Persistent back pain after spinal anaesthesia in the non-obstetric setting: incidence and predisposing factors

K. Schwabe and H.-B. Hopf

Abteilung für Anästhesie und Intensivmedizin, Kreisklinik Langen, Röntgenstrasse 20, D-63225 Langen, Germany

Accepted for publication: November 20, 2000


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
We determined the incidence of persistent back pain (PBP) after non-obstetrical spinal anaesthesia (SPA) and investigated factors predisposing to such pain in a prospective 1 yr follow-up study in 245 patients undergoing elective general or trauma surgery (218 patients undergoing single SPA, 27 undergoing two to six SPAs). All patients received a first questionnaire 3 months after the last SPA, and those reporting PBP after 3 months were sent a second questionnaire 1 year after the operation. Variables were PBP before and within 5 days, at 3 months and 1 year after SPA, patient satisfaction with SPA, patient characteristics and technical data. Statistical analysis was by contingency tables with Fisher’s exact test and an unpaired t-test with logistic regression (P<0.001 after Bonferroni correction was taken as significant). The response rate in patients who had a single SPA was 56% (122/218). Twenty-three of these 122 patients (18.9%) complained of back pain before SPA compared with 12/122 (10.7%, P=0.0015) within 5 days after SPA. After 3 months, 15/122 patients (12.3%) reported PBP with 14 complaining of PBP before SPA (P<0.0001), corresponding to an incidence of new PBP of 1/122 (0.8%). Multiple logistic regression revealed that pre-existing back pain was the only variable associated with PBP after 3 months (P<0.0001). Patient characteristics and technical factors were not associated with PBP. Nine of the 15 patients with PBP after 3 months returned the second questionnaire: four still reported PBP (three of these had suffered from PBP before SPA). Despite PBP after 3 months, 13/15 patients said they would opt for SPA again. The response rate and results in patients who had had multiple SPAs were similiar to those who had had a single SPA.

Br J Anaesth 2001; 86: 535–9

Keywords: anaesthetic techniques, subarachnoid; pain, persistent back pain


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Data on long-term back pain after non-obstetric spinal anaesthesia (SPA) are sparse.1 As back pain is a relevant public health problem,2 3 it seems appropriate to evaluate whether or not spinal anaesthesia is associated with persistent back pain (PBP), especially in view of possible public health costs. In addition, concise information regarding PBP after SPA might improve satisfaction with the anaesthetic procedure by improving pre-operative informed consent of the patient. Therefore, we evaluated, in a prospective 1 yr follow-up study, whether spinal anaesthesia is associated with PBP and, if so, which predisposing factors could be identified.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Within the quality assurance programme of our hospital, all patients scheduled for elective non-obstetric surgery (general, gynecological and orthopaedic surgery) under SPA from January 1 to December 31, 1998 were interviewed using a structured questionnaire.4 At the pre-operative visit all patients were informed that they would be given a questionnaire 3 months after their operation and were asked to fill out the form completely and return it to the hospital. In addition, for those patients suffering from PBP 3 months after SPA, a second questionnaire was sent 9 months after the first evaluation (i.e. 1 yr after SPA). No other interventions were made.

All patients were premedicated with oral midazolam 7.5 mg 20–30 min before transportation to the operation theatre. In the anaesthetic preparation room, standard monitors (ECG, arterial pressure and oxygen saturation) were applied. Thereafter, an i.v. line (without infusion) was inserted under local anaesthesia and flushed with saline. After infiltration of the L3/4 or L2/3 interspace with 5 ml of 1% mepivacaine (Scandicain; Astra Chemicals, Wedel, Holstein, Germany) SPA was performed with hyperbaric bupivacaine 0.5% (Carbostesin; Astra Chemicals) in the right or left lateral decubitus or in the sitting position using a 24G Sprotte needle in patients aged <=64 yr (Pajunk GmbH, Geisingen, Germany) or a 22G Quincke needle (Terumo Europe N.V., Leuven, Belgium) in patients aged >=65 yr.5 The dose of bupivacaine injected intrathecally depended on the duration of the surgical procedure.1 During the operation, patients were placed in the supine, left lateral or right lateral decubitus position. In 16 patients, a semi-lithotomy position was used with the hip-ankle angle not less than 90°.

