British Journal of Anaesthesia 106 (2): 183–8 (2011)

Advance Access publication 14 October 2010 . doi:10.1093/bja/aeq272

CLINICAL PRACTICE

Spinal anaesthesia for ambulatory arthroscopic surgery of

the knee: a comparison of low-dose prilocaine and fentanyl
with bupivacaine and fentanyl
A. S. Black 1*, G. N. Newcombe 1, J. L. Plummer 1, D. H. McLeod 1 and D. K. Martin 2
1
Department of Anaesthesia and Pain Medicine, Flinders Medical Centre, Bedford Park, SA 5042, Australia
2
Sportsmed SA, 32 Payneham Road, Stepney, SA 5069, Australia
* Corresponding author. E-mail: Adam.Black@health.sa.gov.au

Editor’s key points
† Prilocaine is an
alternative to lidocaine
for spinal anaesthesia in
ambulatory care.
† Prilocaine has been
reported to have a lower
incidence of transient
neurological symptoms
than lidocaine.
† Intrathecal prilocaine/
fentanyl was superior to
bupivacaine/fentanyl for
ambulatory knee
arthroscopy.
Background. Prospective data on the use of prilocaine for ambulatory spinal anaesthesia
remain limited. We compared the behaviour and characteristics of subarachnoid block
using prilocaine and fentanyl with that of bupivacaine and fentanyl.
Methods. In a prospective, double-blind, randomized controlled trial, 50 patients undergoing
elective ambulatory arthroscopic knee surgery received subarachnoid anaesthesia, with
either prilocaine 20 mg and fentanyl 20 mg (Group P) or plain bupivacaine 7.5 mg and
fentanyl 20 mg (Group B). Primary endpoints included times for onset of maximum sensory
block level and regression of sensory block to L4, and also motor block at 1 and 2 h, and
levels of haemodynamic stability. Comparisons between the groups were made by x 2 test
for proportions and the Mann–Whitney test for ordinal data. Time-to-event data were
analysed by the Mann–Whitney test for uncensored data or the logrank test for censored data.
Results. At 2 h, motor block in Group P had fully resolved in 86% of patients, compared with
27% in Group B (P,0.001). Median time to regression of sensory block to L4 was
significantly shorter in Group P (97 min) than in Group B (280 min) (P,0.001). A clinically
significant decrease in arterial pressure was more common in Group B (73%) than in Group
P (32%) (P¼0.004). Two patients in Group P required conversion to general anaesthesia, but
for reasons unrelated to prilocaine itself.
Conclusions. The combination of prilocaine and fentanyl is a better alternative to that of low-
dose bupivacaine and fentanyl, for spinal anaesthesia in ambulatory arthroscopic knee surgery.
Keywords: ambulatory; prilocaine; spinal anaesthesia; TNS
Accepted for publication: 25 August 2010

Spinal anaesthesia has some advantages in the ambulatory
setting with a meta-analysis finding both reduced pain
scores and reduced postoperative analgesia requirements.1
The use of spinal anaesthesia for ambulatory surgery has
led to the development of the ‘low dose spinal’ technique.
This involves the use of smaller than previously described
doses of local anaesthetic agents, often with the addition of
fentanyl, which has been shown to increase sensory block
without increasing motor block, or time to micturition.2 3
Bupivacaine and lidocaine have been extensively studied
in this setting.2 – 6 Because of reports of neurotoxicity and
transient neurological symptoms (TNS),7 8 there have been
doubts raised about the latter’s suitability for use in spinal
anaesthesia.9 10
Prilocaine has a similar potency and duration of action to
lidocaine11 12 and has been reported to have a lower inci-
dence of TNS.11 – 16 The prilocaine studies have reported the
use of doses of 50 mg or more, and we have been unable
to find a report of intrathecal prilocaine used in doses equiv-
alent to those recently described for lidocaine.
