Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

[Intervention Review]
Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

Dusanka Zaric1, Nathan Leon Pace2

1Department of Anaesthesiology, University of Copenhagen, Frederiksberg Hospital, Denmark, Frederiksberg, Denmark. 2Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA

Contact address: Dusanka Zaric, Department of Anaesthesiology, University of Copenhagen, Frederiksberg Hospital, Denmark, Nordre Fasanvej 57, Frederiksberg, 2000, Denmark. Dusanka.Zaric@frh.regionh.dk. (Editorial group: Cochrane Anaesthesia Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: New search for studies completed, conclusions not changed)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD003006.pub3
This version first published online: 15 April 2009 in Issue 2, 2009. Last assessed as up-to-date: 14 August 2008. (Help document - Dates and Statuses explained).

This record should be cited as: Zaric D, Pace NL. Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003006. DOI: 10.1002/14651858.CD003006.pub3.

Abstract

Background
Spinal anaesthesia has been in use since 1898. During the last decade there has been an increase in the number of reports implicating lidocaine as a possible cause of temporary and permanent neurologic complications after spinal anaesthesia. Follow up of patients who received uncomplicated spinal anaesthesia revealed that some of them developed pain in the lower extremities after an initial full recovery. This painful condition that occurs in the immediate postoperative period was named 'transient neurologic symptoms' (TNS).

Objectives
To study the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine compared to other local anaesthetics.

Search strategy
We searched the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library, Issue 4, 2008); MEDLINE (1966 to August 2008); EMBASE (1980 to week 35, 2008); LILACS (August 2008); and handsearched the reference lists of trials and review articles.

Selection criteria
We included all randomized and quasi-randomized studies comparing the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine as compared to other local anaesthetics.

Data collection and analysis
Two authors independently evaluated the quality of the relevant studies and extracted the data from the included studies.

Main results
Sixteen trials reporting on 1467 patients, 125 of whom developed TNS, were included in the analysis. The use of lidocaine for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology; the symptoms disappeared spontaneously by the fifth postoperative day. The relative risk (RR) for developing TNS after spinal anaesthesia with lidocaine as compared to other local anaesthetics (bupivacaine, prilocaine, procaine, levobupivacaine, ropivacaine, and 2-chloroprocaine) was 7.31 (95% confidence interval (CI) 4.16 to 12.86). Mepivacaine was found to give similar results as lidocaine and was therefor omitted from the overall comparison to diminish the heterogeneity.

Authors' conclusions
The risk of developing TNS after spinal anaesthesia with lidocaine was significantly higher than when bupivacaine, prilocaine, or procaine were used. The term 'transient neurological symptoms' implies neurologic pathology. Failing identification of the pathogenesis of TNS, consideration should be given to choosing a neutral descriptive term which does not imply a particular causation. One study about the impact of TNS on patient satisfaction and functional impairment demonstrated that non-TNS patients were more satisfied and had less functional impairment after surgery than TNS patients, but this did not influence their willingness to recommend spinal anaesthesia.

Plain language summary

Temporary pain in the lower extremities following spinal anaesthesia with lidocaine compared to other local anaesthetics
Lidocaine is the drug of choice for inducing spinal anaesthesia in ambulatory surgery because of its rapid onset of action, intense nerve blockade, and short duration of action. The possible side effects of spinal anaesthesia in adults, which develop after recovery, are backache, post-dural puncture headache, and transient neurologic symptoms that are characterized by slight to severe pain in the buttocks and legs. TNS symptoms develop within a few hours and up to 24 hours after anaesthesia. They last, in most cases, up to two days. The present review shows that lidocaine is more likely to cause transient neurologic symptoms than bupivacaine, prilocaine, and procaine. However, these drugs produce prolonged local anaesthetic effects and therefore are not desirable for ambulatory patients. It is possible that the reintroduction of 2-chloroprocaine will solve this lack of a suitable intrathecal local anaesthetic; confirmatory studies are needed.


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