Local anaesthetic failure in joint hypermobility syndrome

Local anaesthetic failure in joint hypermobility syndrome | J R Soc Med. 2005 Feb

When taking biopsies to assess skin strength in Ehlers–Danlos syndrome type III (EDS–III), a Danish group noticed that the patients experienced much pain despite conventional local anaesthesia.1

When asked, all these patients reported previous experience of partial or complete failure of local anaesthesia in dental or obstetric procedures—for which reason some had been dismissed as hysterics.

Pursuing this finding, Arendt-Nielsen et al.2 compared the effects of local anaesthesia in 8 patients with EDS–III and 8 controls.  

Although the patients did gain analgesia from intradermal lidocaine the duration of effect was much shorter than in controls. EDS–III (now known as EDS–hypermobility type) is regarded by many authorities as identical to joint hypermobility syndrome (JHS).3,4

We wish to draw attention to the possibility of resistance to local anaesthesia in individuals with this common and under-diagnosed condition.

Box 2 Five-part questionnaire for identifying hypermobility (Ref. 7) Answers in the affirmative to 2 or more questions suggest hypermobility with sensitivity 80–85% and specificity 80–90%

Anesthetic Box2

Box 3 Brighton criteria for joint hypermobility syndrome (JHS) (Ref. 8) JHS is diagnosed in the presence of two major criteria, or one major and two minor criteria, or four minor criteria. Two minor criteria will suffice where there is an unequivocally affected first-degree relative.

Anesthetic Box3

JHS is overrepresented in general rheumatology clinic populations and in our experience (RG and AJH)6 many of these patients report failure of local anaesthetics

A questionnaire was completed by 172 female Caucasian JHS patients, 53 non-hypermobile age-matched controls, and 28 individuals who showed evidence of hypermobility with insufficient features to qualify for JHS (HM-sine-JHS)

We asked ‘If you have ever had a local anaesthetic injection (dentist/minor surgery/epidural), did you think that it was as effective as it should have been?’.

58% of JHS patients, 21% of controls and 14% of the HM-sine-JHS group answered in the negative. For JHS versus controls the odds ratio was a highly significant 2.85.

Although the question was simplistic, non-exploratory, and reliant on recall and selfperception, the difference between JHS and controls was striking. Neither group had knowledge of any study hypothesis. At the time there was nothing of this nature documented in patient information sheets or published research.

We suspect that in many people JHS goes unrecognized. So, how can a busy clinician, mindful of possible resistance to local anaesthesia, make the diagnosis?

The nine-point Beighton hypermobility score (Ref. 9) One point may be gained for each side for manoeuvres 1–4 so that the hypermobility score will have a maximum of nine points if all are positive. A score of ≥4/9 indicates widespread hypermobility.

Anesthetic Box1

 

Although the pathophysiology of this phenomenon remains unresolved, an important clue that a patient is at risk of local anaesthetic failure might be in front of our eyes.  


The study below indicates this lack of response to anesthetics has been known since at least 1991. It is even suggested as a diagnostic tool to differentiate EDS from generally hypermobile patients.

The response to local anaesthetics (EMLA-cream) as a clinical test to diagnose between hypermobility and Ehlers Danlos type III syndrome. – PubMed – NCBI | Scand J Rheumatol. 1991

To make a differential diagnosis of Ehlers Danlos (EDS) Type III syndrome and Hypermobile patients has been difficult. In genetic advising and prognosis of the EDS patients there are need for new tools to separate them from hypermobile patients.

Topical analgesics (EMLA cream) was applied to seven EDS patients, ten hypermobile patients, and to fifteen controls.

The analgesic efficacy of cutaneous analgesia was evaluated by sensory and pain thresholds to brief argon laser stimuli, and the depth of the cutaneous analgesia was measured by sensory and pain threshold depth to controlled needle insertions.

Controls and hypermobiles did not differ in their response to cutaneous analgesia.

