Regional Anesthesia in Lumbar Endoscopic Spine Surgery: Intrathecal Bupivacaine Versus Chloroprocaine

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J Minim Invasive Spine Surg Tech. 2025;10(2):198-202

Publication date (electronic) : 2025 October 31

doi : https://doi.org/10.21182/jmisst.2024.01977

Cesar Bonome-González¹, César Bonome-Roel², Juan Álvarez de Mon-Montoliú³, Efrén García-Calo¹, Adrián Velo¹, Manuel González-Murillo^,3,4

¹Department of Anesthesiology and Reanimation, Hospital San Rafael, A Coruña, Spain

²Complexo Hospitalario de A Coruña, A Coruña, Spain

³EndoColumna, Hospital San Rafael, A Coruña, Spain

⁴Traumadrid, HM Puerta del Sur, Móstoles, Spain

Corresponding Author: Manuel González-Murillo Traumadrid Spine Surgery Unit, University Hospital HM Puerta del Sur, Avenida Carlos V, 70, 28938 Móstoles, Madrid, Spain Email doctorgonzalezmurillo@gmail.com

Received 2024 December 23; Revised 2025 March 20; Accepted 2025 April 7.

Abstract

INTRODUCTION

Endoscopic spine surgery techniques offer minimally invasive alternatives to conventional open procedures for spinal pathologies, promoting faster recovery and shorter durations of both postanesthesia care unit (PACU) and hospital stays [1]. The selection of regional anesthesia, particularly spinal anesthesia, plays a pivotal role in mitigating intraoperative and postoperative complications while influencing patient comfort and recovery trajectories. Evidence suggests that spinal anesthesia is often more dependable than general anesthesia and represents the most commonly utilized regional technique for lumbar endoscopic interventions [2-5].

Recently, chloroprocaine (Ampres), an ultra–short-acting local anesthetic, has gained approval for intrathecal administration [6-8]. Its application in spinal surgery appears particularly appropriate for single-level procedures, such as lumbar microdiscectomy (LMD) or endoscopic lumbar discectomy. However, to date, no studies have directly compared the efficacy and outcomes of intrathecal anesthesia with chloroprocaine versus bupivacaine in the context of lumbar discectomies.

MATERIALS AND METHODS

Approval for this study was obtained from the San Rafael Hospital Ethics Committee prior to conducting the retrospective review of 24 endoscopic lumbar discectomy cases performed under intrathecal anesthesia using either bupivacaine (n=12) or chloroprocaine (n=12). Patients selected for outpatient procedures (hospitalization < 12 hours) underwent single-level disc discectomies. The anesthetic agent was chosen at the surgeon’s discretion based on the anticipated duration of surgery.

Informed written consent for the surgical procedure and anesthetic method was obtained from all patients. Inclusion criteria encompassed individuals presenting with radicular pain or neurological deficits attributable to disc herniation, as confirmed by magnetic resonance imaging. Patients with contraindications to spinal anesthesia—including an international normalized ratio > 1.5, platelet count < 75,000, or ongoing anticoagulant therapy—were excluded.

All patients observed a minimum fasting period of 6 hours prior to the procedure. On arrival in the operating room, an 18G peripheral intravenous catheter was placed, and standard monitoring was initiated, including noninvasive blood pressure measurement, electrocardiography, and pulse oximetry. Hemodynamic events such as systolic blood pressure reductions below 80 mmHg or bradycardia (heart rate < 50 beats/min) were managed with ephedrine administration.

Data collection included demographic variables (age, sex, and body mass index), prior lumbar surgeries, comorbidities (e.g., diabetes, hypertension, obstructive sleep apnea), American Society of Anesthesiologists (ASA) classification, preoperative analgesic use, and baseline visual analogue scale (VAS) scores for radicular pain. Perioperative data encompassed anesthesia duration, surgical duration, use of vasopressors, and intraoperative discomfort. Postoperative outcomes measured included motor block duration, time to mobilization and ambulation, postoperative VAS scores, need for urinary catheterization, and time to discharge from the PACU.

RESULTS

Twelve endoscopic lumbar discectomy procedures were performed using chloroprocaine, and 12 using bupivacaine. No statistically significant differences were identified between the 2 cohorts with regard to sex, body mass index, diabetes, hypertension, obstructive sleep apnea, motor dysfunction, or preoperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) or antiepileptics (p>0.05). However, patients in the bupivacaine group were more likely to be classified as ASA III–IV, of advanced age, and to have a history of preoperative opioid use (p<0.05) (Table 1).

Table 1.

