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Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 181-186  

Spinal, epidural, and general anesthesia for knee joint arthroscopy: Diversity, equity, and inclusion – Comparison study


1 Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
2 Department of Radiology, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
3 Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
4 Department of Orthopedic, Farah Medical Center, Royal Medical Services, Amman, Jordan

Date of Submission10-Jun-2022
Date of Decision04-Jul-2022
Date of Acceptance14-Jul-2022
Date of Web Publication19-Sep-2022

Correspondence Address:
Dr. Rami Alqroom
Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_93_22

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   Abstract 

Background: Knee arthroscopic surgery is a commonly performed procedure for diagnosing and treating knee joint problems. This procedure can be achieved under various types of anesthesia, general; or by applying regional anesthesia or even local. Epidural anesthesia and peripheral nerve blockage have been utilized in short procedures and provided a shorter length of hospital stay than general anesthesia in many former articles; however, spinal anesthesia including bupivacaine infusion has also offered a shorter length of hospital stay compared to general anesthesia. While the literature has not compared optimal techniques for these valid options. Aims: This review was conducted to challenge the hypothesis: What would be of choice for local anesthesia agents (either epidural or spinal anesthesia) that would be comparable to short-acting general anesthesia agents in terms of patient satisfaction and discharge times?! Setting and Design: The review was conducted as a prospective, randomized study. Patients were randomized using a sealed envelope method to be selected to one anesthesia technique (general, epidural, or spinal anesthesia). Materials and Methods: During the period between January 2019 and December 2020, 198 patients underwent unilateral knee joint arthroscopy. Seventy-seven patients refused anesthesia randomization and opted for one option directly. One hundred and twenty-one patients were qualified for the final recruitment stage of this analysis to contribute to the anesthesia randomization and they were assigned into three groups. Results: Demographical analysis showed no significant differences between cohorts. No major surgical or anesthetic adverse effects were reported. Anesthesia reported satisfactory for incision among three groups. For regional anesthesia cohorts, sphincteric control (voiding) considered a mandatory parameter for discharge, was shorter in the epidural group compared to the spinal anesthesia cohort (154 ± 28 vs. 189 ± 47 min, P < 0.0013). Time to discharge for the three cohorts was also significantly shorter for general anesthesia and epidural cohorts as compared to spinal cohort (general, 106 ± 29 min; epidural, 90 ± 18 min; spinal, 151 ± 48 min, P < 0.003). A total of 114 patients stated that they would select the same anesthetic method over again. Conclusion: This review revealed that regional epidural anesthesia using 2-chloroprocaine and general anesthesia using short-acting agents were similarly successful in terms of perioperative conditions and duration of hospital stay in our center. Whereas spinal anesthesia using 10 mg of bupivacaine combined with fentanyl in the same setting lacked behind in terms of extended discharge time and showed a higher prevalence of adverse effects.

Keywords: Keywords: Arthroscopy, epidural anesthesia, knee joint, spinal anesthesia


How to cite this article:
Wesam K, Jraisat I, Harahsheh H, Al Sarairah J, Hiyari R, Al Drous R, Sha'ban F, Abdallat A, Alqroom R. Spinal, epidural, and general anesthesia for knee joint arthroscopy: Diversity, equity, and inclusion – Comparison study. Anesth Essays Res 2022;16:181-6

How to cite this URL:
Wesam K, Jraisat I, Harahsheh H, Al Sarairah J, Hiyari R, Al Drous R, Sha'ban F, Abdallat A, Alqroom R. Spinal, epidural, and general anesthesia for knee joint arthroscopy: Diversity, equity, and inclusion – Comparison study. Anesth Essays Res [serial online] 2022 [cited 2022 Dec 5];16:181-6. Available from: https://www.aeronline.org/text.asp?2022/16/2/181/356419




