Transient Radicular Irritation Research Articles

Transient neurologic syndrome in one thousand forty-five patients after 3% lidocaine spinal anesthesia.

Recent reports have discussed the potential risk of transient radicular irritation (TRI) after spinal anesthesia with lidocaine. Because we have not encountered such neurologic sequelae with the high incidence reported, we prospectively examined the incidence of TRI after spinal anesthesia with lidocaine. One thousand forty-five adult patients (aged 47 +/- 15 yr) receiving spinal anesthesia with 3% hyperbaric lidocaine (1.0-1.5 mL) for anorectal surgery were consecutively studied. After the induction of spinal anesthesia, all patients were placed in the prone position for surgery. Patients were evaluated for neurologic symptoms in the buttocks, thighs, or lower extremities using a checklist to standardize data collection. Although there was no complaint of neurologic symptoms on Postoperative Day (POD) 1, four patients (0.4%) reported aching, hypesthesia, numbness, or dull pain of both lower extremities and buttocks by the morning of POD 3. In three patients, the symptoms resolved without any treatment by POD 5, whereas in one patient, numbness of the lower extremities lasted until POD 7. We conclude that a combination of lidocaine with surgical position or leg manipulation during surgery might be a major contributing factor in the development of transient neurologic syndrome. Recent studies have reported the potential risk of transient neurologic syndrome after lidocaine spinal anesthesia. The current study reports a low incidence of such sequelae in 1045 patients undergoing anorectal surgery during the prone position. Other factors, such as surgical position, may be important in the development of this syndrome.

Transient radicular irritation (TRI) after spinal anaesthesia in day-care surgery.

A high incidence of backache with radiating pains to the lower extremities, termed transient radicular irritation (TRI), has been reported following the use of 5% hyperbaric lidocaine. This has been attributed to a neurotoxic reaction. A retrospective audit has been carried out in our hospital on the postoperative anaesthetic records of all patients from the 1st of January 1993 to the 1st of September 1996, who received spinal anaesthesia with either hyperbaric lidocaine or hyperbaric bupivacaine for day-care surgery. Backache was reported in 1.9% of patients (6/322) receiving hyperbaric lidocaine and in 2.4% of patients (1/41) receiving hyperbaric bupivacaine. This was not associated with any sensory, motor or sphincter disturbances. One patient complained of backache with bilateral pain referred to the gluteal area (TRI), which was assessed as acute facet joint syndrome. Unilateral accidental block of the femoral nerve was observed in 3 patients, sensory disturbances in the L2/3 dermatome was reported in a further 3 patients at 24 h, following wound infiltration with local anaesthetic during hernia repair. The low incidence of backache at 24 h and the absence of associated symptoms of neurogenic pain, sensory and motor disturbances, does not support the hypothesis that TRI is a neurotoxic reaction, subsequent to the use of hyperbaric lidocaine.

PROCAINE SPINAL ANESTHESIA

S2 Recent reports of Transient Radicular Irritation (TRI) after lidocaine spinal anesthesia have raised concerns about potential neurotoxicity [1]. These concerns prompted a reinvestigation of procaine for spinal anesthesia. METHODS: With approval of the IRB and written consent, 106 consecutive patients scheduled for spinal anesthesia for procedures expected to last <or=to 90 minutes received procaine spinal anesthesia. Plain procaine was used for surgeries expected to last <or=to 45 minutes. In order to prolong surgical anesthesia without unduly prolonging time to discharge from the PACU, we studied the effect of adding fentanyl for surgeries anticipated to last 45 to 90 minutes. In either case, procaine was diluted to 5% concentration before injection. Intraoperatively the adequacy of duration, level and intensity of anesthesia were observed. In the PACU, the duration of motor block was measured. Three days postoperatively, patients were questioned intensively in an effort to determine whether back pain and/or symptoms consistent with TRI had occurred. RESULTS: Duration of anesthesia was adequate in all but one instance. The intensity and the sensory level of anesthesia were satisfactory with one exception, a woman who had an unexpectedly low sensory level (L1) after 60 mg of procaine for cerclage, and who was also was the only patient to develop TRI. The incidence of TRI (0.9%) was markedly less than that reported after lidocaine and similar to the incidence observed after bupivacaine [2,3]. Mild back pain without radiation occurred in 11 patients (10%), an incidence which is similar to that seen after bupivacaine and lidocaine. As compared to procaine alone, the addition of fentanyl significantly (P<.0001) prolonged the time to bending knees from 72 minutes to 97 minutes. CONCLUSIONS: 1) Procaine, with the addition of fentanyl when necessary, is a useful alternative to lidocaine as a spinal anesthetic for surgical procedures lasting less than 90 minutes and is less likely to produce severe radiating back pain (transient radicular irritation). 2) Fentanyl prolongs motor block when added to procaine.