We chose to investigate the use of a prilocaine dose of 20
mg, as a previous study has shown that lidocaine (20 mg),
when combined with fentanyl (20 mg), provides satisfactory
spinal anaesthesia for knee arthroscopy.4 We sought to
compare its behaviour and recovery profile with that of bupi-
vacaine and fentanyl.
Methods
This study was approved by the Flinders Medical Centre ethics
committee (protocol 100/023). Written, informed consent
was obtained from all subjects.
Fifty patients with ASA I, II, or III status undergoing
elective ambulatory knee arthroscopy were enrolled. This

& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournal.org
BJA
was a double-blind, randomized controlled trial. Twenty-five
syringes each of either plain bupivacaine (7.5 mg) (Group B)
or prilocaine (20 mg) (Group P) were prepared by the
pharmacy at Flinders Medical Centre, to a total volume of
2 ml, and numbered using a set of computer-generated
random numbers. Allocation codes were held by the
pharmacy and were only disclosed after data analysis.
Patients, researchers, and support staff were all blinded to
the syringe contents. Fentanyl (20 mg) was added to the
syringe by the anaesthetist, at the time of spinal drug
administration. Total syringe volume was 2.4 ml in both
the groups.
Exclusion criteria were standard contraindications to neur-
axial block, known allergy to any of the trial agents, patients
in whom it would not be possible to adequately assess neur-
axial block, minors, and those patients in whom informed
consent would not be possible.
The number of patients enrolled in the trial was deter-
mined after an initial power analysis, with anticipated block
behaviour based upon prior clinical experience. Using a
logrank test, it was determined that 23 subjects in each
arm of the trial would provide 80% power at a two-tailed
type-1 error of 0.05 to detect a difference in median time
to sensory block regression of 1.0 h in one group, vs 2.5 h
in the other. To allow for possible drop-outs or other prob-
lems, the numbers were rounded up to 25 in each arm.
Comparisons between the groups were made by x 2 test
for proportions and the Mann –Whitney test for ordinal
data. Time-to-event data were analysed by the Mann –
Whitney test for uncensored data or the logrank test for cen-
sored data. A P-value of ,0.05 was taken as evidence of a
difference between the groups.
Spinal anaesthesia was commenced in a standard
manner, including establishing i.v. access. I.V. fluids were
not routinely given. Block was performed in the sitting pos-
ition, at either the L3/4 or L4/5 interspace, using a 25 G Whi-
tacre spinal needle. Sedation for block insertion, if required,
was provided with i.v. midazolam. Immediately after inser-
tion of the block, the patient was returned to the supine
position.
Sensation was checked using an ice pack, and sensory
block levels recorded, every 2.5 min, until the level had stabil-
ized for three consecutive tests. Thereafter, assessment con-
tinued at 5 min intervals throughout the remainder of
surgery. Motor block (in the non-operative limb) was
assessed using the Bromage scoring system, concurrent
with sensory block assessment. A baseline non-invasive
arterial pressure (NIAP) reading was recorded in the supine
position before block insertion, and further NIAP readings
were recorded at times of block level observations. Hypoten-
sion was treated with i.v. boluses of ephedrine, i.v. fluids, or
both, as clinically appropriate.
A ‘patient comfort score’ was also assessed at the same
points in time as for the previous observations. This was
done using the following scoring system:
(1) complete absence of sensation in the operative limb;
184
Black et al.
(2) sensation of limb motion only, but with no discomfort
present;
(3) mild discomfort, but with the patient declining any
offer of further analgesia or with no obvious clinical
need for such further intervention;
(4) patient expresses wish for additional analgesia or
exhibits an obvious clinical need for such intervention.
If a patient was uncomfortable, the plan was to use fentanyl,
midazolam, or both in i.v. boluses, with progression to
general anaesthesia if required.
Upon arrival in the post-anaesthesia care unit (PACU),
NIAP, Bromage score, and sensory block level were all
assessed. Thereafter, these parameters were assessed
every 10 min, with such assessment planned to continue
until complete resolution of motor block, and regression of
sensory block to S2. Time of micturition, if it occurred
before discharge, was recorded.
