European Journal of Cardiovascular Medicine

which comprise spinal and epidural blocks. This is because an anesthesiologist can create a dependable block with a single injection, and these blocks have well defined termination points.  Depending on the dosage, volume, and concentration of the local anesthetic used, each of these blocks results in motor, sensory, and sympathetic blockade. The subarachnoid injection of local anesthetics into the central nervous system is known as spinal neural blockade or subarachnoid block (SAB).  A tiny quantity of local anesthetic is needed for the subarachnoid block to provide effective surgical anesthesia, and the physiologic reactions are mostly caused by the local anesthetic's influence on the nerve fibers inside the subarachnoid space.  Between the arachnoid and the pia mater is the subarachnoid space.  It is a continuous area that houses the spinal cord, conus medullaris, and CSF.  It finishes with the conus medullaris at the sacral hiatus and communicates directly with the brainstem via the foramen magnum.  The conus medullaris often finishes around the L3 in pediatric patients, while in adults it ends around the lower border of the L1 or occasionally the L2 vertebral body. The spinal needle is often inserted through the L3-L4 or L4-L5 interspace.  A specific dermatomal level must be attained after SAB in order to provide sufficient surgical anesthesia.  A novel local anesthetic called levobupivacaine has just entered clinical usage due to its less harmful effects on the heart and central nervous system. [1] Levobupivacaine is a good substitute for bupivacaine and offers efficient anesthesia and analgesia for a variety of therapeutic groups. [2] Long-acting, enantiomerically pure (S-enantiomer) amide local anesthetic ropivacaine has a poor lipid solubility and a high pKa. It blocks nerve fibers that transmit pain more than those that regulate motor function (Aβ fibers). Numerous clinical studies have demonstrated that epidural ropivacaine 0.2% is useful for both initiating and maintaining labor analgesia. It also relieves pain following orthopaedic and abdominal surgery, particularly when administered in combination with opiods (coadministration with opiods may also allow for the use of a lower concentration of ropivacaine) [3].

Type of study: This was a prospective, randomized and double blinded study

Place of study: CB-UP Orthopaedic OT complex of Medical College and Hospital, Kolkata.

Study duration: December 2022 to November 2023

Sample size: 94 lower limb orthopaedic patients

Inclusion Criteria:

• Patients scheduled to undergo elective lower limb orthopaedic surgery under spinal anesthesia.
• Patients in the age group of 18-83 years.
• Patients with physical status ASA I and ASA II.

Exclusion Criteria:

• Patient refusal
• Hypotensive patients
• ASA above II
• Allergic to local anaesthetics
• Any lesion at puncture site
• Spinal deformity 6)Uncontrolled hypertension
• Diabetes Mellitus and other endocrine and metabolic disorders
• Cardiovascular diseases which includes mitral and aortic stenosis, mitral and tricuspid regurgitation, diastolic dysfunction higher than grade I, cardiomyopathies, pericardial effusion etc.
• BMI >30
• Known coagulopathies
• H/o lower limb thrombosis like deep vein thrombosis 12)Obstetric patients
• Any neurological deficit(including features of raised intracranial pressure)
• Surgeries in which blood loss exceeded maximum allowable blood loss.
• Patients who required general anaesthesia
• Patients with renal disorders

Study Variables:

• Age of patients
• Gender
• Body weight / BMI
• ASA physical status (I/II)
• Type of local anaesthetic
• Time of onset of sensory block (minutes)

Statistical Analysis:

Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Gender distribution in the two groups

Table 2: Distribution of patients belonging to ASA physical status I & II

Table 3: Time of onset of sensory block, Time of onset of maximum bromage score (motor block), and Distribution of time to two segment regression of maximum sensory block between the two groups

Figure 1: Onset of sensory block, time to peak motor block (Bromage score), and time to two-segment regression of sensory block were compared between the two groups

Figure 2: Distribution of duration of motor block between the two groups

Figure 16: Distribution of mean duration of sensory block between the two groups

In our study, among patients receiving Levobupivacaine, 26 (55.31%) were female and 21 (44.69%) were male, while in the Ropivacaine group, 24 (51.06%) were female and 23 (48.93%) were male. The difference was not statistically significant (p = 0.679), indicating a similar gender distribution between the groups. In our study, the Levobupivacaine group, 23 patients (48.93%) were ASA I and 24 (51.06%) were ASA II, whereas in the Ropivacaine group, 25 patients (53.19%) were ASA I and 22 (46.80%) were ASA II. This difference was not statistically significant (p = 0.67). In our study, the mean time for onset of sensory block was longer in the Levobupivacaine group (8.36 ± 0.73 minutes) compared to the Ropivacaine group (4.53 ± 0.54 minutes, p < 0.001). Conversely, the onset of maximum motor block (Bromage score) was faster with Levobupivacaine (4.76 ± 0.66 minutes) than with Ropivacaine (8.51 ± 0.55 minutes, p < 0.001). Additionally, the time to two-segment regression of maximum sensory block was significantly prolonged in the Levobupivacaine group (61.91 ± 9.29 minutes) compared to the Ropivacaine group (45.85 ± 7.09 minutes,), indicating a longer duration of sensory anesthesia with Levobupivacaine. This difference was statistically significant (p < 0.001).

