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Spinal anesthesia revisited: toxicity of new and old drugs and compounds

Hampl, Karla; Steinfeldt, Thorstenb; Wulf, Hinnerkb

Current Opinion in Anaesthesiology: October 2014 - Volume 27 - Issue 5 - p 549–555
doi: 10.1097/ACO.0000000000000108
REGIONAL ANESTHESIA: Edited by Jacques E. Chelly

Purpose of review: Neural toxicity of substances injected into the intrathecal space has been a matter of debate since the introduction of spinal anesthesia in clinical practice. In recent years, new local anesthetics and adjuvants have been proposed for intrathecal use, and new techniques such as the use of ultrasound have been propagated. The present review summarizes recent clinical and experimental data on the neurotoxic effects of drugs and substances used for or in conjunction with spinal anesthesia.

Recent findings: Chloroprocaine has been demonstrated to be associated with a lower risk of transient neurologic symptoms compared with lidocaine. However, despite extensive research, the issue of chloroprocaine or bisulfite neurotoxicity has not yet been resolved.

Recent experimental data have identified a smaller neurotoxic potential for ropivacaine compared to levobupivacaine, procaine and bupivacaine. The addition of epinephrine has not been shown to increase lidocaine neurotoxicity. In-vivo experimental data suggest that lidocaine and bupivacaine neurotoxicity is not enhanced in diabetic patients.

Furthermore, intrathecal introduction of aqueous ultrasound gel has been demonstrated to cause a distinct neuroinflammatory reaction. Finally, a large cohort study did not find the use of chlorhexidine gluconate for skin disinfection before neuraxial block to be associated with the risk of adhesive arachnoiditis.

Summary: Clinical data suggest a high safety profile for intrathecal drugs and substances used for or in conjunction with spinal anesthesia. Recent experimental models for toxicity have provided further insight into the mechanisms and demonstrated possible, albeit clinically small differences in the relative neurotoxic potential of intrathecal drugs. This may contribute to a further increase in the safe use of spinal anesthesia in the clinical setting.

aDepartment of Anaesthesiology, Spitalzentrum Biel AG, Biel, Switzerland

bDepartment Anaesthesiology & Intensive Care Medicine, University Hospital, Philipps-University, Marburg, Germany

Correspondence to PD Dr med Karl Hampl, Chairman, Department of Anaesthesiology, Spitalzentrum Biel AG, Vogelsang 84, CH-2502 Biel, Bienne, Switzerland. Tel: +41 32 324 3778; e-mail:

© 2014 Lippincott Williams & Wilkins, Inc.