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Transient Neurologic Symptoms Following Spinal Anesthesia with Bupivacaine and Ropivacaine

  • Yue HuEmail author
  • Yong Ye
  • Xue Gong
  • Fei-fei Ran
Medicine
Part of the following topical collections:
  1. Topical Collection on Medicine

Abstract

Transient neurologic syndrome (TNS) is a common self-limited complication of spinal anesthesia. Many local anesthetics can cause transient neurological syndrome, in which the incidence of lidocaine is relatively high. In addition, bupivacaine, levobupivacaine, articaine, and ropivacaine can also cause TNS. We conducted a consecutive retrospective cohort study to investigate the incidence of TNS and its associated factors in patients treated with bupivacaine and ropivacaine. We conducted a retrospective cohort study, reviewing the medical records of surgical patients who received bupivacaine and ropivacaine spinal anesthesia in Chengdu Shuangliu District First People’s Hospital in the past year to determine the incidence of TNS. For the first time, we used the TNS score table to quantify the occurrence of TNS. There were 24 cases (41.38%) of TNS in the bupivacaine group and 45 cases (33.33%) of TNS in the ropivacaine group. There was no significant difference in VAS and TNS scores between the two groups. It was found that the occurrence of TNS with bupivacaine was correlated with VAS score (Pearson correlation = 0.1813), while the occurrence of TNS with ropivacaine was correlated with sensory blockade (Pearson correlation = − 0.0642). The TNS scale can be used to evaluate the postoperative TNS of patients, and ropivacaine is used for spinal anesthesia with appropriate high anesthesia, which is less likely to lead to postoperative TNS.

Keywords

TNS Spinal anesthesia Bupivacaine Ropivacaine 

Introduction

Transient neurological syndrome (TNS) occurred in patients with pain syndrome after spinal anesthesia, and symptoms disappeared within 24 h after the action of unilateral or bilateral hip pain; a few patients show the radiation to the thigh and the following insensitive or hyperalgesia, the nature of pain to sharp pain, tingling, or burning pain [1, 2, 3]. At present, the exact cause of TNS is not clear, but the possible causes include the neurotoxicity of local anesthetics, puncture needle injury, intraoperative position, and the concentration of local anesthetics in cerebrospinal fluid caused by different types of lumbar anesthesia needles [4, 5]. Currently, there is no good diagnostic standard for TNS. The diagnosis of TNS is mainly based on the observation of the postoperative pain performance of patients under spinal anesthesia. However, the description of TNS by patients may be inaccurate due to the postoperative incision pain and other reasons. Compared with lidocaine, bupivacaine has a lower correlation with TNS after spinal anesthesia, while ropivacaine has a lower incidence of TNS after spinal anesthesia [6]. Our aim is to investigate the occurrence of TNS after intraspinal anesthesia with bupivacaine and ropivacaine. The occurrence and clinical manifestations of TNS were analyzed by using the TNS score table, which research and develop independently, and the related factors of TNS were analyzed. In this way, we can systematically evaluate some complications after spinal anesthesia through the TNS scale, so as to obtain the quantitative indicators of postoperative visit patients that can be used clinically and to better study the complications of spinal anesthesia.

Materials and Methods

After receiving approval by the local ethics committee, we conducted a consecutive retrospective cohort study of 255 patients who underwent spinal anesthesia in Chengdu Shuangliu District First People’s Hospital between January 1, 2017, and December 31, 2018. The postoperative visit was conducted to record whether the patient had postoperative hip pain and paresthesia of both lower limbs, and the specific location, duration, and regression time of the pain were analyzed, so as to identify whether TNS occurred. During this period, it is important to distinguish between incision pain and paresthesia of the limb and to rule out definite neuro-positive changes. The dosage of ropivacaine and bupivacaine depends on the specific operation method and operation time. Patients with local anesthetic intoxication, headache after dural puncture, total spinal anesthesia, and complications such as spinal cord or epidural hematoma during anesthesia were excluded from our study. Patients without postoperative follow-up, consultation, or other records were excluded from the analysis.

The data we collected included many types of surgery, such as cesarean section, urological surgery, orthopedic surgery, and vascular surgery. The positions of these surgeries are different, the operation time is different, and the dose of local anesthetics is different, but the common point of these surgeries is that they all use bupivacaine or ropivacaine for spinal anesthesia. The anesthesia positions are all in lateral position, and the puncture space is L3–L4. For patients with serious postoperative complications, patients with serious condition or risk of acute deterioration should be urgently consulted and treated in neurology or neurosurgery.

