Developments in needle design have been driven largely by the need to reduce the incidence of post-dural puncture headache PDPH. Reduction in needle size reduced significantly the incidence of PDPH, but technical difficulties leading to failure of spinal anaesthesia are common when needles of 29G or smaller are used.
Although atraumatic needles reduce the incidence of PDPH, they have been shown to increase the likelihood of neurological deficit because of contact with either the spinal cord or the nerve roots of the cauda equina. The blunt nature of the needle tip and the increased distance that these needles have to be inserted into the subarachnoid space before CSF flow is appreciated are reasons suggested for the increased risk to central nervous system tissue.
Graphical representations of epidural D and spinal needle tip design. Reprinted with permission from reference 1. Further work is needed to determine whether the incidences of failed spinal anaesthesia and PDPH are less with the new needle design.
Only preservative-free agents should be used for spinal anaesthesia, and the agents currently available in the UK are lidocaine, bupivacaine, levobupivacaine and ropivacaine.
It should be noted that only hyperbaric heavy bupivacaine and plain levobupivacaine are licensed for intrathecal use. Data on the incidence with ropivacaine and levobupivacaine are limited so far, but would appear to be similar to that of bupivacaine. Ropivacaine is an amino-amide local anaesthetic agent that is structurally related to bupivacaine and mepivacaine. Currently, it is not licensed for intrathecal use, but a number of clinical studies have been published.
Early evaluation of the drug using glucose-free solutions demonstrated that sensory block of variable extent and intermediate duration was produced. Such findings are consistent with data published for glucose-free solutions of bupivacaine. A number of studies of intrathecal ropivacaine have questioned its suitability for spinal anaesthesia in comparison with bupivacaine.
These studies used plain, glucose-free preparations, but in larger volumes of less concentrated solutions than are normally used in clinical practice. When equal doses of ropivacaine and bupivacaine were compared, the onset and extent of sensory block were similar, but the duration of that sensory block and the degree of motor block produced were both less with ropivacaine.
These findings, particularly the shorter duration of action, led a number of authors to claim that ropivacaine is less potent than bupivacaine such that it offers no significant advantage, even though the patients who received ropivacaine passed urine and mobilized more rapidly than those who received bupivacaine. If the potency of a drug is defined as the degree of effect of a drug relative to the dose administered, then it is the clinical profile of the block produced that defines potency and not duration of action.
Upper levels of sensory block in individual patients with solutions of 0. Horizontal bars represent the median maximum block height. Where hyperbaric solutions of ropivacaine and bupivacaine have been compared in a clinical setting, the onset and extent of sensory block were similar, but the duration of that sensory block and the degree of motor block produced were both less with ropivacaine.
Patients receiving ropivacaine were also able to mobilize and micturate earlier than those receiving bupivacaine. As with bupivacaine, plain solutions of levobupivacaine were shown to produce variable spread of analgesia, which was occasionally unsatisfactory for surgery. A number of direct comparisons of levobupivacaine with racemic bupivacaine have demonstrated that the two drugs produce spinal blocks with similar clinical profiles.
However, one important point that must be noted by clinicians using the commercial preparation of levobupivacaine relates to a change in the regulations governing the presentation of hydrates and salts. As a new drug, levobupivacaine is bound by the directive of the European Economic Community which states that concentrations of hydrates and salts must be expressed in terms of milligrams of active moiety.
Thus, an ampoule of 0. The relevance of this to spinal anaesthesia has yet to be established. The very little published work on the clinical profile of hyperbaric glucose-containing solutions of levobupivacaine suggests that block characteristics are similar to those produced by hyperbaric bupivacaine. These symptoms have also been associated with mepivacaine, but are rare with prilocaine and bupivacaine.
The duration of TNS is widely variable, with the majority patients having resolution of their symptoms within 72 h. However, a small number of patients will continue to have symptoms at 1 week and beyond.
One other factor which has been implicated in the pathophysiology of TNS is flexion of the hips and knees during surgery under spinal anaesthesia e. The stretching of the ligaments, fasciae and muscles, but not the lumbosacral nerve roots, has been postulated as a possible mechanism for these findings.
The supine position results in flattening of the lumbar lordosis, and this is even more pronounced in the lithotomy position leading to hyperflexion of longitudinal ligaments, tendons, muscles and fasciae in the area.
A more profound motor block produced by lidocaine than that seen with bupivacaine, leading to supramaximal flattening of the lordotic arch has been used to explain the absence of TNS after spinal anaesthesia with the latter. There is little evidence that the TNS syndrome is of a neurological or neurotoxic nature and that the clinical picture strongly indicates that it is a myofascial pain condition. This has led some authors to suggest that a more suitable description would be transient lumbar pain TLP.
Spinal anaesthesia represents an attractive proposition for day-case anaesthesia, being associated with less postoperative nausea and vomiting PONV and better postoperative pain relief than general anaesthesia. However, significant concerns restrict the more widespread use of spinal anaesthesia for day-case procedures: the risk of PDPH; the effect on bladder function; and delay in recovery of motor function.
The use of smaller, atraumatic spinal needles has greatly reduced the incidence of PDPH and the incidence has not been shown to increase when spinal anaesthesia is used in the day-case setting. If the same upward trend persists, impact score of joule may rise in as well. Update in Anaesthesia has an h-index of 9. It means 9 articles of this journal have more than 9 number of citations. The h-index is a way of measuring the productivity and citation impact of the publications.
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