Abnormal motor blockade after epidural analgesia caused by pneumorrhachis and the role of hyperbaric oxygen treatment: a case report.

INTRODUCTION: Pneumorrhachis is a rare clinical entity that is usually asymptomatic. Previous reports have associated such events with epidural insertion using a loss of resistance (LOR) to air technique. This report describes a case of symptomatic epidural pneumorrhachis following epidural anaesthesia using LOR to saline. CASE REPORT: A 32-year-old American Society of Anesthesiologists (ASA) Classification II female patient was admitted for unplanned caesarean section. Epidural anaesthesia was performed at the L3-4 space using LOR to saline. The procedure, including delivery of the neonate, was uneventful. In the recovery room, a local anaesthetic infusion via an elastomeric pump (infusion 'balloon') was started. Two hours after initiation of the infusion the patient complained of motor blockade, so it was stopped. Two hours later she remained paraparetic, and a neurologist assessment was required. A computed tomography scan showed epidural pneumorrhachis at the L2-3 level. The patient was referred for emergent hyperbaric oxygen treatment (US Navy Treatment Table 5) and following one session the patient recovered completely. DISCUSSION: Anaesthetists should be aware of this rare complication, which is easily overlooked. Hyperbaric oxygen treatment is a first line treatment for gas-associated lesions with neurological impairment. Timely referral is essential to prevent irreversible deficits.

Epidural space "ballooning" during local anaesthetic injection in infants and children: An ultrasound observational study.

BACKGROUND: Infants and children require a larger dose of a local anaesthetic (LA) to establish epidural analgesia than adults, but the reason for this remains unclear. We hypothesised that prominent ventro-dorsal expansion of the epidural space limits cranio-caudal spread of LA in infants. Accordingly, we studied the dimensions of the epidural space with real-time ultrasound (US) before and after epidural injection. METHODS: Ninety-six infants and children aged 0-12 years who underwent abdominal surgery under combined epidural and general anaesthesia were examined in this prospective observational study. Using a micro-convex probe, US recordings of the posterior epidural space were performed while a LA (0.5 ml kg-1 ) was infused at 0.54 ml s-1 . The width in the ventro-dorsal dimension (VDD) of the posterior epidural space before and after injection was recorded; the change in VDD was defined as "ballooning". Correlations between "ballooning" and patient age, body mass index, and volume and rate of LA administration were analysed. RESULTS: "Ballooning" correlated positively but weakly with age (R2  = 0.25; p < .001) and the infused LA volume (R2  = 0.32; p < .001). The "magnitude of ballooning" ("ballooning" per ml of injected LA) correlated negatively but weakly with age (R2  = 0.27; p < .001). CONCLUSIONS: "Magnitude of ballooning" of the epidural space become inconspicuous with growing during epidural injection. This effect may slow the cranio-caudal spread of LA and explain partially why larger volumes of LA are required to effect a block in children.

Cervical epidural hematoma following interlaminar epidural steroid injection via the contralateral oblique view in patient taking omega-3 fatty acids.

BACKGROUND AND OBJECTIVES: We sought to describe a case of an epidural hematoma after a cervical interlaminar epidural steroid injection (ILESI) performed using contralateral oblique view. We also discuss factors that could have placed this patient at increased risk, including concurrent use of omega-3 fatty acids and non-steroidal anti-inflammatory medications. CASE REPORT: A 74-year-old woman returned to the pain clinic, within 15 min of discharge, after an apparent uncomplicated cervical ILESI using the contralateral oblique technique with severe periscapular pain and muscle spasms. Cervical MRI showed a large epidural hematoma which was subsequently emergently evacuated. On postoperative examination, the patient had no neurologic deficits and full resolution of her painful symptoms. CONCLUSIONS: To our knowledge, this is the first reported case of cervical epidural hematoma in which the contralateral oblique technique was used. Also, this is the second case in which the combination of non-steroidal anti-inflammatory medications and omega-3 fatty acids has been considered as a contributor to increased hematoma risk. This case underscores the risk of epidural hematoma using a novel fluoroscopic technique and the need for potential discontinuation of supplements like omega-3 fatty acids.

Successful Treatment of Postdural Puncture Headache Using Epidural Fibrin Glue Patch after Persistent Failure of Epidural Blood Patches.

OBJECTIVES: Epidural blood patch is the gold standard for the treatment of postdural puncture headache (PDPH) when conservative treatments have failed to provide any relief. However, alternative therapies are lacking when epidural blood patch persistently fails to improve symptoms. Failure to treat PDPH may lead to significant functional impairment of daily living. Alternative therapies should be sought to accelerate recovery from PDPH. CASE REPORT: This case describes a woman who developed PDPH secondary to accidental dural puncture during a spinal cord stimulator trial. She was successfully treated with epidural fibrin glue patch after multiple trials of epidural blood patches. CONCLUSION: Percutaneous injection of fibrin glue to seal the dural defect demonstrated promising outcomes for both immediate and long-lasting resolution of persistent PDPH in our patient. In the event of epidural blood patch failure, epidural fibrin glue patch may be a reasonable alternative for the treatment of persistent PDPH.

Salvianolic acid B reduced the formation of epidural fibrosis in an experimental rat model.

