Mini Review - Anesthesiology and Clinical Science Research (2022) Volume 6, Issue 1
A brief review on neuraxial anesthesia and back pain
Department of Anaesthesiology and Pain Management Centre, B. J. Medical College, Ahmedabad, Gujarat, India
- *Corresponding Author:
- Abella Eden
Department of Anaesthesiology and Pain
B. J. Medical College
Gujarat, India E-mail: [email protected]
Received: 31-Dec-2021, Manuscript No. AAACSR-22-54537; Editor assigned: 03-Jan-2022, PreQC No. AAACSR-22-54537(PQ); Reviewed: 17-Jan-2022, QC No AAACSR-22-54537; Revised: 20-Jan-2022, Manuscript No. AAACSR-22-54537(R); Published: 27-Jan-2022, DOI:10.35841/aaacsr-6.1.102
Citation: Eden A. A brief review on neuraxial anesthesia and back pain. Anaesthesiol Clin Sci Res. 2022;6(1):102.
In the adult population, the incidence of back discomfort after neuraxial anaesthesia is similar to that after general anaesthesia. The pain is usually minor, centred in the low back, rarely radiating to the lower extremities, and only lasts a few days. The lithotomy position, several attempts at block placement, surgery lasting more than 2.5 hours, a body mass index of less than 32 kg/m2, and a history of back discomfort are all risk factors for developing back pain. After neuraxial anaesthesia, however, there is no persistent worsening of preexisting back pain. Immobility of the spine; relaxation of the paraspinal muscles under anaesthesia; flattening of the typical lumbar convexity; and stretching and straining of the lumbosacral ligaments and joint capsules have all been linked to back pain. The use of an anti-inflammatory medicine in conjunction with a local anaesthetic for skin infiltration may reduce the occurrence and intensity of back pain. The use of spinal or epidural anaesthesia in adults, non-obstetrics, and obstetrics should be based on the benefits of the approach rather than the risk of back pain following the treatment. More research is needed to prove the usefulness of epidural dexamethasone or other steroids, as well as the addition of an anti-inflammatory medicine to the local anaesthetic infiltration, in preventing back pain after neuraxial anaesthesia. Future studies should include a physician with experience evaluating persistent low back pain to assist in determining the aetiology of the pain and implementing effective treatment (s) .
Stevens outlined the events that led to back pain after epidural anaesthesia with the previous 2-chloroprocaine formulation. In short, the producer reduced the pH to around 3.5 and added a preservative to extend the shelf life of the medicine. The antioxidant was originally methylparaben; however, it was replaced with sodium bisulfite, and the product was renamed Nesacaine-CETM. The combination of sodium bisulfite and low pH has been blamed for cases of cauda equina syndrome. Other researchers, on the other hand, found that chloroprocaine, not sodium bisulfite, was the problem. In any case, the company originally reduced the sodium bisulfite concentration and added calcium disodium EDTA as a chelating agent . Chloroprocaine was modified to contain very minute levels of disodium EDTA and marketed as Nesacaine MPFTM because to persistent concerns about the presence of sodium bisulfite (methylparaben free). There were several case reports of back pain following epidural injections of this formulation. The back pain began shortly after the epidural anaesthesia had worn off, and it was characterised by acute, burning pain in the low back that usually subsided after 24 hours. The chelation of calcium in the lumbar muscles by disodium EDTA was hypothesised as the cause of back pain, resulting in chemical irritation and "hypocalcemic tetany" of the paraspinal muscles. The volume injected was linked to the prevalence and severity of back discomfort. The use of sodium bicarbonate to raise the pH of chloroprocaine reduced the occurrence and severity of the back pain. The company modified chloroprocaine to its current state, which is free of preservatives and antioxidants. It is now utilised as an epidural local anaesthetic for postpartum tubal ligation and closure of episiotomy or laceration following vaginal delivery due to its short duration of action. There have been no complaints of back pain following epidural blocking with the current formulation of the medication to our knowledge [2,3].
In the 1990s, there were reports of temporary buttock and leg pain after spinal anaesthesia using lidocaine. The pain began in the buttocks and spread to the lower extremities within a few hours, but might last up to 24 hours after the spinal anaesthetic had worn off. There was no evidence of neurologic pathology during the neurologic examination and diagnostic testing. Initially, the condition was known as transitory radicular irritation. The absence of diagnostic evidence for this phrase, as well as the clinical overlap with the previously mentioned musculoskeletal diseases, prompted requests for a change in terminology. The illness, which was later dubbed TNS, was widely researched and then thoroughly reviewed. 16 randomised trials with 1467 people were included in a Cochrane review. The authors observed that, with the exception of mepivacaine, the incidence of transient buttock and leg discomfort following spinal anaesthesia with lidocaine was much higher than the other local anaesthetics. The relative risk (RR) of developing TNS after spinal anaesthetic with lidocaine was 7.31 (95 percent confidence interval (CI), 4.16–12.86) compared to bupivacaine, prilocaine, procaine, levobupivacaine, ropivacaine, and 2-chloroprocaine. The RR was 1.05 (95 percent CI, 0.15–7.45) when lidocaine was compared to mepivacaine alone. The RR for developing TNS with lidocaine was 4.62 (95 percent CI, 2.30–9.26) when mepivacaine was included in the other local anaesthetics. The authors, like other experts, suggested that a more neutral word than TNS be considered. This is because TNS suggest a neurologic condition for which no specific pathophysiology has been found [2-4].
TNS is more common after lidocaine spinal than after bupivacaine, prilocaine, procaine, levobupivacaine, ropivacaine, and 2-chloroprocaine, according to the findings (level 1).