   Introduction Top


Knee arthroscopic surgery is a commonly performed procedure for diagnosing and treating knee joint problems. This procedure can be achieved under diverse types of anesthesia, general, regional, or even local anesthesia. Epidural anesthesia in addition to peripheral nerve blockage both have been utilized in short procedures and provided a briefer extent of hospital stay than general anesthesia in many former articles; however, spinal anesthesia including bupivacaine infusion has also offered a shorter length of hospital stay compared to general anesthesia.[1],[2],[3] Nevertheless, current data indicate that anesthesia agents usually utilized for spinal and epidural regional anesthesia necessitate longer hospital stay than the recently used (propofol and sevoflurane) shorter-acting general anesthesia agents.[4],[5] While the literature has not compared optimal techniques for these valid options. This analysis was conducted to challenge the hypothesis: What would be of choice for regional anesthesia agents (either epidural or spinal anesthesia) that would be comparable to short-acting general anesthesia agents in terms of patient satisfaction and discharge times?! We compared the length of hospital stay, adverse effects of agents applied, and levels of patient satisfaction of the three anesthesia procedures; these procedures were accomplished with an “ultimate” agent, for knee joint arthroscopy.


   Materials and Methods Top


Study ethics

Patients visited our center who booked elective unilateral knee joint arthroscopy have been recruited after applying the inclusion and exclusion criteria. Patients were requested to participate in this prospective, randomized comparative study of anesthetic procedures. This study was approved by the institutional ethics committee (IRB: March 12, 2022) on the 8th of May 2022. Written informed consent was obtained for participation in the study and the use of the patient data for research and educational purposes. The procedure follows the guidelines laid down in the Declaration of Helsinki (2013).

Patient

During the period between January 2019 and December 2020, 198 patients underwent unilateral knee joint arthroscopy. Forty-seven patients refused anesthesia randomization and opted for one option directly. One hundred and twenty-one patients were qualified for the final recruitment stage of this analysis to contribute to the anesthesia randomization and they were assigned into three groups. Patients undertook serial physical examinations and radiological evaluations. Demographical and clinical data among groups showed no differences in terms of age, body mass index, gender, or physical status [Table 1]. The same orthopedic surgeon did all procedures. Perioperatively, no significant surgical or anesthesia-related complications were reported. The anesthesia level was satisfactory for the surgery site in all three procedures.
Table 1: Demographic features of the study population

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Inclusion/exclusion criteria

Inclusion criteria were:

  1. The primary procedure for unilateral knee joint arthroscopy
  2. Age between 18 and 60 years
  3. The American Society of Anesthesiologists Physical Status Classification I–II.


Exclusion criteria were:

  1. Unsatisfactory follow-up
  2. Anterior cruciate ligament repair
  3. Existence of severe systemic disease
  4. Age under 18 years
  5. Allergy to anesthetic agents used
  6. Localized infection
  7. Bleeding disorders
  8. Neurologic disease.


Study design

This review was conducted as a prospective, randomized study. Informed consent was obtained, and then patients were randomized using a sealed envelope method to be selected to one anesthesia technique (general, epidural, or spinal anesthesia).

Standardization of anesthesia and surgical technique

General anesthesia technique

Our protocol of general anesthesia encompasses a perioperative evaluation including patients' laboratory tests and chest X-rays. While the patient in the supine position, we start preoxygenation using a face mask to deliver 100% of oxygen (O2) for 3 min, then we start induction using xylocaine 1 mg.kg−1 plus fentanyl at a dose of 1.5–3 mg.kg−1 and propofol 2 mg.kg−1 intravenous (i.v.). Once this phase was completed and optimal settings for intubation had been attained (eyelash reflex diminished, and apnea occurred). In addition, we usually introduce rocuronium bromide as an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery. The standard intubating dose during routine anesthesia is mg.kg−1; once we achieve visualization of vocal cords with a laryngoscope, after which endotracheal tube was ventilated with O2 and sevoflurane 2% for 2 min. Once the surgical procedure was initiated, the continuous infusion was set as follows: remifentanil 0.25 mg.kg−1.min−1.

