Local Anesthetic Myotoxicity
Regional Anesthesia and Pain Medicine, Vol 29, No 4 (July–August), 2004: pp 333–340

Wolfgang Zink, M.D., and Bernhard M. Graf, M.D., Ph.D.

Skeletal muscle toxicity is a rare and uncommon side effect of local anesthetic drugs. Intramuscular injections
of these agents regularly result in reversible myonecrosis. The extent of muscle damage is dose dependent and
worsens with serial or continuous administration. All local anesthetic agents that have been examined are
myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury.
The histologic pattern and the time course of skeletal muscle injury appear rather uniform: hypercontracted
myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic
reticulum, and by myocyte edema and necrosis over the next 1 to 2 days. Myoblasts, basal laminae, and
connective tissue elements remain intact in most cases, which permits muscular regeneration within 3 to 4

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