Epidural and spinal anaesthesia have no place in a busy day unit?

Properly performed day-care anaesthesia is almost 100% safe in terms of serious adverse outcome, regardless of which anaesthetic method is used. The drawbacks of spinal anaesthesia includes occasional postoperative headache and transient radicular irritation. Epidural anaesthesia may prolong preoperative time consumed and occasionally fail. Both methods may prolong postoperative bedrest, but provide better analgesia and emesis protection than general anaesthesia. Epidural anaesthesia may occasionally be useful in selected long-lasting procedures. Spinal anaesthesia is simple, fast, reliable and should be considered for procedures of medium to long duration when some postoperative pain is expected.

Transient Radicular Irritation After Spinal Anesthesia with Hyperbaric 4% Mepivacaine

Transient Radicular Irritation After Spinal Anesthesia with Hyperbaric 4% Mepivacaine

A829 Transient Radicular Irritation (TRI) following Spinal Anesthesia with Mepivacaine Vs Lidocaine in Ambulatory Surgery

A829 Transient Radicular Irritation (TRI) following Spinal Anesthesia with Mepivacaine Vs Lidocaine in Ambulatory Surgery

Transient radicular irritation after hyperbaric lidocaine spinal anesthesia in parturients

Two cases of transient radicular irritation in pregnant patients are presented. Both cases involve the combination of spinal anesthesia employing hyperbaric 5% lidocaine and a small gauge pencilpoint needle as well as the surgery being performed in the lithotomy position. We recommend that until the potential for lidocaine-induced neuroradicular irritation under these circumstances is evaluated prospectively, hyperbaric lidocaine should not be used for cases in which a small gauge spinal needle is employed and the patient is placed in the lithotomy position.

Prospective Study of the Incidence of Transient Radicular Irritation in Patients Undergoing Spinal Anesthesia

POLLOCK, JULIA E.; NEAL, JOSEPH M.; STEPHENSON, CAROL A.; WILEY, CAROL E. Author Information

A Similar Incidence of Transient Neurologic Symptoms After Spinal Anesthesia with 2% and 5% Lidocaine

Recent reports suggest that transient neurologic symptoms are common after spinal anesthesia with 5% lidocaine.To determine whether reducing the anesthetic concentration might decrease the incidence of symptoms, 50 ASA class I or II patients undergoing brief gynecologic procedures under spinal anesthesia were randomly allocated to receive 1 mg/kg of either 5% or 2% lidocaine in 7.5% glucose. Patients were evaluated on the first postoperative day by an anesthesiologist who was unaware of the solution administered or the details of the anesthetic procedure. Symptoms suggestive of transient radicular irritation were observed in 8 patients (32%) receiving 5% lidocaine, and in 10 patients (40%) receiving 2% lidocaine (NS). These results confirm our previous findings that transient neurologic symptoms may occur in up to one third of the patients receiving 5% lidocaine, and indicate that a modest reduction in lidocaine concentration does not reduce risk. (Anesth Analg 1996;83:1051-4)

