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TNS

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Slide 1 :

Dusanka Zaric Transient neurologic symptoms (TNS) following spinal anesthesia with lidocaine versus other local anesthetics Published in The Cochrane Library Issue 4, 2003 and updated two times Zaric D, Christiansen C, Pace NL and Punjasawadwong Y.

Slide 2 :

Dusanka Zaric Background: The first spinal anesthesia was performed by Bier in 1899 with cocaine Since then, many different local anesthetics (LA) have been used: lidocaine, procaine, tetracaine, prilocaine, mepivacaine, dibucaine and bupivacaine The difference between LA is in: onset, intensity of sensory and motor blockade, duration of surgical anesthesia, regression phase and toxicity

Slide 3 :

Dusanka Zaric Lidocaine is: Suitable for daycase surgery because it has rapid onset of action, intense sensory and motor blockade, short duration of action (about 60 min) and quick regression (3 hours after intrathecal injection, the patients can go home) All LA are potentially neurotoxic Is lidocaine more so than the rest?

Slide 4 :

Dusanka Zaric Neurological complications after spinal anesthesia: Serious and permanent neural injuries are rare Retrospective reviews cite the frequency as 1:10 000 But, in more recent, prospective studies, the frequency is as high as 1: 3 000 spinals Ref

Slide 5 :

Dusanka Zaric Lidocaine neurotoxicity: In the beginig of 1990-s case reports of cauda equina syndrome in young, healthy patients were published, especially when spinal micro catheters and ”heavy” lidocaine were used The cause was probably mechanic trauma caused by micro catheter or high concentration of lidocaine around the sacral and lumbar roots

Slide 6 :

Dusanka Zaric Lidocaine neurotoxicity: Schneider used a new term ”transient neurologic toxicity” describing 4 patients who received spinal anesthesia with hyperbaric lidocaine 5% in 1993 One to 20 hours after uneventful recovery these patients will develop bilateral pain at the back of lower extremities, radiating from their buttocks to the feet These painful condition disappeared completely during the next week

Slide 7 :

Dusanka Zaric New terms: ”Transient radicular irritation” – TRI Hampl 1995 ”Transient neurologic symptoms” - TNS Hampl 1998 In the end of 1990-s a number of editorials were published where the question about lidocaine’s future as intrathecal LA was questioned due to fear of neurological sequllae This was a very popular topic at “pro and contra” sessions at ESRA, ASRA and ESA meetings

Slide 8 :

Dusanka Zaric Cochrane review: Included studies: randomized controlled trials (RCT) with adults that have received spinal anesthesia for surgery One arm with lidocaine and the second arm with any other LA administered intrathecally Excluded studies: combined spinal/epidural or if opioids were administered intrathecally

Slide 9 :

Dusanka Zaric Outcome: TNS Postoperative neurologic deficits lasting longer than 48 hours

Slide 10 :

Dusanka Zaric Literature search: The Cochrane Library MEDLINE EMBASE LILAC

Slide 11 :

Dusanka Zaric Included studies: We found 54 studies that described neurologic symptoms after spinal anesthesia 34 of them were included in the final analyses 14 were judged suitable for the final meta-analyses

Slide 12 :

Dusanka Zaric RCT: The second arm in the included RCTs was with: bupivacaine in 7; prilocaine in 4; mepivacaine in 3 and procaine in 2 RCTs Three RCTs had more than two arms. One of these was with two different concentrations of lidocaine – these were put together in only one arm The other two RCTs used other LA – therefore it was necessary to divide lidocaine group into two, so that the comparisons with each LA could be performed

Slide 13 :

Dusanka Zaric RCT: Geography. 4 RCTs were from USA; 3 from Scandinavia; 2 from Switzerland; 2 from Spain and 1 from Holland, Canada and Lebanon respectively Only two RCTs dealt with pregnant wemen Subgroups that would be interesting to investigate: Pt. in lithotomy contra prone position Pencil-point contra Quincke’s spinal needle The needle size

Slide 14 :

Dusanka Zaric RCT: Outcome in all 14 RCTs was TNS None of the studies was planned to evaluate neurological complications caused by spinal anesthesia The methodological quality of the RCTs was good. All studies were randomized and in 5 of them drop-outs were described. The contact with the authors was established to obtain the additional information

Slide 15 :

Dusanka Zaric Results: 1361 pt were include in these 14 RCTs and the outcome was evaluated in 1349 of them Test for heterogenicity was significant (p=0.014). The risk for development of TNS after spinal anesthesia was significantly higher with lidocaine than with any of the other investigated LA: relative risk was 4.35 (95% CI: 1.98, 9.54).

Slide 16 :

Dusanka Zaric Results: When the three studies with mepivacaine as the other LA were excluded from meta analyses the test for heterogenicity was no longer significant and the relative risk for TNS after lidocaine increased to 7.11 (95% CI 3.91, 12.93). It seems that mepivacaine has a similar tendency to cause TNS as lidocaine, but the number of included pt. is too small for this conclusion

Slide 17 :

Dusanka Zaric Results: Only two RCTs with pregnant women It seem that pregnant women have lower frequency of TNS: only 3 of 258 pts who received intrathecal lidocaine developed TNS But, again number of pts is too small to reach a dependable conclusion

Slide 18 :

Dusanka Zaric Analyses of subgroups: Due to lack of variation, the meta analyses of subgroups was impossible In most of the RCTs the pts were positioned prone (931 of 1349) and pencil-point spinal needle was used in 928 pts, in most cases 25G.

Slide 19 :

Dusanka Zaric Patients with TNS: 94 of 674 pts who received intrathecal lidocaine developed TNS (every seventh patient) Clinical picture: bilateral pain in the buttocks, and the backside of lower extremities of varying intensity (VAS for pain was 2-9.5) TNS started within 24 h after an uncomplicated spinal anesthesia Most of the pts had mild to moderate pain that was sufficiently treated with NSAID drugs In most pts TNS dissapeared by the second postoperative day (maximal duration was 5 days, in one pt it was 10 days)

Slide 20 :

Dusanka Zaric Conclusions: Is lidocaine more prone to cause TNS than bupivacaine, prilocaine or procaine? Yes – every seventh pt who receives intrathecal lidocaine will develop TNA Is lidocaine more neurotoxic than the other LA? No How much are pts bothered by these symptoms? Probably it is comparable to the backache that is described in about 20% of all pts that receive spinal anesthesia None of the pts who developed TNS had any neurological deficits The restitution was complete by the 10th postoperative day

Slide 21 :

Dusanka Zaric We still need information about: Is TNS rare in pregnant women? Does TNS occur as often with mepivacaine as with lidocaine? What is the real frequency of the neurological complications after spinal anesthesia? Why do we not register these rare events in a central database within one of the organizations that deal with regional anesthesia (ESA, ASRA)?

Slide 22 :

Dusanka Zaric Conclusion: There is no evidence that intrathecal lidokain is more neurotoxic than other LA The cause of TNS is as jet unknown – there are no indications that it is a sign of neurotoxicity Lidocaine is still the only local anesthetic that is suitable for ambulatory surgery. The occurrence of TNS is not reason enough to cease its use The pts should be informed about this side effect, just like any other side effect related to anesthesia

	zaricdus@dadlnet.dk 1 Years ago. Category: Anesthesiology

Tags:	Anesthesiology

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