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Invited commentary

Is 4% articaine suitable for spinal anaesthesia?

Malinovsky, Jean-Marc

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European Journal of Anaesthesiology: January 2012 - Volume 29 - Issue 1 - p 5-6
doi: 10.1097/EJA.0b013e32834de295

This Invited Commentary accompanies the following article:

Bachmann M, Pere P, Kairaluoma P, et al. Randomized comparison of hyperbaric articaine and hyperbaric low-dose bupivacaine along with fentanyl in spinal anaesthesia for day-case inguinal herniorrhaphy. Eur J Anaesthesiol 2012; 29:22–27.

Concerns regarding neurotoxicity with lidocaine have prompted efforts to find an alternative local anaesthetic for short-acting spinal anaesthesia. Current practice for ambulatory spinal anaesthesia involves low doses of bupivacaine or ropivacaine to which a lipid-soluble opioid is added. Articaine is not a new local anaesthetics but in common with lidocaine, it has a profile that includes a short duration, suggesting that it may be suitable for ambulatory spinal anaesthesia.1 In support of this, Bachmann et al.2 compared 84 mg of intrathecal 4% articaine with a combination of 7 mg of bupivacaine and 10 μg of fentanyl for the repair of inguinal hernia in 80 ambulatory patients. They chose 84 mg of articaine for this study because a previous study showed that it was as efficient as 108 mg for day-case surgery.3 They found that cephalad spread of anaesthesia was higher and the duration of anaesthesia shorter with articaine than with a bupivacaine–fentanyl combination. There was no significant difference between the two groups in the time that the anaesthesia block height rose to T10; however, despite this, three patients required general anaesthesia because the duration of anaesthesia was too short. Two of these patients had received articaine, and the third had an inadequate block after bupivacaine–fentanyl. The authors found that 84 mg of articaine was equivalent to the 7 mg of bupivacaine and 10 μg of fentanyl combination and felt that it was suitable for ambulatory spinal anaesthesia. They came to this view in the knowledge that two patients in the articaine group had unilateral transient radicular symptoms identical to those associated with spinal anaesthesia, and one patient in the bupivacaine–fentanyl group had sciatica related to the prolapse of an intervertebral disk. No other radicular signs were reported by patients during telephone interviews on postoperative days 1 and 7. Some 56% of patients in the articaine group reported satisfaction with their spinal anaesthesia compared with 44% in the bupivacaine–fentanyl group.2 Articaine has a reputation for low systemic toxicity due to its rapid breakdown into an inactive metabolite,4,5 but little is known about its potential for local neurotoxicity. When all this is taken into account, should we use articaine in our routine practice?

Although lidocaine has a long history of use in spinal anaesthesia, local neurological toxicity was not reported until the 1990s.6–9 After the development of cauda equina syndromes following its use by the intrathecal route, and the reporting of transient radicular irritation, further experiments went on to prove the toxic effects of lidocaine on nervous tissue.10–13 We have understood for a long time that all local anaesthetics are potentially neurotoxic, but the severity of the toxicity varies according to the local anaesthetic used.14 We know that bupivacaine and ropivacaine are less neurotoxic than lidocaine,13,15 but information regarding the potential neurotoxicity of articaine is currently unavailable. Studies that fail to demonstrate clinical signs of neurotoxicity are not sufficient to draw firm conclusions about safety for intrathecal use.

There are no published data about the potential neurotoxic effects of articaine, but because it is a short-acting local anaesthetic much used in dentistry it does have a track record. Residual paraesthesia or dysaesthesia is reported after dental anaesthesia with local anaesthetics in general, mainly lidocaine, prilocaine and articaine. In a survey of the incidence of paraesthesia occurring after dental surgery, Haas and Lennon,16 in the province of Ontario, showed a dramatic rise in this complication in 2000, coincident with the introduction of 4% articaine. Garisto et al.17 showed that reports of paraesthesia with 4% articaine were 3.6 times greater than expected on the basis of its use by US dentists. Pedlar18 at the Leeds Dental Institute made similar observation. The incidence of paraesthesia was higher after mandibular nerve blocks than that after inferior alveolar block.19 A neurotoxic effect cannot be ruled out because the site of local anaesthetic injection is closer to the mandibular nerve. Paraesthesiae were also reported in the present study in two patients, and by Hendriks et al.20 in another study. Recently, Hillerup et al.,21 in an electrophysiological and histological study on the rat sciatic nerve, showed concentration-dependent neurotoxic injuries after injection of articaine that were significantly different between the 2 and 4% formulations. The concentration of articaine used in dental anaesthesia and for spinal anaesthesia was the 4% solution. Before promoting the use of 4% articaine for spinal anaesthesia in routine practice, we must first establish its neurological safety in the experimental laboratory.