Typical monitoring includes (electrocardiogram, noninvasive and invasive monitoring of blood pressure, pulse oximetry recording, and capnography observations). Furthermore, our monitoring includes median nerve stimulation for muscle relaxation titration. Anesthesia was performed by a senior anesthesiologist experienced in total i.v. anesthesia techniques.

About 10 min before the end of the surgery, we start giving morphine at 0.1 mg.kg−1. The i.v. drug infusion was terminated once the trocars were withdrawn from the surgical site. Medical air then stopped; the patient kept on pure oxygen which was stopped with the initiation of skin closure. Residual neuromuscular blocking effects were reversed using 2.5 mg neostigmine and 1 mg atropine.

Epidural anesthesia

  1. Position: Patients who were selected randomly into this group were placed in a sitting position with the affected knee placed in the dependent position and then the patient was placed in the supine position
  2. Entry point: the midline was aimed. After aseptic and antiseptic preparation, the L2–L3 or the L3–L4 interspace was targeted, the overlying skin was injected with 1% lidocaine to decrease discomfort while advancing epidural catheter, and a test dose to rule out intravascular position of the catheter using 3 mL volume of 1.5% lidocaine mixed with 15 mg of diluted epinephrine of was injected.
  3. Injection: A 15 mL of 3% 2-chloroprocaine was infused in 5 mL doses
  4. Block height: A supplementary dose of 5 mL supplied after lapsing of 10 min if the blockade level was not reached above T10.


Spinal anesthesia

Patients who were randomly assigned to the spinal anesthesia group underwent the following steps in common:

  1. Position: Patients were positioned in the lateral decubitus position, with the iliac crest and shoulders perpendicularly placed to the bed, and then patients were placed in the supine position
  2. Entry point: The midline was targeted. After strict aseptic and antiseptic preparation of the designated space, either the L2–L3 or the L3–L4 interspace, the overlying skin was infiltrated with 2 mL of 1% lidocaine; A Quincke number 25G needle was introduced targeting the subarachnoid space
  3. Injection: Once the spinal needle penetrates the dura–subarachnoid space, which is usually indicated by cerebrospinal fluid (CSF) free flowing; a total amount of 10 mg of bupivacaine plus 10–20 mg of fentanyl diluted with an equivalent volume of CSF were injected into the CSF.
  4. Sensory block check: Adequate block was evaluated using the hypodermic needle picket test bilaterally.


Arthroscopy

While the patient is located supine position, with the knee flexed, a tourniquet at the above level is applied; then, an anterolateral incision in addition to the other portals made over the soft spot of the knee is made either in a vertical or horizontal fashion according to pathology targeted. A trocar was then inserted into a capsule, as then the pathology managed expectantly. As a decisive step, 50 mL of 0.25% bupivacaine was infused into the operated knee joint at the finishing point of the technique.

Length of hospital stay

Length of stay is a clinical metric defined as the time elapsed from admittance to the recovery ward till the patient was able to be discharged home, including the alert mental level, and stabilized vital signs, in the absence of nausea or vomiting, after achieving sufficient pain control, gaining the ability to ambulate, and (for regional techniques) the satisfactory sphincteric control. Adverse effects recorded included hypotension or bradycardia, in such case scenarios, if systolic blood pressure reaches 100 mmHg or heart rates dropped below 60 requiring management, ephedrine or atropine were given, respectively. Furthermore, cases developed persistent nausea or vomiting, severe postoperative pain requires i.v. narcotics. Patient satisfaction is measured with different instruments, we opted for a verbal scale of five grades, where is 5 very satisfied, and 1 very dissatisfied.

Statistical evaluation

Patient data were recorded on Microsoft Excel 2010 spreadsheets. We obtained the related material and investigated it on SPSS version 22.0 IBM SPSS 22.0, Chicago, USA. Statistics were described as mean values ± standard deviations. To evaluate clinical results between cohorts, we conducted a two-sample t-test and analysis of variance (ANOVA) assessment. To examine count data, we executed Chi-square test. If P < 0.05, this considered statistically significant.

