Spinal lidocaine is undergoing a clinical re-evaluation for outpatient total joint arthroplasty, challenging its long-standing "canceled" status due to transient neurologic symptoms (TNS). While historical data reported TNS rates as high as 40%, a recent Duke University study of over 1,000 patients found an incidence of only 0.2% when using 2% preservative-free lidocaine. This dramatic reduction suggests that TNS is likely a myofascial phenomenon caused by muscle relaxation and lumbar stretching rather than permanent nerve damage. Modern Enhanced Recovery After Surgery (ERAS) protocols—utilizing multimodal analgesics like ketamine, dexamethasone, and NSAIDs—effectively intercept and mask this inflammatory response before clinical symptoms manifest. Consequently, lidocaine’s intermediate duration of two and a half hours offers a more efficient alternative to bupivacaine for ambulatory surgery, provided it is administered within a robust perioperative analgesic framework that addresses its mechanical side effects.
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