On the day after surgery, the anaesthetist telephoned the
patient and asked about the presence, or otherwise, of any
postoperative problems; in particular enquiring as to any evi-
dence of TNS. A global patient satisfaction score (verbal) was
also obtained, using the following scale:
(1) very dissatisfied;
(2) slightly dissatisfied;
(3) neither satisfied nor dissatisfied;
(4) satisfied;
(5) highly satisfied.
Results
Some of the local anaesthetic syringes were accidentally
desterilized and others had passed their expiry date. The
preparation of replacements by the pharmacy inadvertently
resulted in 26 bupivacaine syringes and 23 prilocaine syr-
inges in total for the trial. This was not discovered until
after the blinding had ended.
Two patients, both from Group P, had their anaesthetic
converted to general anaesthesia. In the first patient, on
insertion of the spinal needle, cerebrospinal fluid (CSF) was
seen to flow back via the needle lumen. However, the flow
was ‘sluggish’, and despite repeated manipulation of the
needle, aspiration of CSF via the syringe was never possible.
The syringe contents were injected via the spinal needle,
but no discernable block was found after injection. This
block failure therefore represented a failure of spinal tech-
nique, rather than of prilocaine itself, and was excluded
from further analysis of block behaviour. In the second
patient, the block was clinically adequate for surgery, but
on the day concerned, the external temperature was in
excess of 408C, and there was an air-conditioning failure in
theatre. The patient was distressed by the environmental
conditions and requested general anaesthesia for this
reason alone, and not because of any block failure. Obser-
vations of block behaviour both before the commencement
of general anaesthesia and after arrival in the PACU were
included in the final analysis.
Low-dose prilocaine in spinal anaesthesia
The median time elapsed from intrathecal drug adminis-
tration, until arrival in the recovery area, was 35 min (range
20–55).
Patient characteristic data
The ages (Group P mean 50 yr, range 23–77; Group B mean
50 yr, range 23 –80) and weights (Group P mean 85 kg, range
60–129; Group B mean 83 kg, range 51–101) of subjects in
both groups were similar.
Onset of block
The median highest block level obtained in Group B was T3
and in Group P was T4. Maximum attained block levels are
shown in Table 1.
A Mann–Whitney U-test showed no significant difference
in the highest level of sensory block between the two groups
(P¼0.056).
The onset time for attainment of the highest sensory
block level was shorter in Group P (median time 11.3 min,
range 2.5 –55 min) compared with Group B (median 20
min, range 7.5–60 min) (Mann –Whitney U-test, P,0.001).
Sensory block regression
A limited number of observations of regression to S2 were
recorded. This was largely due to a number of patients
being ready for discharge, and ambulating well, with a
sensory block level higher than S2. It did not seem reason-
able under these circumstances to detain these patients
BJA
was assumed for the purpose of data analysis that regression
to L4 had occurred at a point midway between these two
sets of observations. This occurred in a total of five cases
(four from Group P and one from Group B).
The Kaplan–Meier plot in Figure 1 shows the proportion of
subjects who had not yet had sensory regression to L4,
against time.
The median time for regression to L4 and the relevant
confidence intervals are shown in Table 2.
A logrank test for equality of survival functions was
applied to these data, and it demonstrated that regression
occurred significantly more quickly in Group P (P,0.001).
Motor block regression
For purposes of statistical analysis, the Bromage scores at
both 1 and 2 h were split into those subjects with a
Bromage score of zero vs those subjects with scores of 1, 2,
or 3.
One patient, as discussed previously, had a failed spinal
block, and this patient was excluded from motor block analy-
sis. In addition, two patients did not have a Bromage score
recorded at 1 h, with the actual score not being able to be
imputed with certainty. These two patients were therefore
also excluded from motor block analysis at the 1 h mark.
