This Article Abstract Résumé de cet Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yokoyama, M. Articles by Morita, K. Search for Related Content PubMed PubMed Citation Articles by Yokoyama, M. Articles by Morita, K.

Total spinal anesthesia provides transient relief of intractable pain

[La rachianesthésie totale permet un soulagement passager de la douleur rebelle]

From the Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine and Dentistry, Okayama City, Okayama, Japan.

Dr. Masataka Yokoyama, Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine and Dentistry, 2-5-1, Shikata-cho, Okayama City, Okayama 700-8558, Japan. Phone and Fax: 81-86-235-7778; E-mail: masayoko{at}cc.okayama-u.ac.jp

	Abstract

TOP Abstract Introduction Materials and methods Results Discussion References

 
Purpose: Intentional total spinal anesthesia (TSA) has been used for intractable pain treatment. However, the long-term effect of pain-relief is controversial. We investigate the short- and long-term effects of pain-relief by TSA.

Methods: Twelve patients with intractable pain participated in a crossover study. All participants received two different treatments in random order at a 30-day interval: iv infusion with 300 mg of lidocaine (iv-Lido), and TSA with 20 mL of 1.5% lidocaine (TSA-Lido). Pain level at rest was scored with the visual analogue scale (VAS: 0–100), and blood pressure and heart rate were measured before and at two hours, 24 hr, seven days, and 30 days after treatment. Plasma lidocaine concentrations were measured at 0.5, one, and two hours.

Results: Heart rate and mean arterial pressure during or after TSA-Lido were similar to those before TSA-Lido. Plasma lidocaine concentrations were similar between the two treatments. No significant difference in any value occurred in the iv-Lido treatment. VAS were similar before both treatments (87 ± 6 for TSA-Lido; 86 ± 7 for iv-Lido). After TSA-Lido, VAS decreased significantly until day seven (two hours, 17 ± 22, P < 0.01; 24 hr, 43 ± 20, P < 0.01; seven days, 66 ± 16, P < 0.01). However, VAS returned to the pre-block values 30 days after TSA-Lido.

Conclusion: Intractable pain was decreased significantly for several days after TSA, but pain-relief was not sustained.

	Introduction

TOP Abstract Introduction Materials and methods Results Discussion References

 
GENERALLY, total spinal anesthesia (TSA) is known as a complication of epidural block. Intentional TSA, however, has been used for the treatment of intractable pain.^1–4 Especially in Japan, this technique is a pain-relief therapy approved by the Ministry of Health and Welfare.² However, the mechanism by which TSA reduces intractable pain is not clear, and the long-term effect of pain relief after TSA is controversial. The purpose of this study is to investigate the short- and long-term effects of pain-relief by TSA.

	Materials and methods

TOP Abstract Introduction Materials and methods Results Discussion References

 
Institutional and Ethics Committee approval was obtained and all participants gave informed consent. A crossover study was conducted in 12 patients with intractable pain for more than one year at an intensity greater than 70 on a visual analogue scale (VAS: 0–100, where 0 is no pain and 100 is the most extreme pain) at rest. Patients had already received analgesics, nerve blocks, and physiotherapy, but their suffering had not diminished. The patient’s data are summarized in Table I.

For TSA-Lido, participants were placed in the lateral position. A 25-gauge spinal needle was inserted into the L₃–L₄ subarachnoid space, and 1.5% lidocaine, 20 mL, was injected in 30 sec. Participants were placed in the supine position and the operating table was tilted into the head-down position immediately after the intrathecal injection to allow the injected lidocaine to spread cephalad. Thiopental, 100 mg iv, was given to avoid any uncomfortable sensation at the beginning of TSA and 40% oxygen in air was given via face mask. After the patient became unconscious and paralyzed, and dilation of pupils and loss of light reflex was observed, a laryngeal mask was inserted without muscle relaxants. Then, the lungs were ventilated mechanically with 40% oxygen in air to maintain the end-tidal carbon dioxide tension between 35 and 40 mmHg. After spontaneous breathing recovered, the laryngeal mask was removed, and 40% oxygen in air was administered via face mask.

For iv-Lido, participants received an iv injection of 60 mg of lidocaine followed by 100 mg of thiopental; then a continuous infusion of lidocaine at a rate of 160 mg•hr^-1 was administered for 1.5 hr as iv-Lido (total dose of lidocaine: 300 mg). During iv-Lido, 40% oxygen in air was given via face mask.

During treatment, ephedrine was given if systolic blood pressure decreased to < 80 mmHg, and atropine if heart rate decreased to < 50 beats•min^-1. At 0.5, one, and two hours after the start of treatment, blood samples were collected to measure plasma lidocaine concentration, and VAS at rest was checked at two hours, 24 hr, seven days and 30 days after both treatments.

Pain assessment was performed by VAS at rest and the percentage of pain-relief. The percentage of pain-relief was calculated using the following formula: .

Plasma lidocaine concentrations were measured with an enzyme immunoassay method (EMIT; Syva, a Syntex Company, Palo Alto, CA, USA) by an automatic analyses system (Aca Star; Dade International Inc., Wilmington, DE, USA).