For our initial outcome measure, we hypothesized that the discharge time standard deviation of a 46 min difference in discharge time and a sample size of 30 per group was verified (power = 80%, P = 0.05). These parameters were based on similar studies by Mulory et al. and the reports from the clinical routine.[18] The secondary outcome, according to our analysis, was competence and productivity, as anticipated by the duration of hospital stay and patient turnover period. Results for the three comparable cohorts were equated by ANOVA and deep rooted with Wilcoxon's nonparametric test; the assumption that values of 2.0 and a sample size of fifty participants per cohort would provide a statistical power of 80% to identify the minimum detectable differences concerning the two groups.


   Results Top


Our study included initially 198 patients who underwent unilateral knee joint arthroscopy during the period from January 2019 and December 2020. After applying our inclusion/exclusion criteria and skipping patients who refused randomization, we recruited 121 patients to participate in the final stage of this study [Figure 1]. Demographical analysis showed no significant differences between cohorts [Table 1]. All procedures were done by the same physician with the same techniques. No major surgical or anesthetic adverse effects were reported. Anesthesia reported satisfactory for incision among three groups. Antiemetics were required for three patients who underwent spinal anesthesia and for five patients who underwent general anesthesia, whereas in the group of epidural anesthesia, only two patients needed antiemetics.
Figure 1: CONSORT diagram

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For regional anesthesia cohorts, sphincteric control (voiding) was considered a mandatory parameter for discharge; time elapsed from drug injection to voiding was shorter in the epidural group compared to the spinal anesthesia cohort (154 ± 28 vs. 189 ± 47 min, P < 0.0013).

Time measured in the recovery room for the three cohorts was also significantly shorter for general anesthesia and epidural cohorts as compared with the spinal cohort (general, 106 ± 29 min; epidural, 90 ± 18 min; spinal, 151 ± 48 min, P < 0.003).

During the postoperative follow-up assessment, 116 out of 121 patients were pleased with the attention they got [Table 2], as five patients complained of moderate back pain on follow-up from the patients allocated in the regional anesthesia (three epidural and two spinal). Two patients in the spinal anesthesia cohort developed a mild positional headache which was resolved without any medication. Other minor adverse effects were sporadic and reported in. A total of 114 patients stated that they would select the same anesthetic method over again.
Table 2: Results

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   Discussion Top


Arthroscopy allows the surgeon to explore and repair some types of joint damage without performing a major surgical incision. To achieve this, the patient should be in a safe and comfortable position without any agonizing and stressful conditions. This further mandates some sort of anesthesia, either general anesthesia or regional anesthesia techniques, which have been applied for knee arthroscopy. Thus far, no consensus on which modality is the best and there has been no precise comparative analysis of the new general anesthetics in contrast to “ideal” regional anesthetic techniques. One of the early studies conducted by Parnass et al.[1] in which they employed isoflurane for general anesthesia. This study had the drawback that none of the recent short-acting anesthesia agents was included in the analysis. As the newly emerged general anesthesia agents such as sevoflurane permit shorter recovery and hospital stay time.

In a study carried by Pavlin et al. on patients underwent ambulatory day- surgery, to determine what factors affect discharge time, they found that general anesthesia with such short acting agents permitted an earlier discharge compared with spinal and epidural anesthesia. Limitation of this study was: the non-specificity for knee arthroscopic procedures, neither the use of short duration regional anesthesia agents.[4] Later, a study performed by Luttropp et al. on patients who underwent knee joint arthroscopy using general anesthesia short-acting agents such as propofol or sevoflurane concluded that this offers a shorter recovery time compared to spinal anesthesia.[5]

