In contrast, 1 study observed the incidence of back pain after spinal anesthesia to be significantly higher than after general anesthesia (26% vs 4%).42 The backache lasted for only 2 days, was mild in intensity, and did not interfere with the patients’ normal activities. In this study, the authors specifically noted the lack of a radicular component, i.e., there was no radiation to the lower extremities. One can conclude from the studies6,39,40,42 that the incidence of back pain after spinal anesthesia is not different from general anesthesia (level 2).
INCIDENCE OF BACK PAIN AFTER NEURAXIAL ANESTHESIA: PREEXISTING BACK PAIN AS A PREDISPOSING FACTOR
In the seminal articles by Dripps and Vandam,1,2 8460 patients undergoing 10,098 spinal anesthetics were studied. Although the incidence was not reported, Dripps and Vandam noted the occurrence of back pain after spinal anesthesia. Other studies in the 1950s and 1960s showed the incidence to be 2% to 3% after epidural anesthesia.3,4 Another study, which looked specifically into the incidence of back pain after epidural anesthesia, demonstrated the incidence to be 7% (11 of 167 patients).5 In this study, the authors examined their patients, which showed limited back flexion in some but with negative neurologic findings. Spine radiographs, when ordered, showed degenerative osteoarthritis. There was tenderness and “minor superficial injury” at the site of injection and they attributed the patients’ pain to these findings. Most back pain disappeared within 24 to 48 hours (7 patients) or, at worst, within several days.5
More recent studies on back pain after spinal anesthesia have reported the incidence to be 10% to 29% (Table 4).43–45 One study noted the backaches to be mild in intensity, characterized by local tenderness at the site of injection, and responded to oral anti-inflammatory drugs or resolved spontaneously.44 The exact duration of the back pain was not noted. The most recent study noted that the incidence of back pain decreased from 29% on postoperative day 1 to 5% 4 weeks after the spinal.45 Not only did the incidence decrease, but the intensity of pain also diminished. The authors noted that at 4 weeks after the spinal anesthesia, only a history of back pain was related to the occurrence of back pain. The 5% incidence of back pain at 4 weeks, observed by Tekgül et al.,45 is closer to the 10% to 11% incidence noted earlier by other investigators.43,44 From the studies mentioned,43–45 it can be stated that the incidence of back pain after spinal anesthesia ranges from 9% to 29%. The pain is mild in intensity and decreases with time (level 1).
Other studies looked at the incidence of back pain after epidural anesthesia (Table 4).41,46,47 In a prospective survey of 105 patients who received epidural anesthesia, the incidence of back pain was 27% (28 of 105).46 Although it appears to be high, the authors’ criteria for back pain were not strict. All the patients characterized their pain as “injection site tenderness,” which lasted for <4 days. In this study,46 patients were only seen or contacted by telephone at 1 week after the surgery. Another study showed an incidence of 18% within 5 days and 11% at 3 months after epidural anesthesia.47 A more recent study noted the incidence of persistent back pain (pain that was consistently reported at day 2, day 10, and week 13 after surgery) after epidural anesthesia to be 2% (10 of 483 patients).41 Seventy-one patients (15%) complained of clinically significant back pain 2 days after epidural anesthesia but it was not persistent; the pain subsided by the 10th day in 38 patients or by the 13th week in 33 patients. The risk factors that were identified by the investigators included higher body mass index, >2 attempts at block placement, lithotomy position, and surgery exceeding 2.5 hours. No patient experienced paresthesia, numbness, or weakness of their lower extremities.41 The relationship of the duration of surgery and development of back pain was noted in the earlier studies of Brown and Elman6 and Urbach et al.39 The incidence of back pain after epidural anesthesia ranges from 7% to 27%. Similar to spinal anesthesia, the back pain is not persistent (level 1).
A randomized study compared the incidence and duration of back pain after spinal and epidural anesthesia.48 In their study of 192 patients younger than 50 years (96 per group), the investigators noted that the incidence of back pain was significantly more frequent (P < 0.05) after epidural compared with spinal anesthesia at postoperative day 1 (29/96 patients [30%] vs 11/96 patients [11%]), day 2 (5 patients [16%] vs 2 patients [2%]), and day 3 (9 patients [(9%] vs 1 patient [1%]). There were no differences in the age, height, weight, sex distribution, or duration of surgery between the 2 groups. The needles used were a 24G Sprotte spinal needle or an 18G Touhy epidural needle. The number of attempts was not noted nor the criteria for back pain stated in the study. It can be stated that the incidence of back pain is higher after epidural anesthesia compared with spinal anesthesia (level 2).
