Incidence of transient neurologic symptoms in patients receiving lidocaine spinal anesthesia for outpatient joint arthroplasty

Spinal anesthesia is commonly administered for lower limb total joint arthroplasty, but the prolonged motor and sympathetic block associated with bupivacaine can delay recovery. In contrast, lidocaine, with its swift onset and intermediate duration, is an attractive alternative that is well-tailored for outpatient lower limb surgery. It has historically been associated with transient neurologic symptoms (TNS), a self-limiting but potentially distressing pain syndrome. The incidence of TNS reported in older studies varies widely, often exceeding 20%, which has led to a decline in the use of lidocaine for spinal anesthesia. This study aimed to evaluate the contemporary incidence of TNS following lidocaine spinal anesthesia in the context of an established multimodal analgesic protocol for total knee and hip arthroplasty. A retrospective review of 1026 patients undergoing knee and hip arthroplasty with lidocaine spinal anesthesia was conducted. We queried our postoperative block database, which included questions specifically related to TNS, including the onset of new non-surgical back or thigh pain following resolution of the spinal block and any other associated symptoms related to TNS. Of the 1011 patients included in the final analysis, only two (0.2%, 95% CI 0.02 to 0.71%) were diagnosed with TNS, both of whom had mild, self-limited symptoms that resolved within 48-72 hours. No cases of prolonged motor or sensory block, cauda equina syndrome, or other significant complications were observed. The low incidence of TNS in this cohort contrasts sharply with historical reports and may be attributable to concurrent administration of comprehensive multimodal analgesics, including acetaminophen, non-steroidal anti-inflammatory drug, intravenous ketamine, and dexamethasone. Lidocaine spinal anesthesia for total joint arthroplasty is associated with a negligible incidence of TNS in the setting of multimodal analgesia. These findings challenge historical concerns regarding the safety of spinal lidocaine and support its use as a viable alternative for outpatient joint replacement surgery.