In contrast, regional anesthesia techniques have been employed with remarkable success in short ambulatory procedures, providing satisfactory anesthesia and rapid discharge, especially for outpatient knee joint arthroscopy.[2],[4],[5],[6],[7] However, comparing techniques such as peripheral nerve blocks, which consume a longer time to be applied, and somehow operator dependent, also have to some extent a higher failure rate, and may have a slower onset of action.[7],[8],[9] While neuraxial block techniques are easier to execute even in the outpatient setup, allow the titration of short-duration local anesthetics. Parnass et al., in a study comparing regional anesthesia (epidural anesthesia using lidocaine) to general technique (using isoflurane) results, showed faster discharge with regional anesthesia (159 compared to 208 min).[1]

In a study comparing different agents for epidural anesthesia to determine which agent might be superior for epidural anesthesia, results were in favor of 2-chloroprocaine, which offers faster resolution compared with lidocaine (127 vs 195 min). This study found that adverse effects were alleviated when low doses of 25 mL or less were applied.[10],[11] Hence, the current clinical practice for knee arthroscopy uses epidural anesthesia with 2-chloroprocaine, which we advocated in our center.

Spinal anesthesia technique is also a strong competitor for outpatient surgery due to its reliability and simplicity but continues to consist of a single-injection technique which is a major drawback. This technique was studied extensively in terms of optimal agents, doses, and combined agents. As larger doses of some agents were needed to achieve adequate anesthesia, which was correlated with a longer duration of action. Lidocaine has been the traditional “short-acting” spinal anesthetic. A small dose of 40 mg provides discharge times equivalent to epidural anesthesia with chloroprocaine but is associated with a 10% failure rate.[12] Luttropp et al. studied lidocaine in a moderately large dose of 70–80 mg. Results showed a longer discharge time compared to general anesthesia.[5] Reports of adverse side effects after lidocaine was used for arthroscopic procedures directed the search toward alternative spinal anesthetics.[13] Ben-David et al. conducted a study using 5 mg bupivacaine combined with 10 mg of fentanyl; the results showed satisfactory anesthesia for knee surgery with minimal transient neurologic symptoms.[14] Studies showed comparable discharge times of spinal anesthesia with 50 mg lidocaine.[15] Procaine has been assessed as an alternative agent to lidocaine.[15],[16] Axelrod et al. using procaine in doses of 60 and 80 mg combined with fentanyl showed shorter recovery times, but inadequate block heights below T10 with a dose of 60 mg.[17] From these accumulative data and results shown in our study, we concluded that 10 mg of bupivacaine combined with fentanyl would provide an adequate and reliable block above T10, shorter discharge duration, and associated with less risk of adverse effects and less transient neurologic symptoms.

In this study, comparing the three techniques, general anesthesia with short-acting agents provided a recovery duration comparable to epidural anesthesia with 2-chloroprocaine. While spinal anesthesia showed, on average 45–56 min longer time for recovery than the other two techniques. Furthermore, showed a higher incidence of adverse effects such as positional headache and pruritus.

In a study comparing the level of patient satisfaction among the three techniques, results were equally high.[18] Our study results were in line.

Finally, our results, in addition to the accumulative available literature, support that using either short-acting agents' general anesthesia or epidural anesthesia using chloroprocaine will offer quick discharge for patients who underwent knee arthroscopy. The predilection concerning one of these two techniques is based on the patient's wanting to be awake throughout the process or not.

This study encountered some limitations, which may weaken the strength of this review. The relatively small sample size and the short follow-up periods might jeopardize the comparability and long-term outcomes.


   Conclusion Top


This review revealed that regional epidural anesthesia using 2-chloroprocaine and general anesthesia using short-acting agents were similarly successful in terms of perioperative conditions and duration of hospital stay/discharge times in our center. Whereas spinal anesthesia using 10 mg of bupivacaine combined with fentanyl in the same setting lacked behind on an average of 45–56 min in terms of extended discharge time and showed a higher prevalence of adverse effects.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Parnass SM, McCarthy RJ, Bach BR Jr., Corey ER, Hasson S, Werling MA, et al. Beneficial impact of epidural anesthesia on recovery after outpatient arthroscopy. Arthroscopy 1993;9:91-5.  Back to cited text no. 1
    