Although most studies reported only short-term follow-up (Table 4), 2 studies observed their patients for 1 year.43,47 In 1 study in which the incidence of back pain before the spinal anesthesia was 19% (23/122), 11% of the patients developed back pain (12/122) within 5 days after the spinal anesthesia and 12% (15/122) at 3 months.43 Seven of the 12 patients who complained of back pain at 5 days and 14 of the 15 patients who still experienced back pain at 3 months suffered from back pain before the spinal anesthesia. One patient with no history of back problems still complained of back pain at 3 months and at 1 year, resulting in a 0.8% incidence of new-onset back pain. Preexisting back pain was the only variable associated with back pain persisting for 3 months. Associations were not found with technical factors or patient characteristics. In another study, 195 patients undergoing epidural anesthesia for knee arthroscopy were followed up for 1 year.47 The incidence of back pain at 5 days was 18% (24/131) and 12% at 3 months (15 of 131 patients); 13 of the 15 patients at the 3-month follow-up suffered from back pain before the epidural anesthetic, making the incidence of new back pain 1.5%. At the 1-year follow-up, 6 of the 7 patients who had back pain before the epidural blockade continued to experience back pain. Their results were similar to the observational findings of Schwabe and Hopf43 and Tekgül et al.45 who stated that long-term back pain after epidural anesthesia was almost exclusively associated with preexisting back pain. Preexisting low back pain is a risk factor for persistent back pain after neuraxial anesthesia (level 2).
WORSENING OF BACK PAIN AFTER NEURAXIAL ANESTHESIA
Although preexisting back pain may be a risk factor for the occurrence of back pain after neuraxial anesthesia,39,43,45,47 neuraxial anesthesia does not appear to worsen the severity of the pain (Table 5). In the study by Urbach et al.39, only 1 of 11 patients noted worsening of their back pain after spinal anesthesia, an incidence similar to that seen after general anesthesia (1 of 14 patients). Three of 11 patients who underwent spinal anesthesia noted improvement, whereas 7 did not notice any change. In the general anesthesia group, 1 of 14 patients with a history of back pain experienced worsening of symptoms, whereas 13 noted no change. In the study by Schwabe and Hopf,43 6 of the 23 patients with preexisting back pain still complained of persistent back pain 1 year after their spinal anesthesia. Another study showed no exacerbation of the patients’ lumbar radicular symptoms after epidural anesthesia.49 As previously noted, some patients can have “relief” of their back pain after spinal anesthesia.39 There can also be improvement in the numbness50 reflecting the transient nature of this problem.51 The improvement of symptoms after the epidural local anesthetic injection has been documented.52 It can be stated that although preexisting back pain is a risk factor for back pain after neuraxial anesthesia, the intensity of the back pain is not worse after a neuraxial procedure (level 2).
A more recent study of 937 patients with history of spinal stenosis, disk disease, or previous lumbar surgery showed 10 of the patients developed postoperative neurologic complications (Table 5).53 Of the 10 patients, 3 experienced new sensory or motor deficits and 7 noted worsening of their symptoms. One of the 3 patients who complained of new deficits also noted complete resolution of her deficits 8 weeks after resection of an epidural ependymoma (case 5). The other 2 patients with new deficits had persistent symptoms at 3 and 7 years after surgery (cases 1 and 6, respectively). Four of the 7 patients with progression of their deficits noted improvement in their preoperative baseline status after 6 years (case 2), 3 months (case 3), 6 weeks (case 4), and 1 week (case 9). Of the remaining 3 patients, 1 partially improved 4 weeks after laminectomy (case 7), whereas the other 2 patients experienced partial resolution after 8 weeks (case 8) and after 4 weeks (case 10).
The reported improvements in back pain after neuraxial anesthesia39 should be contrasted with the reports of worsening of neurologic symptoms after neuraxial anesthesia in patients with spinal stenosis.54 In the study by Hebl et al.,53 4 of the 10 patients who developed new deficits or complained of progression of their deficits after neuraxial anesthesia suffered from spinal stenosis. The patients’ symptoms may have been related to progression of their stenosis. Taking these reports into consideration, the ASRA practice advisory on neurologic complications recommended that risk-to-benefit analysis should be made before neuraxial anesthesia is performed and increased perioperative vigilance be observed in patients with known severe spinal stenosis or those with symptoms suggestive of the problem (class II, as per ASRA’s recommendation).35 Such symptoms include neurogenic claudication or “shopping cart position” of the patient while walking (back flexed forward).
