time the success in the first 100 study patients were compared to the success in the second 100. Results: A successful block to T5 with the double-space and NTN techniques were 80 vs. 54, odds ratio 0.29. Failure to enter the intrathecal space once the epidural space had been located occurred in 29 patients in the NTN group. Time to readiness for surgery was 15 min (95% confidence interval (CI): 12.7-17.4) and 12.9 min (95% CI: 11.5-14.3) for the double-space and NTN techniques, respectively. The median (interquartile range) visual analogue scores for discomfort at insertion were 30 (12.5-51.5) and 32 (12.75-60) and for postoperative backache 0 (0-10) and 0 (0-10.75) in the double-space and NTN groups, respectively. The number of epidural augmentations was similar in both the groups and posture made no difference. There was a tendency to increased success in the second half of the study. Conclusion: The double-space technique had a greater success rate than the NTN technique.

Lateral approach: A better technique for spinal anaesthesia in the modern era

The must commonly used technique in routine spinal anaesthesia practice is the midline approach, compared to the lateral or paramedian approach. With the better understanding of the technique and introduction of fine gauge spinal needles, this practice needs a rethinking. Lateral approach was used in 60 patients undergoing different surgical procedures helow the umbilicus, using 24 or 25 gauge, Quincke spinal needle without an introducer. The result was gratifying. In 77% of the cases the subarachnoid space could be entered in the first attempt. There was no failure. No patient complained of postdural puncture headache or post operative backache. Only one patient reported paraesthesia during needle placement without any residual effect. Various other advantages of the technique are discussed. Thus with due practice, lateral approach is found to he superior in modern day spinal anaesthesia.

The intrathecal lidocaine enigma: On the brink of cauda equinopathy

HE 1990s have not been kind to spinal anesthesia, the introduction, via lumbar puncture, of local anesthetic into spinal fluid. The first of many tremors to come rumbled from over a dozen instances of persistent cauda equina syndrome following continuous catheter spinal anesthesia (mostly with hyperbaric 5% lidocaine). No sooner had the microbore catheter issue been resolved when heavy xylocaine itself was snared in controversy over alleged neurotoxicity. Aftershocks from that eruption fanned out when neurotoxicity was implied not only for 5%, but also for 2.5% and even plain 2% lidocaine. As if that weren't enough, yet another tremor hit home when other local anesthetics (bupivacaine, mepivacaine, and even tetracaine) too became implicated in neurotoxicity, although lidocaine still tops the list. With so many reports of radicular irritation, venting one after another in short order, dawned a growing professional concern over the imputed radiculotoxicity of local anesthetics as a pharmacologic species. Ever since the seminal 1954 report by Dripps and Vandam? intrathecal injection of local anesthetics was considered both safe and efficacious, and lidocaine specifically so in the epochal 1969 multicenter study by Phillips et al.2 One cannot help but wonder what, if anything, has changed about spinal anesthesia in the intervening decades. Did the old masters, in searching out major neurologic complications perhaps overlook or shortchange the minor transient sequelae? Has our practice changed with new techniques, better drugs, and sharper tools for detecting borderline events? Or are we simply paranoid, hyping minor postoperative backache into a major media frenzy that threatens to deny future access to one of the safest and simplest methods of anesthesia? These are the fundamental issues that will be considered in this review.

Spinal Anesthesia Using Hyperbaric 0.75% Versus Hyperbaric 1% Bupivacaine for Cesarean Section

Although 0.75% hyperbaric bupivacaine is commonly administered to provide spinal anesthesia for cesarean section in the United States, in some countries, only the 1% hyperbaric solution of spinal bupivacaine is available. The aim of this study was to compare 0.75% with 1% hyperbaric spinal bupivacaine for cesarean section. In this prospective study, 50 patients undergoing elective cesarean section were randomized to receive a spinal anesthetic with either 1.5 mL of 0.75% bupivacaine (n = 25) or 1.125 mL of 1% bupivacaine (n = 25). There were no statistically significant differences in patient demographics, time to onset of block, or intraoperative pain. All patients had a successful block for surgery. The time from injection of the spinal anesthetic to first request for pain medication in the postanesthesia care unit was longer in the women who received 0.75% bupivacaine (4.3 vs 3 h; P < 0.05). Six women (24%) who received 1% bupivacaine versus one woman (4%) who received 0.75% bupivacaine complained of postoperative backache (P < 0.05). In addition, postdural puncture headache occurred in four women, all of whom received 1% bupivacaine (P = 0.04). In conclusion, our data suggest that 0.75% bupivacaine results in fewer postoperative problems and offers several significant benefits compared with the 1% concentration. Implications: Although 0.75% bupivacaine is usually used to provide spinal anesthesia for cesarean section in the United States, a more concentrated solution is popular in Europe. In this study, we compared 0.75% bupivacaine with 1% bupivacaine when administered for cesarean section and found that the 0.75% solution offers several significant benefits. (Anesth Analg 1998;87:1099-1104)