2.
Patel NJ, Flashburg MH, Paskin S, Grossman R. A regional anesthetic technique compared to general anesthesia for outpatient knee arthroscopy. Anesth Analg 1986;65:185-7.  Back to cited text no. 2
    
3.
Ben-David B, Levin H, Solomon E, Admoni H, Vaida S. Spinal bupivacaine in ambulatory surgery: The effect of saline dilution. Anesth Analg 1996;83:716-20.  Back to cited text no. 3
    
4.
Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H. Factors affecting discharge time in adult outpatients. Anesth Analg 1998;87:816-26.  Back to cited text no. 4
    
5.
Luttropp HH, Orlanders K, Ikonomidou E. Spinal, sevoflurane, or propofol anesthesia for outpatient knee arthroscopy. Anesthesiology 1998;89:A41.  Back to cited text no. 5
    
6.
Mulroy MF, Larkin KL, Hodgson PS, Helman JD, Pollock JE, Liu SS. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2000;91:860-4.  Back to cited text no. 6
    
7.
Dahl V, Gierløff C, Omland E, Raeder JC. Spinal, epidural or propofol anaesthesia for out-patient knee arthroscopy? Acta Anaesthesiol Scand 1997;41:1341-5.  Back to cited text no. 7
    
8.
Goranson BD, Lang S, Cassidy JD, Dust WN, McKerrell J. A comparison of three regional anaesthesia techniques for outpatient knee arthroscopy. Can J Anaesth 1997;44:371-6.  Back to cited text no. 8
    
9.
Casati A, Fanelli G, Borghi B, Torri G. Ropivacaine or 2% mepivacaine for lower limb peripheral nerve blocks. Study Group on Orthopedic Anesthesia of the Italian Society of Anesthesia, Analgesia, and Intensive Care. Anesthesiology 1999;90:1047-52.  Back to cited text no. 9
    
10.
Hodgson PS, Liu SS, Batra MS, Gras TW, Pollock JE, Neal JM. Procaine compared with lidocaine for incidence of transient neurologic symptoms. Reg Anesth Pain Med 2000;25:218-22.  Back to cited text no. 10
    
11.
Kopacz DJ, Mulroy MF. Chloroprocaine and lidocaine decrease hospital stay and admission rate after outpatient epidural anesthesia. Reg Anesth 1990;15:19-25.  Back to cited text no. 11
    
12.
Stevens RA, Urmey WF, Urquhart BL, Kao TC. Back pain after epidural anesthesia with chloroprocaine. Anesthesiology 1993;78:492-7.  Back to cited text no. 12
    
13.
Urmey WF, Stanton J, Peterson M, Sharrock NE. Combined spinal-epidural anesthesia for outpatient surgery. Dose-response characteristics of intrathecal isobaric lidocaine using a 27-gauge Whitacre spinal needle. Anesthesiology 1995;83:528-34.  Back to cited text no. 13
    
14.
Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anesthesia: An epidemiologic study of 1,863 patients. Anesthesiology 1998;89:633-41.  Back to cited text no. 14
    
15.
Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: Better anesthesia without prolonging recovery. Anesth Analg 1997;85:560-5.  Back to cited text no. 15
    
16.
Chiu AA, Liu S, Carpenter RL, Kasman GS, Pollock JE, Neal JM. The effects of epinephrine on lidocaine spinal anesthesia: A cross-over study. Anesth Analg 1995;80:735-9.  Back to cited text no. 16
    
17.
Liu S, Chiu AA, Carpenter RL, Mulroy MF, Allen HW, Neal JM, et al. Fentanyl prolongs lidocaine spinal anesthesia without prolonging recovery. Anesth Analg 1995;80:730-4.  Back to cited text no. 17
    
18.
Axelrod EH, Alexander GD, Brown M, Schork MA. Procaine spinal anesthesia: A pilot study of the incidence of transient neurologic symptoms. J Clin Anesth 1998;10:404-9.  Back to cited text no. 18
    


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