Dual epidural catheters for labor analgesia in a spinal cord injury patient: a case report

Abstract Impediment to local anesthetic solution in the epidural space results in unsatisfactory pain relief during labor epidural. Patients with a history of back trauma and spinal instrumentation have increased rates of epidural failure due to patchy spread of local anesthetic with obliterated epidural space. Dual Epidural Catheters (DEC) can be used in such clinical scenarios with complete labor analgesia and improved patient satisfaction. We present the successful management of a parturient with vertebral fracture at risk for epidural failure and neurologic injury due to bone fragments and inserted cranial and caudal to the fractured vertebra using ultrasound to avoid neurologic sequelae.

Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome

BACKGROUND: Neck and back pain are leading sources of disability placing substantial burden on health care systems. Surgical interventions in managing chronic neck pain secondary to various disorders continue to increase. Even though surgical interventions are effective, a significant proportion of patients continue to have symptomatology and develop cervical post-surgery syndrome. This study was performed to know the effectiveness of cervical interlaminar epidural injections with or without steroids. METHODS: The effectiveness of fluoroscopic cervical interlaminar epidural injections in post-surgery syndrome was evaluated in a randomized, active controlled trial. The study population included 116 patients assigned to 2 groups. Group 1 received cervical interlaminar epidural injections with local anesthetic alone and Group 2 received injection with local anesthetic and steroids. The main outcomes were defined as significant improvement (greater than 50%) of pain relief using the numeric rating scale and/or functional status improvement using the Neck Disability Index (NDI). RESULTS: Both groups had similar results with significant improvement (≥ 50% pain relief and functional status improvement) in 69% of the patients in Group I, whereas, in Group II, 71% of the patients showed significant improvement at the end of 2 years. During a 2-year period, the average number of procedures was 5 to 6, with an average of approximately 12 weeks of significant improvement per procedure. CONCLUSIONS: Fluoroscopic cervical interlaminar epidural injections administered in cervical post-surgery syndrome using local anesthetic, regardless of the use of steroids, may be effective in approximately 70% of the patients at 2-year follow-up.

Pneumocephalus after Interlaminar Lumbar Epidural Block / 대한정형외과학회잡지

Lumbar epidural block using a “loss of resistance” technique (LORT) with air can potentially cause pneumocephalus. Herein, we present a pneumocephalus that occurred after an epidural block. A 58-year-old male patient underwent an interlaminar lumbar epidural block using a LORT with air for L4–5 disc herniation. After the block, the patient complained of headache, vomiting, and truncal myoclonus. For further evaluation, a brain computed tomography was performed, and pneumocephalus was finally diagnosed. The patient underwent conservative treatment and recovered without any complications. He was discharged on the 11th day after the block.

Ultrasonography Evaluation of Vulnerable Vessels Around Cervical Nerve Roots During Selective Cervical Nerve Root Block

OBJECTIVE: To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting. METHODS: This retrospective study included 74 patients with cervical radiculopathy who received an ultrasonography-guided nerve block at an outpatient clinic from July 2012 to July 2014. Before actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of each patient's painful side, with Doppler ultrasound. RESULTS: Out of 74 cases, the C5 level had 2 blood vessels (2.7%), the C6 level had 4 blood vessels (5.45%), and the C7 level had 6 blood vessels (8.11%) close to each targeted nerve root. Moreover, the C5 level had 2 blood vessels (2.7%), the C6 level 5 blood vessels (6.75%), and the C7 level had 4 blood vessels (5.45%) at the site of an imaginary needle's projected pathway to the targeted nerve root, as revealed by axial transverse ultrasound imaging with color Doppler imaging. In total, the C5 level had 4 blood vessels (5.45%), the C6 level 9 blood vessels (12.16%), and the C7 level 10 had blood vessels (13.51%) either at the targeted nerve root or at the site of the imaginary needle's projected pathway to the targeted nerve root. There was an unneglectable prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of the needle' projected pathway to the nerve root. Also, it shows a higher prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of an imaginary needle's projected pathway to the nerve root as the spinal nerve root level gets lower. CONCLUSION: To prevent unexpected critical complications involving vulnerable blood vessel injury during cervical nerve root block, it is recommended to routinely evaluate for the presence of vulnerable blood vessels around each cervical nerve root using Doppler ultrasound imaging before the cervical nerve root block, especially for the lower cervical nerve root level.