The count and frequency of categorical variables as well as the mean, median, and standard deviation of continuous variables were used for descriptive statistics of the entire sample. Pearson correlation coefficient was used to analyze the correlation between TNS score and VAS score, operation time and sensory block plane after anesthesia. We created a TNS score table (Table 1), defined TNS as a score greater than or equal to 3, and described and analyzed the collected data, including patients’ basic information, postoperative pain, and correlation. Statistical analyses were performed using SPSS17.0 and graphs were performed using GraphPad Prism 8.
Table 1

TNS scores for lower extremity symptoms after spinal anesthesia

Symptom

Pain/hypesthesia/numbness

Yes

No

Location

Buttocks

1

0

 

Calves

1

0

 

Thighs

1

0

 

Feet

1

0

*Scores ≥ 3 were defined as TNS

Results

A total of 255 cases of spinal anesthesia were collected, of which 62 were excluded due to incomplete data or other reasons, and 193 cases with complete data were recorded. Fifty-eight patients underwent single spinal anesthesia with bupivacaine, of which 7 patients used bupivacaine solution with hyperbaric and 51 patients with isobaric bupivacaine. Of the 135 patients who underwent single spinal anesthesia with ropivacaine, 123 were treated with isobaric ropivacaine and 12 with hypobaric ropivacaine. Figure 1 describes the process of this study in detail (Fig. 1).
Fig. 1

Flow diagram detailing the identification process for the present cohort of spinal anesthetics

The basic data of our study are shown in Table 2. In these spinal anesthesia, the concentration of bupivacaine is 0.375%, while the concentration of ropivacaine is 0.5%. The average age of bupivacaine is 47.4 years old, and the relatively young age of ropivacaine is 32.3 years old. The gender ratio (male/female) in the two groups was significantly different, with the ratio of 36/22 in the bupivacaine group and 10/125 in the ropivacaine group. There was no significant difference in height, weight, and BMI between the two groups. The highest dermatome included sensory block plane, T8 in bupivacaine group and T6 in the ropivacaine group. The main operation type of ropivacaine group was cesarean section, and the main operation type of bupivacaine group was anorectal surgery.
Table 2

Cohort characteristics

 

Bupivacaine

Ropivacaine

Age, years (median, range)

47.4 (21–85)

32.3 (19–86)

Gender (male/female)

36/22

10/125

Duration of surgery, min (median, range)

37.6 (12–135)

51.2 (28–140)

Height, cm (median, range)

163.3 (146–184)

159.1 (140–180)

Weight, kg (median, range)

64.0 (41–85)

67.9 (48.5–100)

BMI kg/m2 (median, range)

23.9 (17.5–29.3)

26.9 (20.5–41.6)

Anesthetic volume (mg), n (%)

  ≥ 15 mg

13 (22%)

135 (100%)

  11–15 mg

35 (60%)

 

  < 11 mg

10 (18%)

 

Spinal approach, n (%)

  Midline

49 (84%)

126 (93%)

  Paramedian

9 (16%)

9 (7%)

  High dermatome included in sensory block (median, range)

T8 (T6–T10)

T6 (T4–T8)

Surgical procedure, n (%)

  Cesarean section

 

123 (91%)

  TURP

5 (8%)

 

  Transurethral lithotripsy

8 (14%)

 

  HEMORRHOIDS surgery

38 (66%)

 

  Varicose vein

3 (5%)

 

  Orthopedics

4 (7%)

12 (9%)

Intraoperative position, n (%)

  Lateral

 

123 (91%)

  Lithotomy

50 (86%)

 

  Supine

8 (14%)

12 (9%)

The situation of TNS after anesthesia was also different in the bupivacaine group and ropivacaine group, but the difference was not significant. As shown in Table 3, TNS may occur after operation with either bupivacaine or ropivacaine, but the probability of TNS with bupivacaine is higher. The location of pain after anesthesia in the two groups was mainly located in the buttocks and thighs. According to our TNS score, TNS was assessed as greater than or equal to 3 points. Independent sample t test of patients’ VAS score and TNS score showed that there was no significant difference between the two groups in VAS score and TNS score (p0.543, P = 0.206) (Fig. 2a). Although there was no statistical difference, we can see the VAS score and TNS score were lower in the ropivacaine group (Table 4).
Table 3

Transient neurological symptoms after spinal anesthesia

 

Bupivacaine

Ropivacaine

P value

Number of patients, n (%)

24 (41.38%)

45 (33.33%)

Location of pain (n)

  Buttocks

20

26

 

  Thighs

26

56

 

  Calves

28

57

 

  Feet

28

54

 

  buttocks, thighs, calves, and feet

18

24

 

  Buttocks, thighs, calves

0

0

 

  Thighs, calves, and feet

6

21

 

  TNS scores (mean ± SD)

1.8 ± 1.7

1.4 ± 1.6

0.206

  VAS scores (mean ± SD)

2.3 ± 1.1

2.2 ± 0.76

0.543

Fig. 2

The VAS scores and TNS scores of each group and the Pearson correlation of TNS in bupivacaine. a The VAS scores and TNS scores of each group; there was no significant difference between the two groups in VAS score and TNS score (p0.543, P = 0.206). b The Pearson correlation of TNS and sensory plane in bupivacaine; the Pearson correlation coefficient was − 0.06269, P = 0.5925. c The Pearson correlation of TNS and duration surgery in bupivacaine; the Pearson correlation coefficient was 1.445, P = 0.4114. d The Pearson correlation of TNS and VAS scores in bupivacaine; the Pearson correlation coefficient was 0.1813, P = 0.0236. There was linear correlation between the VAS scores and TNS scores