Patient demographics and preoperative variables

None of the procedures required conversion to general anesthesia, and all patients achieved a complete motor block. Intraoperative discomfort or mild pain was reported by 1 patient in the bupivacaine group and 3 in the chloroprocaine group. Of these, 2 patients in the chloroprocaine group required additional sedation with propofol, although the difference was not statistically significant (p>0.05) (Table 2).

Table 2.

Patient intraoperative and postoperative variables

The duration of surgery was significantly longer in the bupivacaine group (p<0.05). Although intraoperative vasopressor administration and bladder catheterization were more frequent in the bupivacaine group, these differences did not reach statistical significance (p>0.05) (Table 2). Both groups reported minimal radicular pain during the postoperative period in the PACU.

Chloroprocaine was associated with significantly shorter motor block duration, earlier mobilization and ambulation, and faster PACU discharge compared to bupivacaine (p<0.05). Hospital discharge was also shorter in the chloroprocaine group, though this difference was not statistically significant. Patient satisfaction scores were comparable between the 2 groups (Table 2).

DISCUSSION

LMD is conventionally performed under general anesthesia; however, intrathecal anesthesia has gained recognition as an effective and reliable alternative, offering reduced risks associated with general anesthesia [1-5]. In this study, older patients and prolonged surgeries did not significantly affect hospitalization duration. Nonetheless, hospital stays were notably shorter in patients receiving chloroprocaine. Some patients in the chloroprocaine group experienced intraoperative discomfort requiring sedation, suggesting that a larger patient sample might reveal statistically significant differences in hospital stay, surgical discomfort, and the need for propofol supplementation.

In our retrospective study, bupivacaine is used more frequently in patients classified as ASA III–IV and of advanced age because, if a conversion to general anesthesia is necessary due to an extended surgical procedure, the risk is higher than in younger patients with a lower anesthetic risk. However, the outcomes of the variables under study depend on the pharmacological characteristics of the local anesthetic used, and this bias is minimized.

The surgical duration in the chloroprocaine group consistently remained under 1 hour, with no cases requiring conversion to general anesthesia or deep sedation. For extended procedures, however, adjunct measures such as local anesthetic infiltration or deeper sedation may be necessary. Patient comfort was rated excellent during both intraoperative and postoperative periods. Routine intraoperative analgesia, including NSAIDs and corticosteroids, effectively controlled postoperative radicular pain, obviating the need for additional PACU analgesics.

This study highlighted key recovery metrics, including duration of motor block, time to mobilization, ambulation, and PACU discharge, all of which were significantly faster in the chloroprocaine group compared to bupivacaine. These findings align with previously reported outcomes for bupivacaine [9-13]. However, no prior studies have compared chloroprocaine with bupivacaine specifically in the context of spinal surgery.

In patients receiving chloroprocaine, neurological assessments in the PACU revealed rapid recovery of sensory and motor function within minutes, while patients in the bupivacaine group required hours for similar recovery. Early neurological evaluation is critical in spinal surgery, and the delayed ambulation observed with bupivacaine not only prolonged PACU stays but also delayed mobilization on the hospital floor. Although this study did not detect statistically significant differences in overall hospital stay due to the small sample size, these delays could have broader implications for resource utilization and patient throughput.

At present bupivacaine is used in spinal surgery but is associated with intense motor blockade and urinary retention in the postoperative period, further delaying ambulation and early discharge. Chloroprocaine is an amino ester local anesthetic agent with a short half-life, provide adequate spinal anesthesia for short-duration procedures lasting less than 60 minutes. The early onset, adequate muscle relaxation and pain relief during the procedure along with early ambulation and discharge and faster recovery profile of chloroprocaine make it suitable for short procedures in spinal surgery.

This study has several limitations. First, it is a retrospective study and there may be confounding factors and biases, particularly in patient selection. Surgical times in the chloroprocaine group were shorter than in the bupivacaine group, suggesting simpler cases and that surgeons operated more quickly knowing that they were using a shorter-acting spinal anesthetic. However, this study does demonstrate the efficacy of chloroprocaine and the rapidity of recovery in these selected patients. The study size was small, however, sufficiently so for the results observed and there are no previous studies with chloroprocaine in spinal surgery.

CONCLUSIONS

Recovery times in LMD or endoscopic lumbar discectomy significantly influenced by the choice of local anesthetic for intrathecal administration. Chloroprocaine demonstrated superior outcomes in terms of expedited recovery, mobilization, and PACU discharge. However, its use should be reserved for spinal surgeries anticipated to last less than 1 hour, given its pharmacodynamic profile.

Intrathecal chloroprocaine may be an alternative to bupivacaine, allowing early ambulation and reducing postoperative care unit stay in short-duration spinal surgical procedures. These findings underline the importance of applying a personalized approach in the anesthesiologic management to improve postoperative outcome and patient satisfaction.

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