Relative Risk of Operation between Lumbar Far Lateral Disc Herniation and Posterolateral Disc Herniation: A Retrospective Cohort Study / 대한정형외과학회잡지

PURPOSE: We reported relative risk of operation between patients who were diagnosed with lumbar far lateral disc herniation and posterolateral disc herniation after transforaminal epidural block. MATERIALS AND METHODS: A retrospective cohort study was performed on 295 patients (131 male and 164 female) who underwent transforaminal epidural block for unilateral radiculopathy caused by lumbar intervertebral disc herniation. Among these 295 patients, 34 patients were diagnosed with far lateral disc herniation and 261 patients with posterolateral disc herniation. The median follow-up period was 23.9 months, with an average age of 55.7 years. RESULTS: Fifty-one patients underwent surgical treatment. Among them, 38 patients had posterolateral disc herniation and 13 patients had far lateral disc herniation. Patients with far lateral disc herniation, when compared with posterolateral disc herniation, had a relative risk of operation of 2.67 (1.59-4.48, 95% confidence interval) with statistical significance (p=0.0002). At the final follow-up, the average visual analogue scale (VAS) score for radicular pain in the surgical and non-surgical groups was 0.69 and 1.50, respectively; the average Korean-Oswestry Disability Questionnaire (K-ODI) score was 11.7 and 9.6, respectively. The difference of average VAS score showed a statistical significance (p=0.035), however, that of K-ODI showed no statistical significance (p=0.266). CONCLUSION: In the case of far lateral disc herniation, the relative risk of surgery after transforaminal epidural block was 2.67, which is higher than that of posterolateral disc herniation. Therefore, we should consider surgical treatment more aggressively.

The Use of Contrast in Caudal Epidural Injections under Image Intensifier Guidance: Is It Necessary?

BACKGROUND: We investigated the value of using contrast as an additional aid to confirm the accuracy of needle placement for caudal epidural injections under intraoperative image intensifier guidance. METHODS: A total of 252 consecutive patients were included in this study. Their mean age was 46.7 years (range, 32 to 76 years). There were 133 males (53%) and 119 females (47%) over a 12-month period. RESULTS: Of the 252 consecutive procedures, the contrast enhanced image intensifier confirmed accurate needle placement on first attempt in 252 cases (100%). Needle resiting following the infiltration of contrast was required in 0 case. CONCLUSIONS: The results from this study demonstrate that a surgeon beyond the learning curve can accurately place caudal epidural injections using image intensification only, without the use of contrast.

Effectiveness of Selective Nerve Root Block on the Need for Surgical Treatment of Patients with Cervical Radicular Pain: A Minimum 5 Years Follow-Up / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to assess the 5-year outcome of patients considering surgery for complaint of cervical and radiating pain treated by selective nerve root block (SNRB). MATERIALS AND METHODS: Between January 2001 and December 2007, 39 cases were selected from patients who underwent SNRB before the operation and were followed-up for more than five years. The mean follow-up period was 64.3 months and the mean age was 57.7 years. The patients were divided into the operation group and the only cervical SNRB group. The groups were compared for gender, age, duration, disease, single or multi-level, and root compression rate on magnetic resonance imaging. The clinical results were analyzed using the neck disability index (NDI) and the visual analogue scale (VAS) score. RESULTS: Among the 39 cases scheduled for the operation, 20 cases (51.3%) did not proceed to the operation and 13 cases among them were treated with additional conservative treatment. The average VAS score for the operation group and the cervical SNRB group was 8.1 points and 7.5 points at the preoperative state and the pre-injection state. After surgical treatment and cervical nerve root block, the scores were 3.0 points for all. The NDI for the operation group was 11.3 points at the last follow-up. The NDI for the cervical nerve root block group was 13.6 at the last follow-up. There was no significant difference between the two groups. Shorter duration and younger age tended to show a higher operation rate. At the last follow-up, 7 cases (17.9%) after cervical SNRB had persistent symptom relief without other treatment. CONCLUSION: Cervical SNRB is considered an effective treatment for patients with cervical disease with radiating pain and who are scheduled for an operation.