Reply

Department of Anesthesiology, Virginia Mason Medical Center, B2-AN 1100 Ninth Avenue, Seattle, Washington 98111, Electronic mail: anejep@vmmc.org.In Reply:-We appreciate the comments of Lambert et al. and apologize for incorrectly representing their work. We agree that clarification on this point is important because both laboratory and clinical data support the safety of intrathecal bupivacaine in comparison with other local anesthetic agents.Although we are convinced of the safety of intrathecal bupivacaine, we believe that, currently, there is insufficient clinical data to warrant the total abandonment of 5% and 2% lidocaine for spinal anesthesia. Despite an incidence of transient radicular irritation of 16% in our study, all patients were recovered and completely asymptomatic at 2-week follow-up. [1]In addition, it is difficult to ignore the long safety record of intrathecal lidocaine. One of the many questions remaining to be answered is, after years of clinical use of subarachnoid lidocaine, why are we only now beginning to see patients with postoperative radicular symptoms? We agree with Lambert et al. that ongoing investigation is essential to answer these questions and to identify other appropriate spinal agents for practitioners seeking an alternative to lidocaine. [2]Julia E. Pollock, M.D., Joseph M. Neal, M.D., Carol Stephenson, R.N., Carol E. Wiley, M.D., Department of Anesthesiology, Virginia Mason Medical Center, B2-AN 1100 Ninth Avenue, Seattle, Washington 98111, Electronic mail: anejep@vmmc.org.(Accepted for publication August 19, 1996.)

Prospective Study of the Incidence of Transient Radicular Irritation in Patients Undergoing Spinal Anesthesia

There is considerable controversy regarding the role of subarachnoid 5% hyperbaric lidocaine in the syndrome transient radicular irritation (TRI). This randomized, double-blinded, prospective study was designed to determine the incidence of TRI and identify factors possibly contributing to its development. One hundred fifty-nine ASA physical status 1 or 2 patients undergoing outpatient knee arthroscopy or unilateral inguinal hernia repair were prospectively randomized to receive spinal anesthesia with 5% hyperbaric lidocaine with epinephrine (60 mg with 0.2 mg epinephrine for arthroscopy or 75 mg with 0.2 mg epinephrine for hernia repair), 2% isobaric lidocaine without epinephrine (60 mg for arthroscopy or 75 mg for hernia repair), or 0.75% hyperbaric bupivacaine without epinephrine (7.5 mg for arthroscopy or 9.0 mg for hernia repair) in a double-blinded fashion. On the 3rd postoperative day, patients were contacted by a blinded investigator and questioned regarding the incidence of postoperative complications including TRI, defined as back pain with radiation down one or both buttocks or legs occurring within 24 h after surgery. Postoperatively, time from injection to block resolution, ambulation, voiding, and ready for discharge were recorded by a postanesthesia care unit nurse blinded to the group assignment. The incidence of TRI was greater in patients receiving lidocaine than in those receiving bupivacaine (16% vs. 0%; P = 0.003). There was no difference in the incidence of TRI between the patients receiving 5% hyperbaric lidocaine with epinephrine and those receiving 2% isobaric lidocaine without epinephrine (16% vs. 16%; P = 0.98). The incidence of TRI was greater in patients undergoing arthroscopy than in those undergoing hernia repair (13% vs. 5%; P = 0.04). There was no difference in discharge times in patients receiving bupivacaine versus those receiving hyperbaric lidocaine with epinephrine (292 vs. 322 min; P = 0.61). The incidence of TRI is greater with lidocaine than bupivacaine, decreasing the lidocaine concentration to 2% does not prevent TRI, and surgical position may be an important contributing factor. Discharge times at our institution are not different when equipotent doses of 0.75% hyperbaric bupivacaine or 5% hyperbaric lidocaine with 0.2 mg epinephrine are used in ambulatory patients undergoing spinal anesthesia.

Intrathecal Hyperbaric 0.5% Tetracaine as a Possible Cause of Transient Neurologic Toxicity

Intrathecal Hyperbaric 0.5% Tetracaine as a Possible Cause of Transient Neurologic Toxicity

Transient Radicular Irritation After Spinal Anaesthesia with Hyperbaric 5% Lignocaine