We found that in the Levobupivacaine group, 26 patients (55.31%) were female and 21 (44.69%) were male; while in the Ropivacaine group, 24 patients (51.06%) were female and 23 (48.93%) were male. The difference was not statistically significant (p = 0.679).In similar study by Athar M et al [4] (2016) observed that 28 patients (Group L) received 15 mg of 0.5% hyperbaric levobupivacaine, and 30 patients (Group R) received 22.5 mg of 0.75% hyperbaric ropivacaine for spinal anaesthesia in lower limb orthopaedic surgeries.

We observed that, in the Levobupivacaine group, ASA II patients were slightly higher at 24 (51.06%) compared to ASA I at 23 (48.93%), whereas in the Ropivacaine group, ASA I patients were higher at 25 (53.19%) compared to ASA II at 22 (46.80%). The difference was not statistically significant (p = 0.67).In others study by Uzun U et al [5] (2025) showed that 50 patients classified as ASA I-II undergoing inguinal hernia surgery were randomized to receive either 0.5% hyperbaric bupivacaine (n=25) or 0.5% hyperbaric levobupivacaine (n=25) for spinal anesthesia. The ASA classification distribution was similar between the two groups.

We showed that, the time to two-segment regression of maximum sensory block was longer in the Levobupivacaine group (61.91 ± 9.29 minutes) than in the Ropivacaine group (45.85 ± 7.09 minutes), indicating a prolonged duration of sensory block with Levobupivacaine. Conversely, the onset of sensory block was faster with Ropivacaine (4.53 ± 0.54 minutes) compared to Levobupivacaine (8.36 ± 0.73 minutes), while the onset of maximum motor block occurred earlier with Levobupivacaine (4.76 ± 0.66 minutes) than with Ropivacaine (8.51 ± 0.55 minutes). All differences were statistically significant (p < 0.001).In similar study by Juneja D et al [6] (2025) showed that levobupivacaine produced a longer duration of sensory and motor block, whereas ropivacaine showed a faster onset of sensory block in cesarean section patients.

We concluded that in this study, which compared 0.5% hyperbaric Levobupivacaine and 0.75% hyperbaric Ropivacaine for lower limb orthopaedic surgery, there were no statistically significant variations between the groups' demographic characteristics, such as gender and ASA physical status.  Ropivacaine showed a quicker onset of sensory block, while Levobupivacaine showed a significantly longer duration of sensory block, as indicated by a longer time to two-segment regression.  Levobupivacaine had a longer-lasting motor impact than Ropivacaine, as seen by the earlier onset of maximum motor block.  According to these results, levobupivacaine produces anesthesia that lasts longer, but ropivacaine permits a speedier sensory onset. Depending on therapeutic priorities, both medications are useful.

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2. Sanford M, Keating GM. Levobupivacaine: a review of its use in regional anaesthesia and pain management. Drugs. 2010 Apr;70(6):761-91.
3. McClellan KJ, Faulds D. Ropivacaine: an update of its use in regional anaesthesia. Drugs. 2000 Nov;60(5):1065-93.
4. Athar M, Ahmed SM, Ali S, Doley K, Varshney A, Siddiqi MM. Levobupivacaine or ropivacaine: A randomised double blind controlled trial using equipotent doses in spinal anaesthesia. Colombian Journal of Anesthesiology. 2016 Apr 1;44(2):97-104.
5. Uzun U, İdin K. Comparison of Onset Times and Hemodynamic Changes of Bupivacaine and Levobupivacaine Used in Spinal Anesthesia. Anatolian Journal of General Medical Research. 2025 Aug 11.
6. Juneja D, Verma K, Singh S, Deganwa M, JUNEJA D, SINGH S. A Double-Blind Randomized Controlled Trial Comparing Intrathecal 0.5% Isobaric Levobupivacaine With Fentanyl to 0.5% Isobaric Ropivacaine With Fentanyl for Elective Cesarean Section. Cureus. 2025 Jan 3;17(1).