MECHANISMS AND CHARACTERISTICS OF BACK PAIN AFTER NEURAXIAL ANESTHESIA
Back pain after spinal anesthesia has been attributed to tears or other trauma to the ligaments, fascia, or bone with localized bleeding or to injury to the nerve roots in the cauda equina.2,41,42 Potential musculoskeletal mechanisms include immobility of the spine, relaxation of the paraspinal muscles under anesthesia, flattening of the normal lumbar convexity, and stretching of the paraspinal ligaments and joint capsules, especially during the lithotomy position.6,39 Pelvic rotation during the lithotomy position can accentuate the reduction in the normal lumbar lordosis from paraspinal muscle relaxation during neuraxial anesthesia, thus straining the lumbosacral ligaments.41 Increased stress to the lumbosacral ligaments also occurs during relaxation of the back muscles during spinal anesthesia.41 The risk factors for development of back pain after neuraxial anesthesia include preexisting back pain, immobilization during the surgery >2.5 hours, lithotomy position during surgery, body mass index ≥32 kg/m2, and multiple attempts at neuraxial placement.6,39,41,43,45,47
Studies examining the occurrence of back pain after neuraxial anesthesia frequently fail to describe the characteristics of the back pain. Although the back pain is typically localized to the lower back, a few studies noted the occurrence of radiation of the pain to the buttock and/or lower extremities.39,42 Most studies did not comment on the characteristics of the back pain, whether it was axial (localized to the low back), radicular, or there were signs and symptoms of facet syndrome, discogenic pain, sacroiliac joint syndrome, or piriformis syndrome. Future studies should involve a back pain specialist because a more detailed description of the patient’s symptoms and an appropriate physical examination would help define the exact nature of the back pain. It would also assist in determining the appropriate treatment of the back pain.55
EFFECTIVENESS OF NEURAXIAL ANESTHESIA IN BACK PAIN PATIENTS
The efficacy of neuraxial anesthesia in patients with low back pain has been the subject of several studies. Publications on the subject can be divided into spinal or epidural anesthesia, whether the patient underwent back surgery and whether the anesthesia was for obstetrical or general surgery. In a detailed study of the onset of sensory blockade after epidural local anesthetic injection in patients with back pain, Benzon et al.56 showed that 7 of 15 patients (46%) experienced delayed sensory blockade of some dermatomes, ranging from 35 to 95 minutes (Table 6). These nerve roots were blocked 10 to 70 minutes after the corresponding nerve roots in the contralateral lower extremity. The dermatomes with delayed onset of block corresponded to the nerve roots identified as demonstrating pathologic changes in the electromyogram or myelogram studies. They cited inflammation of the nerve roots, intraneural fibrosis, and extradural adhesions as possible reasons for the delayed onset of sensory blockade. In a prospective study of 57 patients who had had spine surgery, 52 patients received successful epidural anesthesia for their total hip or total knee replacements.49 Technical difficulty was noted in 3 patients, whereas inadequate spread in the lumbosacral segments was seen in 2 patients. None of the patients complained of exacerbation of their radiculopathy. In a retrospective study of 937 patients with spinal stenosis or lumbar disk disease, 207 of whom had previous spine surgery, the overall success rate of neuraxial anesthesia (spinal, epidural, and combined spinal–epidural [CSE] anesthesia) was 97%.53 The authors showed that previous spine surgery did not affect the success rate or frequency of technical complications. However, they reported patchy blockade in 10 patients and lack of sensory block in 16 patients. New deficits were noted in 3 patients and worsening of preexisting symptoms in 4 patients. Of the 10 patients who developed complications, 4 complications were associated with surgical etiology, 1 of the remaining cases may have been worsened by the epidural, whereas another may have been exacerbated by positioning of the patient during surgery.
With regard to the efficacy of spinal anesthesia in patients with back pain, a study noted successful placement in 41 of 42 spinal anesthetics57; spinal anesthesia was adequate for surgery in all 41 cases with full recovery of both sensory and motor functions. In non-obstetric cases, spinal anesthesia is effective in patients with back pain, whereas epidural anesthesia may result in incompletely blocked or delayed blockade of the lumbosacral nerve roots (level 2 evidence).