We have studied prospectively 600 patients who had spinal anaesthesia for minor surgery, to evaluate the incidence of transient radicular irritation after the block. The anaesthetic agent (hyperbaric 5% lignocaine, hyperbaric 0.5% bupivacaine or plain 0.5% bupivacaine) was chosen according to the anticipated duration of surgery. We obtained information after operation from 537 patients (282 by telephone, 255 by letter). Ten percent of patients anaesthetized with hyperbaric 5% lignocaine (27 patients) had transient bilateral radiating pain in the lower extremities, buttocks, or both. Typically the pain started within 24 h after spinal anaesthesia, lasted less than 2 days and was described as mild. Lignocaine was the only variable that correlated with this pain. Two patients complained of symptoms after hyperbaric 0.5% bupivacaine but these were atypical compared with pain after lignocaine. None of the patients anaesthetized with plain bupivacaine had similar complaints. We conclude that the use of 5% hyperbaric lignocaine for spinal anaesthesia should be reconsidered. (Br. J. Anaesth. 1995; 74: 328–329)

Transient radicular irritation after bupivacaine spinal anesthesia.

Transient radicular irritation (TRI) has been described to occur following spinal anesthesia with hyperbaric 5% lidocaine. The authors recently used only isobaric or hyperbaric 0.5% bupivacaine for spinal anesthesia. All patients who had spinal anesthesia for various kinds of surgery were interviewed after the operation to discover the possibility of TRI following bupivacaine spinal anesthesia. The study included 226 patients. Isobaric 0.5% bupivacaine was given to 116 patients and hyperbaric 0.5% bupivacaine to 110. The local anesthetic was chosen according to the expected duration of surgery. All patients were interviewed by an anesthesiologist 24 hours after spinal anesthesia, and after 1 week the patients were asked to return a written questionnaire. If pain not associated with operation was noted, the patients were interviewed by phone. One 48-year-old woman reported TRI after spinal anesthesia (saddle block) with hyperbaric 0.5% bupivacaine in the 24-hour interview. Her spinal anesthetic was performed in a sitting position and the anal surgery in a lithotomy position. In the 1-week questionnaire (response rate 92%), none of the other patients fulfilled our criteria for TRI. In spite of one case of TRI, the authors consider bupivacaine to be safe for spinal anesthesia. The association of the sitting and lithotomy positions to the restricted distribution of hyperbaric solution and consequent TRI warrants further studies.

Transient radicular pain following spinal anesthesia: Review of the literature and report of a case involving 2% lidocaine

Recent reports of transient radicular irritation following intrathecal administration of 5% lidocaine in 7.5% dextrose, a common drug choice in many obstetric centers, have generated concern that its use for single injection spinal anesthesia can result in transient neurologic toxicity. Accordingly, many have advocated dilution of this anesthetic solution prior to subarachnoid administration. The present report describes a case in which transient neurologic symptoms occurred following intrathecal injection of a solution containing approximately 2% lidocaine. The similarity of the present case to those previously reported implies a common etiology and suggests that risk is not restricted to the use of 5% lidocaine with 7.5% glucose. It underscores the need for carefully controlled prospective evaluation of the factors that affect transient neurologic dysfunction following spinal anesthesia.

Transient radicular irritation after spinal anaesthesia with hyperbaric 5% lignocaine

We have studied prospectively 600 patients who had spinal anaesthesia for minor surgery, to evaluate the incidence of transient radicular irritation after the block. The anaesthetic agent (hyperbaric 5% lignocaine, hyperbaric 0.5% bupivacaine or plain 0.5% bupivacaine) was chosen according to the anticipated duration of surgery. We obtained information after operation from 537 patients (282 by telephone, 255 by letter). Ten percent of patients anaesthetized with hyperbaric 5% lignocaine (27 patients) had transient bilateral radiating pain in the lower extremities, buttocks, or both. Typically the pain started within 24 h after spinal anaesthesia, lasted less than 2 days and was described as mild. Lignocaine was the only variable that correlated with this pain. Two patients complained of symptoms after hyperbaric 0.5% bupivacaine but these were atypical compared with pain after lignocaine. None of the patients anaesthetized with plain bupivacaine had similar complaints. We conclude that the use of 5% hyperbaric lignocaine for spinal anaesthesia should be reconsidered.

The Importance of Surgical Positioning and Anesthetic Concentration in the Incidence of Transient Radicular Irritation

The Importance of Surgical Positioning and Anesthetic Concentration in the Incidence of Transient Radicular Irritation

Spinal Anesthetics and the Incidence of Transient Radicular Irritation

Spinal Anesthetics and the Incidence of Transient Radicular Irritation