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Anesth Analg 2004;99:1270-1271
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000133957.92418.48

LETTERS TO THE EDITOR

Overnight Stay Lowers Incidence of Lidocaine Radiculotoxicity ("TNS")

Rudolph H. de Jong, MD

Professor, University of South Carolina School of Medicine, Columbia, SC, dejong@nuvox.net

To the Editor:

In their investigation of correlation between incidence of postspinal lumbosacral radicular pain ("TNS"; "TRI") and timing of ambulation, Silvanto et al. (1) observed no benefit from keeping patients in bed overnight. However, when recalculating their observations—eliminating the arbitrary temporal substratification of the "same-day discharge" group—one notes that next-day discharge reduces the statistical incidence of transient postspinal radicular pain (12.5%) as against same-day discharge (17.7%) (Table 1). This is not to belittle the landmark study itself, but rather to caution that cutting the subgrouping of the "same-day discharge" cohort too finely (about 4 h versus 6 h after intrathecal lidocaine administration) loses sight of the forest for the trees, thereby obscuring a clear trend towards risk reduction after overnight hospitalization (>20 h postspinal).


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  		Table 1. Overnight Stay Lowers TRI Incidence
 
Whether the 30% reduction in postlidocaine radicular pain is of sufficient clinical (let alone economic) significance to warrant overnight hospitalization remains to be seen (2). Nonetheless, the authors’ claim that the timing of ambulation after recovery from lidocaine spinal anesthesia bears little or no relation to the incidence of TRI will remain an open issue (3). Perhaps the more meaningful take-home message from the study (first two columns in Table 1) is that delaying ambulation, once the spinal block has regressed fully, heightens substantially the risk of subsequent transient radicular pain, unless the patient is bedded down for the night. Put differently if, for whatever reason, earliest postspinal ambulation is not an option, overnight hospitalization might well be justified.

References

  1. Silvanto M, Turkel P, Macula M-L, Rosenberg PH. The influence of ambulation time on the incidence of transient neurologic symptoms after lidocaine spinal anesthesia. Anesth Analg 2004; 98: 642–6.[Abstract/Free Full Text]
  2. Freedman JM, Li D-K, Drainer K, et al. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1,863 patients. Anesthesiology 1998; 89: 633–41.[Web of Science][Medline]
  3. Pollock JE Transient neurologic symptoms: etiology, risk factors, and management. Reg Anesth Pain Med 2002; 27: 581–6.[Web of Science][Medline]
 

Response

Pekka Tarkkila, MD PhD

Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland

In Response:

We greatly appreciate the opportunity to respond to the comment submitted by Professor de Jong concerning our study about the incidence of transient neurologic symptoms (TNS) after lidocaine spinal anesthesia with different ambulation times (1). The functional stratification is no doubt clear, but regardless of the trend towards risk reduction, the difference is not statistically significant. Furthermore, we agree with Professor Jong that the TNS reduction of 30% may not be clinically significant either. Contrary to Dr Jong’s assumption, the temporal stratification in our study is not arbitrary, but was designed to resemble normal clinical practice. In some hospitals, to improve the turnover times, the patients are ambulated as soon as possible, whereas in others the patients are allowed to stay in bed for longer periods of time and ambulate at any time that is convenient. The incidence of TNS in the next-day discharge group (12,5%) is higher than reported with bupivacaine spinal anesthesia Therefore, we do not think that keeping the patient bedded down after lidocaine spinal anesthesia is justified. According to present knowledge, using bupivacaine spinal anesthesia is the best method in avoiding TNS, although it is not an ideal alternative for day-case surgery (2). More studies are still needed in order to find the mechanism(s) causing TNS and assess the clinical significance of this syndrome.

References

  1. Silvanto M, Tarkkila P, Mäkelä M-L, Rosenberg PH. The influence of ambulation time on the incidence of transient neurologic symptoms after lidocaine spinal anesthesia. Anesth Analg 2004; 98: 642–6.
  2. Pollock JE. Transient neurologic symptoms: etiology, risk factors, and management. Reg Anesth Pain Med 2002; 27: 581–6.




This Article
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2004 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press