Proportion not yet regressed to L4

and delay their discharge home. 1.00

Accordingly, regression time to L4 was chosen instead as
the endpoint for analysis, as it was the most clinically signifi- 0.75
cant level with enough observations present for meaningful
analysis. Where a block level was recorded as being at L3
0.50
at one set of observations and 10 min later at L5, then it

0.25
Group P
Table 1 Highest attained sensory block levels Group B
0.00
Highest attained level Number of subjects 0 100 200 300
Group P Group B Time (min)

C4 1 4
C5 1 0 Fig 1 Times in minutes for regression of sensory block to derma-
tome level L4. Regression to L4 occurred more rapidly in Group P
C6 0 0
than in Group B. Proportion not yet regressed to L4 refers to the
C7 0 0
proportion of subjects in each group in whom sensory block level
T1 2 3 had not yet regressed to dermatome level L4.
T2 1 2
T3 2 6
T4 6 8
T5 4 1
Table 2 Median times (in minutes) for regression of sensory block
T6 3 0
to L4
T7 0 0
T8 2 0 Group No. of Median time (95% confidence
T9 0 1 subjects intervals)
T10 0 1 P 22 97 (90 –115)
Total 22 26 B 26 280 (207 –not computable)

185
BJA
Fifteen of 20 subjects in Group P (75%) had a Bromage
score of zero at 1 h, compared with none of 26 subjects
(0%) in Group B (P,0.001, x 2 test).
At the 2 h mark, 19 of 22 patients in Group P had a
Bromage score of zero, compared with only seven of 26
patients in Group B (P,0.001, x 2 test). Indeed, three patients
from Group B still had a Bromage score of 1 recorded at
4 h. In contrast, the longest time recorded for motor block
to resolve in Group P was 220 min (although no Bromage
scores had been recorded for this subject, from 50 min,
when the score was 1, until the next recording at 220 min;
so it may actually have resolved much earlier).
Time to micturition
Although voiding before discharge was not mandated, this
did occur in 15 subjects (of 22) in Group P and 18 subjects
(of 26) in Group B. A logrank test for equality of survival func-
tions was applied to these data, and it demonstrated that
voiding occurred significantly more quickly in Group P
(P,0.001). The median times to void and the confidence
intervals are shown in Table 3.
Haemodynamic changes
Baseline systolic NIAP was similar in the two groups, but a
greater percentage decrease from baseline was noted in
Group B (P¼0.005, Mann –Whitney U-test).
In addition, a clinically significant decrease in systolic
arterial pressure of .20% occurred in seven of 22 (32%) sub-
jects in Group P and in 19 of 26 (73 %) subjects in Group B
(P¼0.004, x 2 test).
Pruritus
A total of six subjects from Group B and two from Group P
complained of pruritus. In all cases, this resolved before dis-
charge without treatment.
Comfort scores
The distribution of comfort scores is shown in Table 4.
A Mann–Whitney U-test did not show a significant differ-
ence in comfort scores between the two groups (P¼0.09).
Satisfaction scores
All satisfaction scores (SSs) were recorded as either 4 or 5. In
Group P, four subjects gave an SS of 4 and 18 subjects gave
an SS of 5. In Group B, 10 subjects gave an SS of 4 and 15
subjects gave an SS of 5.
One subject from Group P did not have an SS recorded.
This was the patient in whom there was a failure in spinal
Table 3 Median times (in minutes) to first void
Group No. of Median time (95% confidence
subjects intervals)
P 22 205 (185 – 220)
B 26 275 (250 – 300)
186
Black et al.
Table 4 Comfort scores. Comfort refers to comfort scores
assessed on a scale of 1– 5 (see Methods). Number refers to the
number of subjects reporting the respective comfort score. One of
the subjects in Group P had a comfort score recorded as ‘1 or 2’.
For the purpose of analysis, it was recorded as 1.5
Comfort Number
Group P Group B
1 3 5
1.5 1 0
2 10 19
3 4 1
4 4 1
Total 22 26
anaesthesia. A score was not recorded, as the intention of
the study was to compare satisfaction between the two
study treatments, and not with general anaesthesia. In
addition, an SS was also not recorded for one subject in
Group B, as the anaesthetist was unable to contact the
patient.