This article was checked and accepted by the editors, but was not sent for external peer review.


1. Kaukinen S, Eerola R, Eerola M, Kaukinen L. A comparison of carticaine and lidocaine in spinal anaesthesia. Ann Clin Res 1978; 10:191–194.
2. Bachmann M, Pere P, Kairaluoma P, et al. Randomized comparison of hyperbaric articaine and hyperbaric low-dose bupivacaine along with fentanyl in spinal anaesthesia for day-case inguinal herniorrhaphy. Eur J Anaesthesiol 2012; 29:22–27.
3. Kallio H, Snall EV, Luode T, Rosenberg PH. Hyperbaric articaine for day-case spinal anaesthesia. Br J Anaesth 2006; 97:704–709.
4. Leuschner J, Leblanc D. Studies on the toxicological profile of the local anaesthetic articaine. Arzneimittelforschung 1999; 49:126–132.
5. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 1997; 33:417–425.
6. Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 1991; 72:275–281.
7. Schell RM, Brauer FS, Cole DJ, Applegate RL 2nd. Persistent sacral nerve root deficits after continuous spinal anaesthesia. Can J Anaesth 1991; 38:908–911.
8. Schneider MC, Birnbach DJ. Lidocaine neurotoxicity in the obstetric patient: is the water safe? Anesth Analg 2001; 92:287–290.
9. Zaric D, Pace NL. Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics. Cochrane Database Syst Rev 2009:CD003006.
10. Johnson ME. Potential neurotoxicity of spinal anesthesia with lidocaine. Mayo Clin Proc 2000; 75:921–932.
11. Lambert LA, Lambert DH, Strichartz GR. Irreversible conduction block in isolated nerve by high concentrations of local anesthetics. Anesthesiology 1994; 80:1082–1093.
12. Radwan IAM, Saito S, Goto F. The neurotoxicity of local anesthetics on growing neurons: a comparative study of lidocaine, bupivacaine, mepivacaine, and ropivacaine. Anesth Analg 2002; 94:319–324.
13. Sakura S, Kirihara Y, Muguruma T, et al. The comparative neurotoxicity of intrathecal lidocaine and bupivacaine in rats. Anesth Analg 2005; 101:541–547.
14. Kalichman MW, Powell HC, Myers RR. Quantitative histologic analysis of local anesthetic-induced injury to rat sciatic nerve. J Pharmacol Exp Ther 1989; 250:406–413.
15. Malinovsky JM, Charles F, Baudrimont M, et al. Intrathecal ropivacaine in rabbits: pharmacodynamic and neurotoxicologic study. Anesthesiology 2002; 97:429–435.
16. Haas DA, Lennon DA. A 21 year retrospective study of reports of paraesthesia following local anaesthetic administration. J Can Dent Assoc 1995; 61:319–320.
17. Garisto GA, Gaffen AS, Lawrence HP, et al. Occurrence of paresthesia after dental local anesthetic administration in the United States. J Am Dent Assoc 2010; 141:836–844.
18. Pedlar J. Prolonged paraesthesia. Br Dent J 2003; 195:119.
19. Hillerup S, Jensen R. Nerve injury caused by mandibular block analgesia. Int J Oral Maxillofac Surg 2006; 5:437–443.
20. Hendriks MP, de Weert CJ, Snoeck MM, et al. Plain articaine or prilocaine for spinal anaesthesia in day-case knee arthroscopy: a double-blind randomized trial. Br J Anaesth 2009; 102:259–263.
21. Hillerup S, Bakke M, Larsen JO, et al. Concentration-dependent neurotoxicity of articaine: an electrophysiological and stereological study of the rat sciatic nerve. Anesth Analg 2011; 112:1330–1338.
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