Published literature on epidural anesthesia in obstetric patients who had previous spine surgery has been limited to case reports,58,59 retrospective reports,60–62 a prospective observational study (Table 7),63 a prospective case-controlled study,64 or a prospective case-matched study (Table 7).65 In a retrospective study of patients who had Harrington rod instrumentation, Crosby and Halpern60 noted problems in placing the epidural catheter in 4 of 9 patients (Table 7). In the other retrospective study,61 continuous lumbar epidural anesthesia was established in 20 of 21 attempts although excessive local anesthetic requirements were noted in 8 patients. Incomplete sensory anesthesia was noted in 8 patients (Table 7). In the third retrospective study, Villevieille et al.62 noted technical failure in 2 of 22 patients and analgesic failure in another 2 patients. In a recent prospective, case-matched study in patients who had surgery for correction of scoliosis, neuraxial analgesia failure (defined as inability to initiate satisfactory neuraxial analgesia or any epidural catheter requiring replacement for inadequate analgesia at any time during labor or operative delivery) was sought.65 Such failures were noted in 12% (5 of 41) of patients who underwent surgery compared with none in the control group (0 of 41). The time to complete the neuraxial technique was longer and required more needle redirections in the patients who had surgery for correction of their scoliosis (Table 7).65 In summary, placement of the epidural needle or insertion of the epidural catheter can be difficult in patients who underwent lumbar spine surgery (level 2). Incomplete sensory blockade may occur after epidural anesthesia in obstetric patients who had previous back surgery (level 2).
In a prospective observational study, epidural anesthesia was used for women in labor who had scoliosis with or without previous spine surgery.63 CSE anesthesia or single-shot spinal anesthesia was offered for those with mild uncorrected scoliosis and continuous spinal anesthesia for women with severe scoliosis with or without surgery (Table 7).63 In that study, epidural catheters were placed in 7 women with uncorrected scoliosis, which resulted in satisfactory analgesia for labor, and continuous spinal anesthesia provided effective analgesia for labor and delivery. In the patients who underwent cesarean delivery, anesthesia was provided by CSE, single-shot spinal, or continuous spinal anesthesia. The authors noted that epidural anesthesia was effective for labor in patients with uncorrected scoliosis. A prospective, case-controlled, observational study did not look at completeness of sensory blockade but rather the bupivacaine consumption per hour of labor analgesia.64 The authors noted no difference in the hourly bupivacaine consumption in parturients with previous lumbar discectomy compared with control subjects. In this study, the majority of patients received a CSE anesthesia for initiation of their analgesia. The same investigators repeated their study in patients who had surgery for correction of scoliosis.65 Although they noted more analgesic failures and longer times to do the epidural anesthesia (Table 7), they noted no difference in the bupivacaine hourly consumption between the patients who had back surgery (median, 15 mg/h; interquartile range, 12.5–18.7 mg/h) compared with the patients who did not have previous surgery (median, 14 mg/h; interquartile range, 11.8–16 mg/h; Table 7).65 Overall, studies showed the efficacy of epidural for labor analgesia in women who had previous lumbar spine surgery (level 2).
PREVENTION OF BACK PAIN FROM NEURAXIAL INJECTION
Field block anesthesia, wherein the local anesthetic is injected into the interspinous space near the lamina, resulted in a decreased incidence of backache: 6% (18 of 322 epidural and spinal anesthetics) vs 14% (286 of 2046 “lumbar punctures”).66 This study, published as a Letter to the Editor, was retrospective, and it was not clear whether the “lumbar punctures” were spinal anesthetics or diagnostic lumbar punctures. It also appears that the control group was the patients who had the neuraxial procedure earlier, before the field block anesthesia was performed by the authors.
Controlled studies evaluating the prevention of back pain after neuraxial anesthesia involved mostly the use of an anti-inflammatory medication or steroid, given epidurally or as part of the intradermal injectate. Wang et al.67,68 and Wang and coworkers69 performed a series of studies wherein they added a steroid into their epidural injectate or added an anti-inflammatory medication to the local anesthetic for skin infiltration. In their first study, they noted that the addition of 5 mg dexamethasone to the epidural anesthesia resulted in a significantly lower incidence of back pain at 24, 48, and 72 hours after the epidural anesthesia (Table 8).67 In their second study, the addition of tenoxicam to the lidocaine for skin infiltration not only decreased the incidence of back pain after epidural anesthesia but also shortened the duration of the pain.68 In their third study, the addition of ketoprofen, a more lipid-soluble anti-inflammatory drug, to the lidocaine for skin infiltration also reduced the incidence and decreased the severity of back pain after epidural anesthesia.69 It is tempting to impart a high evidence score because the studies were randomized, controlled, and double blinded. However, it appears that the same control group was used in all 3 studies (the same incidences of back pain at 24, 48, and 72 hours). All patients in the 3 studies had hemorrhoidectomy, implying that 2000 patients had the surgery in the same hospital within 3 years and 4 months. In view of these limitations, we consider level 2 evidence and grade II recommendation on the efficacy of epidural dexamethasone for preventing back pain after epidural anesthesia.