The thresholds to cutaneous laser stimulation and the depth of analgesia increased significantly less in the Ehlers Danlos patients compared to the other two groups.

In clinical practice a needle insertion test can easily be applied to investigate if patients are responders or non-responders to local analgesics.


This is a discussion from the EDS support forum on MDJunction:

Do local/dental anesthetics fail for you?

Many patients with EDS are resistant to lidocaine, the most commonly used local anesthetic. Resistance to local anesthetics was proposed as a way of distinguishing benign hypermobility from Ehlers-Danlos syndrome, hypermobility type, but the research has not yet been replicated and the proposal has not been accepted.

I am not sure of the portion of EDS patients who have this, but think it is on the order of 10 to 20 percent.

Have you had a problem where a local anesthetic failed or where larger doses and more frequent renewal of the anesthesia was necessary?

Some folks with EDS have said that articaine (Septocaine®) works better than lidocaine. You might consider copying that name onto a small card carried in your wallet or purse so that, if you should encounter difficulty, you can tell the dentist or physician about the choice.

I came across an internet article that asserted the poor effect was the result of loose tissue and rapid reabsorption of the lidocaine from the area where it was deposited. The recommended solution was to use epinephrine to constrict the vessels locally, slowing reabsorption, or to use bupivacaine (Marcaine(R)), an inherently longer-lasting drug. I’m not at all sure I’m convinced by the theory of why lidocaine doesn’t work, but the recommended solutions might help some folks.  

 

 

Advertisements

3 thoughts on “Local anaesthetic failure in joint hypermobility syndrome

  1. jemmabrown

    Reblogged this on Through My Eyes and commented:
    So imagine having to go to the dentist having a filling and the anaesthetic doesn’t work. The next time you go back you are scared that the same thing will happen again see you put it off. Eventually you have to go back but because you put it off you now need your tooth out. The dentist numbs your mouth but at that crucial moment when the tooth is almost out you can feel everything it is not numb.

    That has happened to me, more than once I’ve also had eye surgery and stitches in my knee all with local Anesthetic that did not work.

    You get labelled as a hysteric, people don’t believe you and assume your pain is actually just a panic response. This makes the situation worse you walk into the doctor or dentist terrified that the local anaesthetic is not going to work again then you are a nervous patient and it must all be in your head.

    This lead me to develop ‘hospital phobia’ at its worst I struggled to set foot in a hospital without getting the shakes. Eventually following eye surgery wherr the local anaesthetic and sedation were both ineffective in addition to me being terrified I developed full blown post-traumatic stress disorder.

    My dental troubles where no better – I simply stopped going and avoided it at all costs. At its worst I walked round with an abcess in my tooth for 2 weeks in agony rather than seeking a dentist. As a result of this I have had far more teeth removed than average soon to be 5.

    I now carry an alert card with information on it and wear a medical ID – if a medical professional doesn’t believe me I whip out the card and play the broken record until they do.

    I really wish I had known about this sooner and that medical professionals had the training and time to recognise that I was not hysterical. With proper patient doctor communication I have found it is possible to achieve good local anaesthetic and thanks to doctors willing to work with me I’ve found having 4x the regular amount and them working quickly it is possible to have relatively pain free minor surgery.

    Liked by 2 people

    Reply
  2. K

    I recently got diagnosed with JHS and this article was like a breath of fresh air – I have a severe dentist phobia after, at the age of 16, I was given 27 (!!!!) lidocaine injections by a dentist and still felt it when she drilled into my teeth – she got angry and shouted at me to stop overreacting. Luckily, my new dentist is lovely but I haven’t been back since the local failed again. He was kind about it, but the pain from having a nerve drilled into is too terrifying to face again

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      I’m glad you were able to solve the mystery. When I learned about this, it explained why I’d felt every slice of the scalpel during a wart removal and every stab of the needle when getting stitches.

      The worst part of it is that everyone else is absolutely certain that you are numb!

      Like

      Reply

Other thoughts?

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s