A medical-legal review regarding the standard of care for epidural injections, with particular reference to a closed case.

Interventional pain management is an evolving field, with a primary focus on the safety of the patient. One major source of risk to patients is intraarterial or intraneural injections. Interventional pain physicians have considerable interest in identifying techniques which avoid these complications. A recent article has reviewed complications associated with interventional procedures and concluded that the complications were due to deviation from a specific prescribed protocol. One of the cases reviewed went to jury trial and the record of that case is in the public domain. Two of the authors of the recent review were expert witnesses in the trial. They provided conflicting testimony as to alleged violations of the standard of care. Their criticisms also differed from a third criticism contained in the article as well as the protocol being advocated in the article, thus contravening the claim that there is one prescribed protocol which must be followed. The definition of standard of care varies amongst jurisdictions, but is generally defined as either that care which a reasonably well-trained physician in that specialty would provide under similar circumstances or as what would constitute reasonable medical care under the circumstances presented. Analysis of the case which went to trial indicates that there is not one prescribed protocol which must be followed; the definition of standard of care is broader than that. Interventional pain management is an evolving field and the standard of care is broadly defined.

Simultaneous posterior ischemic optic neuropathy, cerebral border zone infarction, and spinal cord infarction after correction of malignant hypertension.

A 31-year-old woman developed bilateral posterior ischemic optic neuropathy and infarctions of the cerebral arterial border zones and spinal cord after correction of malignant hypertension. Although a few reports have described patients with neurologic abnormalities after treatment of malignant hypertension, full clinical and neuroimaging documentation of this combination of findings has not occurred. This case report suggests that the relative hypotension of autoregulatory failure induced by treatment of malignant hypertension may give rise to these neurologic complications.

[Spinal cord protection and opioids].

Opioids, when administered in large doses, were reported to produce brain damage primarily in limbic system and association areas in animals. We recently found the result that intrathecal (IT) morphine after a short interval of aortic occlusion in the rodent model induced transient spastic paraparesis via opioid receptor-coupled effects in the spinal cord. Histopathological analysis revealed the possibility that IT morphine could induce degeneration of spinal ventral neurons even after a short lasting of spinal cord ischaemia in rats, and this degeneration was associated with the activation of spinal N-methyl-D-aspartate receptors by elevation of glutamate release in cerebrospinal fluid after IT morphine. Therefore, we would like to emphasize that all anesthesiologists should be aware of the possibility of morphine-induced paraplegia after thoracic aortic surgery and that we should carefully select appropriate analgesic agents from the several available opioids for these patients.