Small-Dose Hypobaric Lidocaine-Fentanyl Spinal Anesthesia for Short Duration Outpatient Laparoscopy. I. A Randomized Comparison with Conventional Dose Hyperbaric Lidocaine

A randomized, single-blind trial of two spinal anesthetic solutions for outpatient laparoscopy was conducted to compare intraoperative conditions and postoperative recovery. Thirty women (ASA physical status I and II) were assigned to one of two groups. Group I patients received a small-dose hypobaric solution of 1% lidocaine 25 mg made up to 3 mL by the addition of fentanyl 25 micro g. Group II patients received a conventional-dose hyperbaric solution of 5% lidocaine 75 mg (in 7.5% dextrose) made up to 3 mL by the addition of 1.5 mL 10% dextrose. All patients received 500 mL of crystalloid preloading. Spinal anesthesia was performed at L2-3 or L3-4 with a 27-gauge Quincke point needle. Surgery commenced when the level of sensory anesthesia reached T-6. Intraoperative hypotension requiring treatment with ephedrine occurred in 54% of Group II patients but not in any Group I patients. Median (range) time for full motor recovery was 50 (0-95) min in Group I patients compared to 90 (50-120) min in Group II patients (P = 0.0005). Sensory recovery also occurred faster in Group I patients (100 +/- 22 min) compared with Group II patients (140 +/- 27 min, P = 0.0001). Postoperative headache occurred in 38% of all patients and 70% of these were postural in nature. Oral analgesia was the only treatment required. Spinal anesthesia did not result in a significant incidence of postoperative backache. On follow-up, 96% said they found spinal needle insertion acceptable, 93% found surgery comfortable, and 90% said they would request spinal anesthesia for laparoscopy in future. Overall, this study found spinal anesthesia for outpatient laparoscopy to have high patient acceptance and a comparable complication rate to other studies. The small-dose hypobaric lidocaine-fentanyl technique has advantages over conventional-dose hyperbaric lidocaine of no hypotension and faster recovery. (Anesth Analg 1997;84:59-64)

Does Lumbar Support during Spinal Anesthesia Prevent Postoperative Backache?

Does Lumbar Support during Spinal Anesthesia Prevent Postoperative Backache?

SPINAL ANAESTHESIA FOR CAESAREAN SECTION: COMPARISON OF 22-GAUGE AND 25-GAUGE WHITACRE NEEDLES WITH 26-GAUGE QUINCKE NEEDLES

We have studied 150 women undergoing elective Caesarean section under spinal anaesthesia. They were allocated randomly to have a 22-gauge Whitacre, a 25-gauge Whitacre or a 26-gauge Quincke needle inserted into the lumbar subarachnoid space. The groups were compared for ease of insertion, number of attempted needle insertions before identification of cerebrospinal fluid, quality of subsequent analgesia and incidence of postoperative complications. There were differences between groups, but they did not reach statistical significance. Postdural puncture headache (PDPH) was experienced by one mother in the 22-gauge Whitacre group, none in the 25-gauge Whitacre group and five in the 26-gauge Quincke group. Five of the six PDPH occurred after a single successful needle insertion. Seven of the 15 mothers in whom more than two needle insertions were made experienced backache, compared with 12 of the 129 receiving two or less (P < 0.001). We conclude that the use of 22- and 25-gauge Whitacre needles in elective Caesarean section patients is associated with a low incidence of PDPH and that postoperative backache is more likely when more than two attempts are made to insert a spinal needle.

POSTOPERATIVE BACKACHE: THE USE OF AN INFLATABLE WEDGE

An inflatable wedge was used to support the lumbo-sacral curve of patients undergoing anaesthesia and surgery in either the supine or lithotomy position. Of the operative factors investigated, the presence of a wedge was the only one found to have a useful influence on the incidence of postoperative backache, which was reduced significantly (P less than 0.001).