Abteilung für Anästhesie und Intensivmedizin, Kreisklinik Langen, Röntgenstrasse 20, D-63225 Langen, Germany
Accepted for publication: November 20, 2000
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Abstract |
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Br J Anaesth 2001; 86: 5359
Keywords: anaesthetic techniques, subarachnoid; pain, persistent back pain
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Introduction |
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Materials and methods |
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All patients were premedicated with oral midazolam 7.5 mg 2030 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 patients 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 Fishers 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 (Bonferronis method) a P-value of <0.001 was considered significant.
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Results |
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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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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.
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Discussion |
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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 1015% 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 17) 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: 5.429%) 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.
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Acknowledgement |
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References |
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