The questionnaire assessed back pain before, within 5 days and 3 months after SPA. Patient satisfaction was evaluated at the end of the questionnaire by asking whether or not the patient would opt for SPA again. We designed the questionnaire specifically to evaluate back pain and not transient neurological symptoms (e.g. unilateral or bilateral pain or dysaesthesia with radiation into buttocks, thighs, calves or legs, as defined by Hampl and colleagues6).

Age, gender, height, weight, needle size, interspace punctured, bupivacaine dose, duration of anaesthesia, duration of surgery, and sedation achieved by intravenous injection of midazolam at the patient’s request were noted during anaesthesia. All data were stored in a Apple Macintosh computer for later analysis.

All data are presented as means (SD). Categorical data were analysed by means of contingency tables and Fisher’s exact test. Continuous variables were evaluated by an unpaired t-test. To identify variables associated with PBP after 3 months, multiple logistic regression analysis was carried out with PBP as the dependent variable. After correction for multiple testing (Bonferroni’s method) a P-value of <0.001 was considered significant.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A total of 285 spinal anaesthetics were performed in 245 patients during the investigation period (218 patients had a single SPA and 27 underwent SPA two to six times).

Single spinal anaesthesia
Patient characteristics are shown in Table 1. No significant difference was found between the patients suffering from back pain before, within 5 days after SPA and 3 months after SPA and those who did not. There was no relationship between the interspace punctured (L2/2, L3/4 or L4/5) and the incidence of PBP after SPA (P=0.3 and 0.4 for PBP after 5 days and 3 months, respectively). There was no relationship between needle size (24G or 22G) and PBP (P=0.12 and 0.27 for PBP 5 days and 3 months after SPA, respectively). Likewise there was no relationship between gender and back pain (Table 2).


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Table 1 Patient characteristics and technical data for 122 patients with and without back pain preoperatively (‘before SPA’), within 5 days postoperatively and 3 months postoperatively. Data represent mean (SD); SPA=spinal anaesthesia; P-value=result of an unpaired t-test; n=number of patients with and without back pain; the dose of local anaesthestic was rounded to the next 0.5 mg before SPA
 

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Table 2 Gender and presence (‘Yes’) or absence (‘No’) of persistent back pain after spinal anaesthesia (SPA) (n=122). P-values are from Fisher’s exact test
 
Overall, the incidence of back pain was 18.9%, 10.7% and 12.3% before and within 5 days and 3 months after SPA, respectively. There was a strong relationship between back pain before, within 5 days and after 3 months (Table 3): 14 of 15 patients with PBP after 3 months had complained of back pain before SPA (Table 3). Moreover, multiple logistic regression revealed that pre-existing back pain was the only variable associated with PBP after 3 months (P<0.0001, Table 4). Only one patient who had not suffered from back pain before SPA still suffered from back pain after 3 months. Thus, the incidence of PBP of new onset 3 months after SPA was 1/122 (0.8%).


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Table 3 Pre-existing back pain and incidence of persistent back pain after spinal anaesthesia (n=122). P-values are the results of {chi}2 test followed by Fisher’s exact test
 

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Table 4 Multiple logistic regression analysis of possible variables associated with back pain 3 months after spinal anaesthesia (SPA). Data represent the results of a multiple logistic regression analysis with back pain 3 months after SPA as the dependent variable and the other variables as the independent variables. P-values of <0.001 were considered significant
 
Overall, 114/122 of the patients (93.5%) were satisfied with the anaesthetic procedure. Of the 15 patients with PBP after 3 months, 13 said they would opt for SPA again. Nine of the 15 patients with PBP after 3 months returned the second questionnaire. Four patients still suffered from back pain; three of these had complained of back pain before SPA. The one patient who complained of new onset of back pain 1 yr after SPA complained also of back pain after 3 months. Seven patients said they would choose SPA again.

Multiple spinal anaesthesia
Twenty-seven patients (nine female) received SPA two to six times. Fifteen of these (56%) returned the first questionnaire. The mean age of the responders was 70 (13) yr. Eleven patients had suffered from back pain before SPA. Three months after the last SPA, only two patients (one female and one male, each of whom had had three spinal anaesthetics) reported back pain; both of them had suffered from back pain before SPA. All 15 patients said they would opt for SPA again. Both patients with PBP after 3 months returned the second questionnaire: both still suffered from back pain; the male patient said he would not opt for SPA again.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The main conclusions of this study were as follows: PBP after SPA is almost exclusively associated with pre-existing back pain; new onset of PBP is a rare event; and patient characteristics and technical factors play no significant role.