As all SSs were either 4 or 5, results were analysed using a
x 2 test. Analysis did not demonstrate a significant difference
in scores between the two groups (P¼0.10). No patient in
either group developed symptoms consistent with the occur-
rence of TNS.
Discussion
Previous studies examining prilocaine as a spinal anaesthetic
agent have used higher doses than the 20 mg used in our
study. Doses ranged from 50 to 80 mg,11 12 14 – 16 or 1 mg
kg21.13
We chose to use 20 mg as the prilocaine dose in our trial,
based on the work of Ben-David and colleagues,4 5 who
found that lidocaine in the dose of 20 mg, when combined
with fentanyl, provided satisfactory anaesthesia for knee
arthroscopy. The bupivacaine dose was based on previous
dose-finding studies.2 6 Ben-David and colleagues,6 in exam-
ining spinal anaesthesia for knee arthroscopy, had failure of
surgical anaesthesia in four of 15 patients when using bupi-
vacaine 5 mg; but no failures in doses of 7.5 mg and higher.
In a later study, failure occurred in six of 25 patients receiving
bupivacaine 5 mg alone, but in none of 25 patients who
received fentanyl 10 mg, along with the same dose of bupiva-
caine.2 This would suggest that, in the presence of fentanyl,
bupivacaine 5 mg given intrathecally would be the ideal dose
to use in the ambulatory setting. Indeed, a recent review
suggested that bupivacaine 4–5 mg can produce effective
spinal anaesthesia for knee arthroscopy. However, this is
when hyperbaric bupivacaine is used, along with unilateral
positioning.17 Were we to have done likewise, we would not
have been able to blind our trial, as prilocaine is not available
in a hyperbaric solution. Importantly, Ben-David and col-
leagues6 also found that in patients receiving intrathecal
Low-dose prilocaine in spinal anaesthesia
bupivacaine, recovery times were not significantly different
between the groups receiving 5 and 7.5 mg doses. Using
the same dose of fentanyl (20 mg) in both of our study
groups aided blinding.
Onset of sensory block peak height was faster in Group P than
in Group B. This is likely to allow for fewer delays before the com-
mencement of surgery. Interestingly, a previous study, using
intrathecal ‘plain’ prilocaine (50 mg), found a median peak
sensory block height of T10, compared with T4 in our study
(with a lower dose of prilocaine).16 It may be that the addition
of fentanyl, and the accompanying baricity changes, contributed
to this difference. However, as in our study, the previous study
also found a wide range of peak block heights around the
median. It may be therefore that the difference in median
block heights simply represents a widespread variation in indi-
vidual block heights across the two studies.
Although the vast majority of our subjects did void before
discharge from hospital, the timing of this event is subject to
many variables. Regression of sensory block to S2 has been
argued to be a marker for the ability to void.3 18 In examining
block behaviour, we therefore aimed to use S2 as our end-
point for sensory block regression, but instead had to use
L4 as the closest level to S2 with enough observations
recorded in order to allow for interpretation of the data (for
reasons mentioned in Results). The return of the ability to
void is a complicated issue, and there remains room for
further study into the area. We did not mandate that
patients void before discharge, but nevertheless, most
patients did so. As with return of sensory function, return
of the ability to void was also faster in the prilocaine group.
Overall, both in this study and in our clinical experience of
more than 200 cases of low-dose prilocaine spinal anaesthe-
sia, the ability to void afterwards has never been of concern.
This no doubt is in part due to the absence of routine peri-
operative i.v. fluid administration, and the early return of
both motor and sensory functions.
Motor block regression was also much faster in the prilo-
caine group. Indeed, five of 22 patients in Group P never at
any stage attained a Bromage score of greater than zero,
compared with Group B where this did not occur in any
patient. Such early regression of motor block allowed for
earlier fitness for discharge. In our clinical experience, sur-
geons are generally happy with the block obtained with pri-
locaine, and the lesser degree of motor block does not
seem to hinder surgery in the co-operative patient.