Statistical analysis
Data are expressed as mean ± SD. The Kruskal-Wallis test followed by Dunn’s procedure was used to compare variables. Values were considered statistically significant at P < 0.05.

	Results

TOP Abstract Introduction Materials and methods Results Discussion References

 
For each variable examined, the value before TSA-Lido treatment was similar to that before iv-Lido treatment. In the iv-Lido treatment, no significant changes were found in any values. Plasma lidocaine concentrations were similar between the two groups (Table II). During TSA-Lido, loss of consciousness and cessation of spontaneous breathing were observed within three minutes, and dilation of pupils and loss of light reflex were observed within eight minutes in all participants. The duration of mechanical ventilation was 58 ± 10 min. All patients were awake by 90 min after the start of TSA-Lido. At two hours, sensory and motor disturbances were not observed, and no patient remembered insertion of the laryngeal mask. Heart rate and mean arterial pressure during or after TSA-Lido were similar to those before TSA-Lido (Table II). However, ephedrine (4–8 mg) was required in four of 12 patients, and atropine (0.25 mg) was used in two patients during TSA-Lido. At two hour after the start of TSA-Lido, VAS had decreased in all patients (Figure A, B). Five of 12 patients reported no pain and VAS was still decreased significantly at 24 hr. At seven days, VAS was decreased significantly, but nine patients reported more than 50 of VAS and three patients reported more than 80. At 30 days, VAS returned to the pre-block values. Diagnosis, region, or duration of pain did not affect the changes of VAS (Figure B). The percentages of pain-relief after TSA were 81 ± 24% at two hours, 51 ± 22% at 24 hr, 25 ± 16% at seven days, and 5 ± 5% at 30 days, respectively.

View larger version (24K): [in this window] [in a new window]   FIGURE A, Changes in mean visual analogue scale (VAS) during both treatments. VAS were similar before both treatments. There were no significant changes after iv-Lido. After TSA-Lido, VAS decreased significantly. These values were also significantly lower than those of iv-Lido (P < 0.01). Mean values ± SD are shown. **P < 0.01 vs zero hour, P < 0.01 vs iv-Lido. TSA-Lido = total spinal anesthesia with lidocaine; iv-Lido = iv injection with lidocaine. B, Changes in individual VAS during TSA treatment.

	Discussion

TOP Abstract Introduction Materials and methods Results Discussion References

Tsumura et al.¹ reported that TSA is effective for whiplash syndrome and symptoms, including pain, disappeared in nearly 100% of patients without organic changes within one week and the effect continued for one month in nearly 50%. These authors administered steroids with local anesthetics for TSA. Yamashiro et al.³ reported a case of severe herpetic neuralgia treated with TSA and, also, administered steroids with local anesthetics. Recently, Kotani et al.⁵ reported that intractable postherpetic neuralgia was reduced for a prolonged period with the intrathecal injection of steroids. Although previous reports did not mention the importance of steroids during TSA, steroids may play an important role on long-term pain-relief after TSA. However, the mechanism by which TSA (without steroids) induces short-term pain-relief, as observed in our study, remains unclear.

TSA blocks the vagus and the sympathetic nervous system.⁶ Consequently, the balance between sympathetic and parasympathetic nervous activity may be preserved. Hence, heart rate, which reflects the net effect between sympathetic and parasympathetic nervous activities³ was not altered (only two patients required atropine).

A prior report noted that repetition of TSA is more effective for pain-relief in some patients.⁵ Further studies are required to elucidate the mechanisms by which TSA reduces intractable pain, to determine the kind(s) of pain that can be appropriately treated by TSA and the optimal treatement modalities.

	Footnotes

 
Support was provided solely from departmental sources.

Revision received July 11, 2002. Accepted for publication May 27, 2002.

	References

TOP Abstract Introduction Materials and methods Results Discussion References

 
1 Tsumura Y, Hoshiga T. Subarachnoidal injection therapy in chronic cases of the so-called whiplash syndrome. Acta Anaesthesiol Scand 1971; 15: 61–4.[Medline]

2 Kimura T, Komatsu T, Hirabayashi A, Sakuma I, Shimada Y. Autonomic imbalance of the heart during total spinal anesthesia evaluated by spectral analysis of heart rate variability. Anesthesiology 1994; 80: 694–8.[Medline]

3 Yamashiro H, Hirano K. Treatment with total spinal block of severe herpetic neuralgia accompanying median and ulnar nerve palsy. Masui 1987; 36: 971–5.[Medline]

4 Kimura T, Goda Y, Kemmotsu O, Shimada Y. Regional differences in skin blood flow and temperature during total spinal anaesthesia. Can J Anaesth 1992; 39: 123–7.[Abstract/Free Full Text]

5 Kotani N, Kushikata T, Hashimoto H, et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia. N Engl J Med 2000; 343: 1514–9.[Abstract/Free Full Text]

6 Goda Y, Kimura T, Goto Y, Kemmotsu O. Power spectral analysis of heart rate and peripheral blood flow variations during total spinal anesthesia. Masui 1989; 39: 1275–81.

This Article Abstract Résumé de cet Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yokoyama, M. Articles by Morita, K. Search for Related Content PubMed PubMed Citation Articles by Yokoyama, M. Articles by Morita, K.