Our conclusions depend on questioning 245 patients who had undergone 285 spinal anaesthetics for elective general or orthopaedic surgery. Patient questionnaires are an accepted method for evaluating the qualitiy of anaesthetic management and the degree of patient satisfaction with the anaesthetic procedure.79 The response rate, 56%, was comparable to that found by others810 and sufficient for statistical analysis.11 Our questionnaire, which has been used previously to evaluate PBP after lumbar epidural anaesthesia,4 was designed specifically to evaluate PBP and not transient neurological symptoms, a syndrome almost specifically associated with the use of hyperbaric lidocaine.1220 In addition, hyperbaric 0.5% bupivacaine only marginally, if at all, involved in reports of transient neurological symptoms after SPA.1214 Finally, in our questionnaire, patients were asked to report other neurological symptoms or complaints after SPA to take into account possible damage caused by the needle or the position during the operation.

Since the long-term side effects of a given medical procedure are at least as relevant as those during the hospital stay, we interviewed our patients at least 3 months after the spinal anaesthetic to detect late PBP. Those patients still suffering from back pain 3 months after SPA were sent a second questionnaire to detect PBP after 1 year. We did not use a control group (e.g. those given general anaesthesia for identical types of surgery) in the present study since our main intention was to establish the previously unknown incidence of new onset of PBP after SPA. Since the results obtained in patients with multiple SPA derive from only a small group, we restrict our main conclusions to those patients with single SPA. Therefore, we are confident that our results and conclusions concerning the incidence and predisposing factors of persistent back pain after SPA are valid.

Considering the fact that, in any one year, more than half of the population will suffer from back pain on at least one occasion3 and that 10–15% of these patients will go on to develop chronic back pain,2 the problem of PBP after SPA should be discussed with the patient during the preoperative evaluation. Surprisingly, no firm data regarding PBP after SPA exist. Virtually all papers evaluating back pain after SPA have focused on short-term (post-operative day 1–7) incidence of either transient neurological symptoms1219 or back pain2030 but not on PBP or the association with pre-existing back pain. The mean incidence of back pain in studies primarily dealing with short-term back pain2030 was 15.4% (range: 5.4–29%) which is comparable to the incidence of back pain found in our study, namely 18%, 10.7% and 12.3% before, within 5 days and 3 months after SPA, respectively. This is also comparable to the incidence found in epidemiological data.2 3 That the number of patients with back pain after spinal anaesthesia was less than those who had back pain before anaesthesia reflects the often transient character of back pain in some of the patients, as described previously.2 3 Therefore, it is not surprising that 11 and eight patients each who complained of back pain before spinal anaesthesia did not report these complaints 5 days and 3 months after spinal anaesthesia, respectively.

Our study reveals for the first time that the true (new) incidence of PBP is only 0.8% (1/122) 3 months after SPA and that there is a close relationship between back pain before and after SPA. In fact, 14/15 patients with single SPA and 11/15 patients with multiple spinal anaesthetics suffering from PBP after 3 months had complained of back pain before. Thus any conclusions regarding the incidence or aetiology of PBP after SPA are not valid without knowledge of the preoperative status.

The one patient with new onset of PBP after single SPA in our study did not report transient neurological or radicular symptoms,1219 so PBP in this patient may have been caused by a flattened lumbar curve secondary to muscle relaxation induced by SPA.1 However, we cannot exclude the possibility that factors other than SPA may have played a role in the new onset of PBP in this patient.

Our study also shows that most patients do not link their post-operative complaints of low back pain to the spinal anaesthetic. In fact, only two of 15 patients with PBP said they would refuse SPA when operated on again. Moreover, all 15 of the patients who had had multiple spinal anaesthetics said they would opt for SPA again despite persistent low back pain. Thus we believe that it is not justified to deny patients with pre-existing low back pain the benefits of SPA for ‘medico-legal’ reasons. Rather it seems appropriate to discuss the anaesthetic procedure including the problem of PBP pain pre-operatively more intensively.


    Acknowledgement
 
The authors acknowledge Dr Matthias Leischik for critical review of the manuscript.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
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