Pruritus is a known side-effect of intrathecal fentanyl use.
It is generally mild, settles within several hours, and seldom
requires treatment.4 – 6 Eight of our patients spontaneously
complained of itch. None required treatment, and no one
mentioned itching as a problem on postoperative follow-up.
Associated with doubts about the use of intrathecal lido-
caine, and the high incidence of TNS associated with its use,
there have been many attempts to find an alternative short-
acting local anaesthetic for intrathecal use. Procaine has a
low incidence of TNS,19 – 21 but a high incidence of nausea19
and block failure,19 21 and fentanyl does not augment its
action.20 Chloroprocaine has a suitable block profile and a
BJA
low incidence of TNS.22 However, its use in previous formu-
lations containing sodium metabisulphate has been associ-
ated with permanent neurological injury,23 and although
preservative-free solutions are currently available, a recent
editorial has still questioned its use.24 Articaine has also
been shown recently to be a viable alternative for day-case
spinal anaesthesia, with a low incidence of TNS.16 25 – 27
This study demonstrates the superiority of the combi-
nation of prilocaine (20 mg) and fentanyl (20 mg) over that
of bupivacaine (7.5 mg) and fentanyl (20 mg) for spinal
anaesthesia in ambulatory arthroscopic knee surgery. Of
note is that this is in doses of prilocaine lower than previously
studied. It is superior because of faster attainment and res-
olution of block, together with greater haemodynamic sta-
bility. Potential advantages include earlier ambulation,
reduced risk of urinary retention, and earlier patient dis-
charge. In addition, because of the low reported incidence
in other studies of TNS associated with its use, we believe
that it represents an excellent alternative to lidocaine in
the ambulatory setting.
Acknowledgements
We would like to acknowledge the assistance provided by the
pharmacy department at Flinders Medical Centre, in formu-
lation of the trial drug syringes, and also the library staff at
the ANZCA library, for their assistance in background
research.
Conflict of interest
None declared.
Funding
Financial support was provided by the Department of Anaes-
thesia and Pain Medicine, Flinders Medical Centre, Adelaide,
South Australia. There was no external funding.
References
1 Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of
regional versus general anesthesia for ambulatory anesthesia: a
meta-analysis of randomized controlled trials. Anesth Analg
2005; 101: 1634–42
2 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
3 Liu S, Chiu AA, Carpenter RL, et al. Fentanyl prolongs lidocaine
anesthesia, without prolonging recovery. Anesth Analg 1995;
80: 730– 4
4 Ben-David B, DeMeo PJ, Lucyk C, Solosko D. A comparison of mini-
dose lidocaine– fentanyl spinal anesthesia and local anesthesia/
propofol infusion for outpatient knee arthroscopy. Anesth Analg
2001; 93: 319– 25
5 Ben-David B, Maryanovsky M, Gurevitch A, et al. A comparison of
minidose lidocaine–fentanyl and conventional-dose lidocaine
spinal anesthesia. Anesth Analg 2000; 91: 865– 70
6 Ben-David B, Levin H, Solomon E, et al. Spinal bupivacaine in
ambulatory surgery: the effect of saline dilution. Anesth Analg
1996; 83: 716– 20
187
BJA
7 Pollock JE. Transient neurologic symptoms: etiology, risk factors
and management. Reg Anesth Pain Med 2002; 27: 581–6
8 Zaric D, Pace NL. Transient neurologic symptoms (TNS) following
spinal anaesthesia with lidocaine versus other local anaesthetics.
Cochrane Database Syst Rev 2009: CD003006
9 Severinghaus JW. Intrathecally, Caine may dis-Able. Reflections
on lidocaine for spinal anesthesia. Acta Anaesthesiol Scand
Suppl 1998; 113: 3– 7
10 Gaiser RR. Should intrathecal lidocaine be used in the 21st
century? J Clin Anesth 2000; 12: 476 –81
11 Østgaard G, Hallaråker O, Ulveseth OK, Flaatten H. A randomised
study of lidocaine and prilocaine for spinal anaesthesia. Acta
Anaesthesiol Scand 2000; 44: 436–40
12 de Weert K, Traksel M, Gielen M, Slappendel R, Weber E, Dirksen R.