BACKGROUND: Salvianolic acid B (Sal B) was newly reported to be able to attenuate fibrosis in the animal model. The aim of the present study was to investigate the effect of the intragastric application of Sal B on the prevention of epidural fibrosis (EF). METHODS: Forty healthy adult male Wistar rats were divided into four treatment groups (n = 10 per group): (1) 10 mg/kg Sal B, (2) 30 mg/kg Sal B, (3) 50 mg/kg Sal B and (4) Saline (vehicle treatment, control group). All animals underwent a laminectomy at the lumbar 1-2 (L 1-2) level. After intragastric treatment, all rats were sacrificed at post-operative week 8. The extent of the epidural scar, the regeneration of the vasculature and the expression levels of vascular endothelial growth factor (VEGF) were analysed. RESULTS: The animals' recovery was uneventful during the experimental period. The extent of the epidural scar, the regeneration of the vasculature and the expression levels of VEGF suggested better outcomes in the Sal B-treated groups. Sal B exerted the ability to prevent the formation of an epidural scar and vascularization at the laminectomy sites. The effects of Sal B were dose-dependent, with the 50 mg/kg Sal B group showing the best outcomes compared with the other groups. CONCLUSIONS: Post-operative intragastric application of Sal B can prevent the formation of epidural scarring. Sal B exerted these effects in a dose-dependent manner, and 50 mg/kg dose was shown to be the best effect in the present study. The results of this study reveal that Sal B could be a potential therapy for EF and valuable for further research.

Ultrasound-guided caudad epidural access for the lumbosacral neurostimulation: case report and technical note.

OBJECTIVES: This is a case report and description of a new ultrasound-guided caudad epidural needle placement for percutaneous stimulation of the lumbosacral roots. MATERIALS AND METHODS: Case report. RESULTS: Using ultrasonography pertinent spinal and neuroaxial anatomy was visualized. In-plane approach with continuous monitoring of the needle advancement was utilized. The needle was seamlessly placed in the epidural space on the first attempt. CONCLUSIONS: Spinal sonography is a promising imaging method to facilitate percutaneous caudad epidural access.

Fluoroscopically guided transforaminal epidural dry needling for lumbar spinal stenosis using a specially designed needle.

BACKGROUND: This report describes the methodological approach and clinical application of a minimally invasive intervention to treat lumbar spinal stenosis (LSS). METHODS: Thirty-four patients with LSS underwent fluoroscopically guided transforaminal epidural dry needling using a specially designed flexed Round Needle. The needle was inserted 8-12 cm lateral to the midline at the level of the stenosis and advanced to a position between the anterior side of the facet joint and pedicle up to the outer-third of the pedicle. The needle was advanced medially and backed laterally within a few millimetres along the canal side of the inferior articular process between the facet joint and pedicle. The procedure was completed when a marked reduction in resistance was felt at the tip of the needle. The procedure was performed bilaterally at the level of the stenosis. RESULTS: The average follow-up period was 12.9 +/- 1.1 months. The visual analogue scale (VAS) pain score was reduced from 7.3 +/- 2.0 to 4.6 +/- 2.5 points, the Oswestry Disability Index (ODI) score decreased from 41.4 +/- 17.2 to 25.5 +/- 12.6% and the average self-rated improvement was 52.6 +/- 33.1%. The VAS scores indicated that 14 (41.2%) patients reported a "good" to "excellent" treatment response, while 11 (32.4%) had a "good" to "excellent" treatment response on the ODI and 22 (64.7%) had a "good" to "excellent" treatment response on the self-rated improvement scale. CONCLUSIONS: These results suggest that fluoroscopically guided transforaminal epidural dry needling is effective for managing LSS.

Spinal cord stimulation for severe degenerative joint disease of the shoulder in a patient with severe chronic obstructive pulmonary disease: a new indication?

Approximately 70% of the United States population older than 65 yr has osteoarthritis. Chronic obstructive pulmonary disease (COPD) is also more prevalent in the elderly, and thus, the likelihood of having elderly patients with osteoarthritis and COPD in clinical settings is significant. COPD may preclude the optimum use of opioids, thus the potential to provide pain control with nonpharmacological treatment modalities becomes a valuable option. We present the case of an elderly woman with severe degenerative joint disease of the shoulder and severe COPD in whom spinal cord stimulation was used to provide pain control.

[Ultrasound and local anaesthesia. Part III: ultrasound and neuroaxial local anaesthesia]. / Ultraschall und Regionalanästhesie. Teil III: Ultraschall und neuroaxiale Regionalanästhesie.

The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia. This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques. The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented. We review all presently available data on the prediction of the puncture depth. The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm. Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31. The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels. The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved. The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.

Quantitative anatomy of the thoracolumbar epidural space.

Quantitative measurements of the epidural space between T-7 and L-4 were made in the sagittal and coronal planes utilizing x-ray films made after the injection of iodized oil into the epidural space in the low thoracic and upper lumbar areas. These data reveal a 1-mm ventral epidural space and a 2-mm lateral epidural space, with a sawtooth shape to the dorsal epidural space measuring between 1.1 and 2.9 mm at the rostral lamina and between 3.8 and 6.5 mm at the caudal lamina. Additionally, five patients with chronic pain were studied by computed tomography of T-8 to T-12, with confirmation of the sawtooth shape of the dorsal epidural space. Computed tomography showed the measurements of the epidural space at the rostral lamina to vary between 1.3 and 1.6 mm and those at the caudal lamina/interlaminar space to range from 6.9 to 9.1 mm.