In a practise guideline on neurologic problems associated with regional anaesthesia, the American Society of Regional Anesthesia (ASRA) discussed the possibility of TNS after 2-chloroprocaine. The authors found that the risk of TNS following intrathecal 2-chloroprocaine doses of 40 to 50 mg is minimal, and that the number of published 2-chloroprocaine spinal anaesthetic trials is insufficient to assess the drug's risk of neurotoxicity (class III). In the paediatric population, there is little research on back discomfort following neuraxial injections. Back discomfort was not one of the nine issues listed in a national survey looking into the side effects of epidural infusion in children. In a study of 2278 single-injection neuraxial blocks, no back pain was recorded. Back discomfort was explicitly measured in a 2010 prospective trial of 135 children who had caudal analgesia, with an incidence of 5% (5 of 106) at postoperative day 2 and 1% (1 of 94) at postoperative day 15. By the 15th postoperative day, all occurrences of back pain had subsided and disappeared. Four of the five patients experienced pain at the injection site, while the fifth experienced back pain that was not limited to the injection site. The one patient who developed back discomfort after 15 days had it for the first time. In comparison to lumbar epidural placement, studies after caudal analgesia demonstrate that this method is more popular in youngsters. It's debatable if the discomfort at the injection site is indeed "back ache." Regardless, back pain in children following caudal blockage is uncommon and self-limiting (level 2) .
The incidence of back discomfort after spinal anaesthesia and general anaesthesia has been observed to be similar. Brown and Elman6 found a 21% (16 of 76) incidence of back discomfort after spinal anaesthesia compared to 19% (62 of 325) after general anaesthesia in 1961. They discovered that back discomfort frequently followed surgeries performed in the supine or lithotomy positions, and that the length of time the patient was motionless during surgery was a crucial determinant in the development of back pain. They also discovered that as the period of surgery/anesthesia was increased, a higher percentage of patients got backache. Other researchers have come to the same conclusion about the similarities in the occurrence of back discomfort after spinal and general anaesthesia. The incidence of new back pain after spinal anaesthesia was 24 percent (54 of 225 patients), compared to 17 percent after general anaesthesia, according to one study. They, like Brown and Elman, believed that the length of time the patient was immobilised on the operating table was the primary cause of back discomfort following anaesthesia, despite the lack of data.
Although prior back pain may be a risk factor for back pain following neuraxial anaesthesia, it does not appear that neuraxial anaesthesia worsens the degree of the pain. Only one out of eleven participants in one research reported worsening back pain after spinal anaesthesia, a rate similar to that recorded after general anaesthesia (1 of 14 patients). Three of the 11 patients who underwent spinal anaesthesia reported improvement, whereas the other seven did not. One of 14 patients with a history of back pain in the general anaesthesia group had increased symptoms, while the other 13 reported no change. Six of the 23 patients with prior back pain in Schwabe and Hopf's trial still complained of persistent back pain one year after their spinal anesthesia. Another study found that after epidural anaesthesia, patients' lumbar radicular symptoms did not worsen. As previously stated, spinal anaesthesia can provide "relief" for some patients suffering from back pain. Because of the temporary nature of this condition, there may be some improvement in numbness.
Several studies have looked into the effectiveness of neuraxial anaesthesia in people with low back pain. Spinal or epidural anaesthesia, whether the patient had back surgery, and whether the anaesthetic was for obstetrical or general surgery are all topics covered in the literature. In a comprehensive assessment of the beginning of sensory blockade after epidural local anaesthetic injection in patients with back pain, it was discovered that 7 of 15 individuals (46%) had delayed sensory blockage of specific dermatomes, which lasted between 35 and 95 minutes. These nerve roots were blocked 10 to 70 minutes after the contralateral lower extremity's comparable nerve roots were blocked. The nerve roots identified as displaying pathologic alterations in the electromyogram or myelogram investigations related to the dermatomes with delayed onset of block. They suggested that nerve root inflammation, intraneural fibrosis, and extradural adhesions could all be factors in the delayed start of sensory blockage. 52 people in a prospective analysis of 57 patients who had spine surgery obtained effective epidural anaesthesia for total hip or total knee replacements. Three patients had technical difficulties, while two others had insufficient spread in the lumbosacral regions. There was no evidence of radiculopathy aggravation in any of the individuals. The total success rate of neuraxial anaesthesia (spinal, epidural, and combination spinal–epidural [CSE] anaesthesia) was 97 percent in a retrospective study of 937 patients with spinal stenosis or lumbar disc disease, 207 of whom had previously undergone spine surgery. Previous spine surgery did not alter the success rate or the frequency of technical difficulties, according to the authors.
In study they find patchy blockade in ten patients and no sensory block in 16 others. Three patients experienced new deficiencies, while four others saw worsening of prior symptoms. Four of the ten patients who experienced difficulties had a surgical aetiology, one of the other instances may have been increased by the epidural, and another may have been exacerbated by the patient's placement during surgery.
- Bonica JJ, Backup PH, Anderson CE et al. Peridural block: analysis of 3,637 cases and a review. Anesthesiology. 1957;18(5): 723-84.
- Lund PC, Cwik JC, Quinn JR. Experiences with epidural anesthesia: 7730 cases: part 1. I. Anesth Analg. 1961;40(1):153-63.
- Cotev S, Robin GC, Davidson JT. Back pain after epidural analgesia. Anesth Analg. 1967;46(2):259-63.
- Brown EM, Elman DS. Postoperative backache. Anesth Analg. 1961;40(6):683-5.