Total spinal anesthesia provides transient relief of intractable pain

Abstract

P Pu ur rp po os se e: : Intentional total spinal anesthesia (TSA) has been used for intractable pain treatment. However, the long-term effect of painrelief is controversial. We investigate the short-and long-term effects of pain-relief by TSA.M Me et th ho od ds s: : 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.R Re es su ul lt ts s: : Heart rate and mean arterial pressure during or after TSALido 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.C Co on nc cl lu us si io on n: : Intractable pain was decreased significantly for several days after TSA, but pain-relief was not sustained. Objectif : La rachianesthésie totale (RAT) intentionnelle est utilisée comme traitement de la douleur irréductible même si son effet analgésique à long terme est controversé. Nous avons exploré les effets analgésiques de courte et de longue durée produits par la RAT. Méthode : Douze patients souffrant de douleurs rebelles ont participé à un essai croisé. Tous les participants ont reçu deux traitements différents, selon un ordre aléatoire, à 30 jours d'intervalle : une perfusion iv avec 300 mg de lidocaïne (Lido-iv) et une RAT avec 20 mL de lidocaïne à 1,5 % (Lido-RAT). Le niveau de douleur au repos a été coté selon l'échelle visuelle analogique (EVA : 0-100), et la tension artérielle (TA) et la fréquence cardiaque (FC) ont été mesurées avant, puis deux heures, 24 h, sept jours et 30 jours après le traitement. Les concentrations plasmatiques de lidocaïne ont été mesurées à 0,5, une et deux heures. Résultats : La FC et la TAM, pendant et après la Lido-RAT, ont été similaires à celles d'avant la Lido-RAT. Les concentrations plasmatiques de lidocaïne ont été similaires pour les deux traitements.Aucune valeur n'a affiché de différence significative avec le traitement à la Lido-iv. Les cotes de l'EVA étaient comparables pour les deux thérapies (87 ± 6 avec la . Après l'administration de Lido-RAT, les résultats de l'EVA ont baissé significativement jusqu'au septième jour (deux heures, 17 ± 22, P < 0,01; 24 h, 43 ± 20, P < 0,01; sept jours, 66 ± 16, P < 0,01

Effects of intrathecal lidocaine on hyperalgesia and allodynia following chronic constriction injury in rats

“…Their result was not contrary to our findings, as they used only 500 lg lidocaine, which equaled approximately 2 mg/kg in 250 g rats. Since no response was elicited by a skin clamp through out the body in animals receiving 15 and 35 mg/kg lidocaine, suggesting that these doses of drugs also caused TSA in rats in the present study, our behavioral result is in agreement with the clinical study by Yokoyama et al, who reported sustained analgesic effects of TSA therapy with lidocaine for the relief of neuropathic pain (Yokoyama et al, 2002). In addition, our results extend this previous study by showing that lower doses of intrathecal lidocaine, which are not sufficient to cause TSA, also induce long-term suppression of hyperalgesia, and that the role of intrathecal lidocaine in providing relief of allodynia has a ''ceiling effect", which means higher doses of intrathecal lidocaine do not result in any greater anti-allodynic effects once the dose reaches the TSA level.…”

“…Recently, evidence that lidocaine exerts some of its analgesic effects via actions in the spinal cord (Olschewski et al, 1998; Ness, 2000) has led to an interest in intrathecal therapy with this agent for chronic pain treatment. Several studies have reported that large doses of intrathecal lidocaine, which will generally lead to total spinal anesthesia (TSA) in the clinics, produced reduced pain scores for up to 7 days in patients (Yokoyama et al, 2002). The unexpected long‐term pain‐relief effect of intrathecal lidocaine has added a new modality to the treatment regimen for intractable neuropathic pain.…”

In reply to “Is intrathecal lidocaine administration risk‐free in rats with neuropathic pain?”

“…lidocaine has also been shown by electrophysiological examinations to reduce spontaneous and peripherally‐evoked neuronal activity in the spinal cord of rats following selective nerve root ligation (Chapman et al, 1998). Consistent with these mechanistic studies, numerous behavioral studies in animals as well as in clinical patients clearly indicate that lidocaine given intrathecally can indeed reduce neuropathic pain (Yamashiro and Hirano, 1987; Mao and Chen, 2000; Yokoyama et al, 2002; Ma et al, 2003). In Japan, intentional total spinal anesthesia is a pain‐relief therapy approved by the Ministry of Health and Welfare (Yokoyama et al, 2002).…”

“…Consistent with these mechanistic studies, numerous behavioral studies in animals as well as in clinical patients clearly indicate that lidocaine given intrathecally can indeed reduce neuropathic pain (Yamashiro and Hirano, 1987; Mao and Chen, 2000; Yokoyama et al, 2002; Ma et al, 2003). In Japan, intentional total spinal anesthesia is a pain‐relief therapy approved by the Ministry of Health and Welfare (Yokoyama et al, 2002). Taken together, these reports as well as our findings (Gu et al, 2008; Tian et al, 2009) support the hypothesis that i.t.…”

Management of Complex Regional Pain Syndrome Type 1 With Total Spinal Block

“…There is also the case of transient hearing loss following repeated total spinal anesthesias [10], Yokoyama et al [11] and Cheon et al [9] report there was no hemodynamic instability in their cases, and the unexpected loss of consciousness loss was slowly recovered, following the recovery of respiration. Additionally, promoting safety by careful preparation and using local anesthetics diversely is recommended.…”