The incidence of transient neurological symptoms after spinal
anaesthesia with lidocaine compared to prilocaine. Anaesthesia
2000; 55: 1020– 4
13 König W, Ruzicic D. Absence of transient radicular irritation after
5000 spinal anaesthetics with prilocaine (correspondence).
Anaesthesia 1997; 52: 182
14 Martinez-Bourio R, Arzuaga M, Quintana J, et al. Incidence of
transient neurologic symptoms after hyperbaric subarachnoid
anesthesia with 5% lidocaine and 5% prilocaine. Anesthesiology
1998; 88: 624– 8
15 Hampl KF, Heinzmann-Wiedmer SRA, Luginbuehl I, et al. Transi-
ent neurologic symptoms after spinal anesthesia: a lower inci-
dence with prilocaine and bupivacaine than with lidocaine.
Anesthesiology 1998; 88: 629 –33
16 Hendriks MP, de Weert CJM, Snoeck MMJ, Hu HP, Pluim MAL,
Gielen MJM. Plain articaine or prilocaine for spinal anaesthesia
in day-case knee arthroscopy: a double-blind randomized trial.
Br J Anaesth 2009; 102: 259– 63
188
Black et al.
17 Nair GS, Abrishami A, Lermitte J, Chung F. Systematic review of
spinal anaesthesia using bupivacaine for ambulatory knee
arthroscopy. Br J Anaesth 2009; 102: 307–15
18 Liu S, Pollock JE, Mulroy MF, Allen HW, Neal JM, Carpenter RL.
Comparison of 5% with dextrose, 1.5% with dextrose, and 1.5%
dextrose-free lidocaine solutions for spinal anesthesia in
human volunteers. Anesth Analg 1995; 81: 697–702
19 Hodgson PS, Liu SS, Batra MS, Gras TW, Pollock JE, Neal JM. Pro-
caine compared with lidocaine for incidence of transient neuro-
logic symptoms. Reg Anesth Pain Med 2000; 25: 218– 22
20 Boucher C, Girard M, Drolet P, Greiner Y, Bergeron L, Le Truong HH.
Intrathecal fentanyl does not modify the duration of spinal pro-
caine block. Can J Anaesth 2001; 48: 466–9
21 Le Truong HH, Girard M, Drolet P, Grenier Y, Boucher C, Bergeron L.
Spinal anesthesia: a comparison of procaine and lidocaine. Can J
Anaesth 2001; 48: 470–3
22 Kouri ME, Kopacz DJ. Spinal-2-chloroprocaine: a comparison with
lidocaine in volunteers. Anesth Analg 2004; 98: 75– 80
23 Moore DC, Spierdijk J, van Kleef JD, Coleman RL, Love GF. Chloro-
procaine toxicity: four additional cases. Anesth Analg 1982; 61:
155– 9
24 Drasner K. Chloroprocaine spinal anesthesia: back to the future?
(Editorial) Anesth Analg 2005; 100: 549–52
25 Kallio H, Snäll E-VT, Luode T, Rosenberg PH. Hyperbaric articaine
for day-case spinal anaesthesia. Br J Anaesth 2006; 97: 704–9
26 Bachmann M, Pere P, Kairaluoma P, Rosenberg PH, Kallio H. Com-
parison of hyperbaric and plain articaine in spinal anaesthesia for
open inguinal hernia repair. Br J Anaesth 2008; 101: 848–54
27 Dijkstra T, Reesink JA, Verdouw BC, Van der Pol WSCJM,
Feberwee T, Vulto AG. Spinal anaesthesia with articaine 5% vs
bupivacaine 0.5% for day-case lower limb surgery: a double-blind
randomized clinical trial. Br J Anaesth 2008; 100: 104–8