Another group of investigators noted the beneficial effect of adding 6 mg ketorolac to the lidocaine for skin infiltration for reducing the incidence of back pain after epidural labor analgesia.70 In their vaginal delivery group, a difference in back pain scores was noted at 24 but not at 72 hours after delivery. In the cesarean delivery group, significant differences were noted at the 24 and 72 hours. Although randomized, placebo controlled, and double blinded, the study has limitations (Table 8). The results of the 3 controlled studies on the addition of an anti-inflammatory drug to the local anesthetic for skin infiltration68–70 led us to conclude that such intervention may decrease the incidence of back pain after an epidural (level 2). The presence of limitations in the 3 studies calls for prospective, randomized-controlled studies on the subject.
SUMMARY STATEMENTS ON BACK PAIN AND NEURAXIAL ANESTHESIA WITH LEVELS OF EVIDENCE
- The incidence of TNS after lidocaine spinal anesthesia is higher than after the other local anesthetics (level 1).
- The incidence of TNS after spinal anesthesia with 40 to 50 mg 2-chloroprocaine spinal is low (level 1).
- The occurrence of back pain after caudal anesthesia in children is low, mild in intensity, and self-limiting (level 2).
- The incidence of back pain after spinal anesthesia in adult non-obstetric patients is not substantially different from that seen after general anesthesia (level 2).
- The incidence of back pain is higher after epidural anesthesia compared with spinal anesthesia (level 2).
- Back pain after spinal or epidural anesthesia is mild in intensity and decreases with time (level 1).
- Preexisting low back pain is a risk factor for persistent back pain after neuraxial anesthesia. The intensity of back pain, however, is not worse after neuraxial anesthesia (level 2).
- In non-obstetric cases, spinal anesthesia is effective in patients with back pain. Epidural anesthesia, however, may result in unblocked or delayed onset of block of the lumbosacral nerve roots (level 2). This is especially true if the patient had previous spine surgery.
- The placement of an epidural needle or insertion of an epidural catheter can be difficult in patients with previous spine surgery (level 2). Incomplete sensory blockade may occur after epidural anesthesia in obstetric patients who had lumbar spine surgery (level 2).
- Epidural blockade is effective for labor analgesia in women who had previous lumbar spine surgery (level 2).
- Patients with back and radicular leg pain may improve after epidural local anesthetic injection. However, worsening of neurologic symptoms may occur after neuraxial procedures in patients with spinal stenosis (level 2).
- The addition of dexamethasone to the epidural local anesthetic may decrease the incidence of back pain (level 2).
- The addition of an anti-inflammatory drug to the local anesthetic infiltration may be effective for the prevention of back pain after epidural anesthesia (level 2).
- The number of published studies on 2-chloroprocaine spinal is not sufficient to determine the risk of neurotoxicity of the drug (class III).
- The use of neuraxial anesthesia in patients with low back pain should depend on the advantages offered by the technique and not on the possibility of worsening the patient’s symptoms (class II).
- A risk-to-benefit analysis should be made before neuraxial anesthesia is performed in patients with known severe spinal stenosis or those with symptoms suggestive of the problem. Increased perioperative vigilance after neuraxial anesthesia should be used in these patients (class II).35
- An anti-inflammatory drug may be added to the local anesthesia for skin infiltration before the neuraxial injection to prevent back pain after epidural anesthesia (class II).
Name: Honorio T. Benzon, MD.
Contribution: This author helped write the manuscript.
Attestation: Honorio T. Benzon approved the final manuscript.
Conflicts of Interest: Honorio T. Benzon consulted for Pacira.
Name: Yogen G. Asher, MD.
Contribution: This author helped write the manuscript.
Attestation: Yogen G. Asher approved the final manuscript.
Conflicts of Interest: Yogen G. Asher declares no conflicts of interest.
Name: Craig T. Hartrick, MD.
Contribution: This author helped write the manuscript.
Attestation: Craig T. Hartrick approved the final manuscript.
Conflicts of Interest: Craig T. Hartrick declares no conflicts of interest.
This manuscript was handled by: Terese T. Horlocker, MD.
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