Table 4

The Pearson correlation of each group

Bupivacaine

VAS

Duration

Sensory

Ropivacaine

VAS

Duration

Sensory

TNS

Pearson correlation

0.1813*

1.445

− 0.063

TNS

Pearson correlation

0.078

− 0.01902

− 0.064*

Sig. (2-tailed)

0.024

0.411

0.592

Sig. (2-tailed)

0.058

0.980

0.007

N

58

58

58

N

135

135

135

*P < 0.05

We made a simple Pearson correlation coefficient analysis for the two groups’ TNS score and used SPSS statistical software to analyze it. It was found that there was a certain linear correlation between the postoperative VAS score and TNS score in the bupivacaine group, and the correlation coefficient was 0.1813 (Y = 0.1813 × X + 1.974, P = 0.0236) (Fig. 2b–d). This indicates that the higher the postoperative VAS score, the greater the possibility of postoperative TNS. In the ropivacaine group, there was a linear correlation between the postoperative TNS score and the post-anesthesia sensory block plane, with the correlation coefficient of − 0.06424 (Y = − 0.06424 × X + 6.166, P = 0.0075) (Fig. 3), indicating that the higher the post-anesthesia sensory block plane, the greater the possibility of postoperative TNS. Of course, this is a simple correlation analysis.
Fig. 3

The Pearson correlation of TNS in ropivacaine. a The Pearson correlation of TNS and VAS scores in ropivacaine; the Pearson correlation coefficient was 0.07771, P = 0.0578. b The Pearson correlation of TNS and sensory plane in ropivacaine; the Pearson correlation coefficient was − 0.06424, P = 0.0075. There was linear correlation between the sensory plane and TNS scores. c The Pearson correlation of TNS and duration surgery in ropivacaine; the Pearson correlation coefficient was − 0.01902, P = 0.9805

Discussion

At present, there is no definite diagnostic scale and the gold standard for the diagnosis of TNS, only based on whether the patient has postoperative recoverable pain and paresthesia in the buttocks and radiated to the thighs [7]. However, patients’ description of postoperative pain is highly subjective and cannot objectively reflect their specific pain. In addition, there is no objective basis for the diagnosis of TNS at present. This study is the first to use the TNS scoring system for the diagnosis of TNS, which provides a certain scoring standard for the diagnosis of clinical complications after spinal anesthesia surgery. In our study, we found that the patients with higher TNS score had more clinical symptom sites, and it is related to the type of local anesthetic. Although it is not the most accurate, it is indeed a practical standard.

Many previous studies have found that the occurrence of TNS after spinal anesthesia seems to be related to the use of special local anesthesia. Both bupivacaine and ropivacaine may develop TNS after spinal anesthesia, and lidocaine has been found to be more correlated with TNS than other local anesthetics, so this study first excluded lidocaine anesthesia [8, 9, 10, 11, 12]. In recent years, the concept of advanced analgesia and postoperative analgesia has been gradually promoted, which also confuses the patients’ unclear description of their pain and paresthesia during postoperative visits. Therefore, in this study, the cases of advanced analgesia and postoperative analgesia were firstly deleted, which eliminated the errors brought by many analgesia technologies and made the obtained data more reliable.

The exact mechanism of TNS is not fully understood, but the toxic effects of local anesthetics play a significant role [13]. For example, ropivacaine mainly causes axonal injury by activating apoptosis mechanism, especially p38 mitogen–activated protein kinase (MAPK) [14]. In this study, Pearson correlation coefficient was used to analyze the correlation between TNS and operative time, postoperative incision pain, post-anesthesia sensory block plane, etc., and it was found that there was a certain correlation between TNS of bupivacaine and postoperative pain (i.e., VAS score), and TNS of ropivacaine and post-anesthesia sensory block plane. Although Pearson correlation coefficient analysis is simple, it has a certain effect on preliminary analysis and prevention of TNS after spinal anesthesia, which has a certain guiding effect on clinical anesthesia and postoperative analgesia. The most effective drug to treat TNS is NSAIDs, and opioids can be added to those who are ineffective. In addition, physical methods such as physiotherapy hot compress also have certain curative effect [15, 16].

The shortcomings of this study are that the sample size of various surgeries is insufficient, and the types of drugs studied are relatively simple. In addition, more detailed TNS scores should be provided for the diagnosis of TNS.

Conclusion

The TNS score was correlated with sensory block level, postoperative VAS score, and local anesthetic. The TNS scale can be used to evaluate the postoperative TNS of patients, and ropivacaine is used for spinal anesthesia with appropriate high plane anesthesia, which is less likely to lead to postoperative TNS.

Funding Statement

Support was provided solely from the Department of Anesthesiology, The First People’s Hospital of Shuangliu District, Chengdu.

Notes

Compliance with Ethical Standards

This study was approved by the ethics committee of The First People’s Hospital of Shuangliu District, Chengdu. All study subjects gave informed consent prior to participating in the study.

Conflict of Interest

The authors declare that they have no competing interests.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyThe First People’s Hospital of Shuangliu DistrictChengduChina

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