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LETTERS TO THE EDITOR

Bilateral Buttock and Leg Pain After Lidocaine Epidural Anesthesia

Department of Anesthesiology Kaiser-Permanente Medical Center Santa Rosa, CA 95403

A syndrome of transient bilateral buttock and leg pain without neurologic deficit after lidocaine spinal anesthesia has been described (1–5). The mechanism underlying this syndrome is unknown. Freedman et al. (6) suggest that symptoms are more likely to occur in patients who have undergone surgery in the lithotomy position. There is only one case report of such symptoms occurring after uncomplicated lidocaine epidural anesthesia (7). We now report a second case and discuss its significance.

A healthy 38-yr-old woman with no history of radiculopathy underwent cystoscopy and urethral dilation under continuous epidural anesthesia. An epidural catheter was placed atraumatically 3 cm into the epidural space at the L3-4 interspace. After a negative test dose of 3 mL of 1.5% lidocaine with epinephrine 1:200,000, 15 mL of 2% lidocaine with epinephrine 1:200,000 was injected in 5-mL increments. A sensory level of T9 by pinprick was achieved. The intraoperative and immediate postoperative courses were uneventful, and the patient was discharged home pain-free 2 h after the procedure. Approximately 2 h after discharge, the patient developed severe bilateral buttock and posterior leg pain. She described the pain as "deep, aching, and excruciating." The pain was worse when she was immobile and better when standing versus sitting or lying down. There was no associated back pain, weakness, sensory changes, or bowel/bladder dysfunction. The pain persisted for 3 days, at which time the patient took ibuprofen and experienced rapid relief of her pain. Ibuprofen was then discontinued 2 days later, and the pain did not return.

These symptoms are strikingly similar to those described after the administration of intrathecal lidocaine. Case reports have demonstrated symptoms after the subarachnoid injection of lidocaine in concentrations as low as 0.5% (8), and controlled studies have demonstrated that reducing the lidocaine concentration to 2% for spinal anesthesia does not reduce the incidence of symptoms (4,9). These data imply that lower cerebrospinal fluid concentrations of lidocaine, such as might be expected to occur with uncomplicated epidural administration, may not be protective. Ours is the second case report of symptoms occurring after uncomplicated epidural anesthesia in the lithotomy position, which indicates that such patients may also be at risk of this syndrome. Whether this phenomenon represents a manifestation of neurotoxicity and whether it is part of a continuum that extends to neurologic injury is unknown.

References

1. Schneider M, Ettlin T, Kaufmann M, et al. Transient neurologic toxicity after hyperbaric subarachnoid anesthesia with 5% lidocaine. Anesth Analg 1993;76:1154–7.[Free Full Text]
2. Hampl K, Schneider M, Ummenhofer W, Drewe J. Transient neurologic symptoms after spinal anesthesia. Anesth Analg 1995;81:1148–53.[Abstract]
3. Tarkkila P, Huhtala J, Tuominen M. Transient radicular irritation after spinal aneasthesia with hyperbaric 5% lignocaine. Br J Anaesth 1995;74:328–9.[Abstract/Free Full Text]
4. Pollock J, Neal J, Stephenson C, Wiley C. Prospective study of the incidence of transient radicular irritation in patients undergoing spinal anesthesia. Anesthesiology 1996;84:1361–7.[Web of Science][Medline]
5. Salmela L, Cozanitis D. Leg and back pain after spinal anaesthesia involving hyperbaric 5% lignocaine. Anaesthesia 1996;51:391–3.[Web of Science][Medline]
6. Freedman J, Li D, Drasner K, et al. Risk factors for transient neurologic symptoms after spinal anesthesia : an epidemiologic study of 1863 patients. Anesthesiology 1998;89:633–41.[Web of Science][Medline]
7. Wong C, Benzon H, Kim C. Bilateral radicular pain after epidural lidocaine. Regional Anesthesia 1996;21:600–1.
8. Pollock J, Stephenson C. Spinal anesthetics and the incidence of transient radicular irritation [abstract]. Anesthesiology 1994;81:A1029.
9. Hampl K, Schneider M, Pargger H et al. A similar incidence of transient neurologic symptoms after spinal anesthesia with 2% and 5% lidocaine. Anesth Analg 1996;83:1046–50.[Abstract]

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