Back Pain Following Epidural Sedation with Chloroprocaine

H. Breivik^*
*Correspondence: H. Breivik, Department of Anaesthesiology and Intensive Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway, Email:

Introduction

Because of its quick hydrolysis, chloroprocaine first became a popular epidural anaesthetic, especially in obstetrics, because it essentially eliminated worries about systemic toxicity and foetal exposure to the local anaesthetic. Unfortunately, enthusiasm for neuraxial administration of chloroprocaine was dampened by neurotoxic damage, which is thought to result from unintentional intrathecal injection of large dosages intended for the epidural space. The commercial formulation's sodium bisulfite preservative was assumed to be the culprit behind this toxicity. However, later research indicated that intrathecal bisulfite was not neurotoxic and may even have beneficial properties; it did not show neurotoxicity in animal trials. In any case, a chloroprocaine formulation free of antioxidants and preservatives is available.

Description

After receiving epidural anaesthesia, chloroprocaine has been linked to extremely painful backaches. Disodium ethylenediaminetetraacetic acid (EDTA), significant amounts of chloroprocaine, chloroprocaine's low pH, and local chloroprocaine infiltration are all factors that have been put out as contributing to this issue. For labour and delivery, some surgeries, and some types of chronic pain, epidurals are a popular technique to offer pain relief or numbness [1]. Although receiving an epidural is generally relatively safe, there are certain dangers and potential negative consequences [2].

At clinical quantities, chloroprocaine does not seem to be neurotoxic in and of it. However, when used in epidurals, formulations including EDTA can result in throbbing back pain. Large doses of formulations containing sodium bisulfate as a preservative might produce local neural irritation when applied epidurally or intrathecally; this is likely due to the formulation's low pH and sodium bisulfate's presence rather than the local anaesthetic [3]. There have been reports of persistent neurological impairments, the pathogenesis of which is debatable.

Chloroprocaine in a preservative-free formulation might be a strong competitor to replace lidocaine as the preferred medication for short-acting spinal anaesthesia. Three distinct dosages of chloroprocaine (30, 45, and 60 mg) were compared in healthy volunteers in a dose-ranging, randomised, crossover trial. The recommended range of doses of antioxidant- and preservative-free chloroprocaine for spinal anaesthesia, according to the authors, is 30-60 mg [4]. The authors cautioned against using adrenaline because 11 out of 18 administrations of chloroprocaine with adrenaline resulted in flu-like symptoms while there were no such complaints with chloroprocaine alone.

Minor localised backaches are frequently reported after regional anaesthesia, with epidural anaesthesia having a higher frequency of backaches than spinal anaesthesia. Other factors should be taken into account if you experience back pain after regional anaesthesia, even though the needles used may be a factor. For instance, using local anaesthetics may play a role. With subarachnoid injections of disodium EDTA, animal models have shown tetanic spasm followed by hindlimb paralysis as well as mild to severe localised degeneration of spinal nerve roots. Calcium pretreatment stopped the paralysis of the hindlimbs and tetanic contractions. This has led to the hypothesis that the back pain experienced by patients is caused by disodium EDTA's chelation of Ca²⁺ ions in the lumbar muscles. The psoas or quadratus lumborum muscles may experience hypocalcemic tetany as a result of EDTA-containing solution leakage from the spinal space following a highvolume injection. The precise cause of back pain after chloroprocaine epidural anaesthesia is yet unknown, though.

The preservative EDTA, massive chloroprocaine injections, and local chloroprocaine infiltration are all thought to play a role in back pain that develops after chloroprocaine epidural anaesthesia. The total volume and concentration of chloroprocaine provided correlate with the frequency and intensity of back pain among all the stated parameters.

Following a chloroprocaine epidural anaesthetic, back discomfort is selflimiting and typically goes away in a day or two. However, systemic opioid analgesia or epidural fentanyl has been successful in treating severe back pain. Maintaining a low overall chloroprocaine dosage or utilising the medicine in its preservative-free version can help with prevention.

Local anesthetics for the management of pain

Procaine derivative 2-Chloroprocaine (2-CP) is metabolised by plasma cholinesterase and has a fast beginning of action and even faster degree of clearance (plasma half-life, less than 30 seconds). In order to quickly start an epidural anaesthetic or peripheral nerve block, it is most frequently employed at concentrations of 2 percent to 3 percent. Due to its quick onset of effect and low possibility for systemic toxicity in both the parturient and foetus, epidural anaesthesia for caesarean birth is the most popular clinical usage for 2-CP. Older forms of 2-CP had sodium metabisulfite as a preservative, which has been connected to serious brain damage after unintended intrathecal injection of doses meant for epidural anaesthesia [5].

Conclusion

Later, 2-CP was reformulated with ethylenediaminetetraacetic acid (EDTA) as the preservative; however, in doses greater than 40 mL, EDTA's chelating effect has been linked to the development of severe paravertebral muscle spasms that persist even after the epidural anaesthetic has worn off. More recently, it has been demonstrated that preservative-free 2-CP can quickly and consistently induce spinal anaesthesia, with a predictable dose-dependent short duration of action. This might make it possible for it to take the place of lidocaine as the preferred medication for brief ambulatory spinal anaesthesia.

Conflict of Interest

The author declares that there is no conflict of interest associated with this manuscript.

References

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