The Effect and Safety of Steroid Injection in Lumbar Spinal Stenosis: With or Without Local Anesthetics

OBJECTIVE: To compare the long-term effect and safety of an epidural steroid injection in spinal stenosis patients, with or without local anesthetics. METHODS: Twenty-nine patients diagnosed with spinal stenosis were included and randomly divided into two groups. Translaminar epidural and selective nerve root spinal injection procedures were performed using steroids mixed with local anesthetics or normal saline. The effects of spinal injection procedures were measured with visual analogue scale (VAS) and functional rate index (FRI). These measurements were performed before injection, at 1 month after injection and at 3 months after injection. The occurrence of side effects was investigated each time. RESULTS: The VAS and FRI scores were significantly reduced in both the local anesthetics group and normal saline group at 1 and 3 months after the injection. However, there was no significant difference in VAS and FRI score reduction between the two groups each time. Side effects are not noted in both groups. CONCLUSION: The spinal injection procedures using steroids mixed either with local anesthetics or normal saline have an effect in reducing pain and improving functional activities. However, there was no significant difference between the two groups in relation to side effects and the long-term effects of pain and function.

The Prognostic Value of Enhanced-MRI and Fluoroscopic Factors for Predicting the Effects of Transforaminal Steroid Injections on Lumbosacral Radiating Pain

OBJECTIVE: To investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain. METHODS: A total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups. RESULTS: According to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group. CONCLUSION: Among the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.

What is the Role of Epidural Injections in the Treatment of Lumbar Discogenic Pain: A Systematic Review of Comparative Analysis with Fusion

BACKGROUND: Lumbar discogenic pain without pain mediated by a disc herniation, facet joints, or the sacroiliac joints, is common and often results in chronic, persistent pain and disability. After conservative treatment failure, injection therapy, such as an epidural injection, is frequently the next step considered in managing discogenic pain. The objective of this systematic review is to determine the efficacy of lumbar epidural injections in managing discogenic pain without radiculopathy, and compare this approach to lumbar fusion or disc arthroplasty surgery. METHODS: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and lumbar fusion or disc arthroplasty in managing lumbar discogenic pain was performed with methodological quality assessment and grading of evidence. The level of evidence was based on the grading of evidence criteria which, was conducted using 5 levels of evidence ranging from levels I to V. RESULTS: Based on a qualitative assessment of the evidence for both approaches, there is Level II evidence for epidural injections, either caudal or lumbar interlaminar. CONCLUSIONS: The available evidence suggests fluoroscopically directed epidural injections provide long-term improvement in back and lower extremity pain for patients with lumbar discogenic pain. There is also limited evidence showing the potential effectiveness of surgical interventions compared to nonsurgical treatments.

Cervical Meningomyelitis After Lumbar Epidural Steroid Injection

Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.

Use of Magnetic Resonance Imaging to Identify Outcome Predictors of Caudal Epidural Steroid Injections for Lower Lumbar Radicular Pain Caused by a Herniated Disc

OBJECTIVE: We used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD). METHODS: Ninety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half ), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure-clear nucleus and height of intervertebral disc). RESULTS: A centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical. CONCLUSION: The HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.

Clinical experiences of performing transforaminal balloon adhesiolysis in patients with failed back surgery syndrome: two cases report / 대한마취과학회지

Epidural fibrosis is a contributing factor to the persistent pain that is associated with failed back surgery syndrome (FBSS) and other pathophysiologies, particularly as it inhibits the passage of regional medications to areas responsible for pain. Therefore, effective mechanical detachment of epidural fibrosis can contribute to pain reduction and improve function in FBSS patients. In this report, we describe the successful treatment of FBSS patients with epidural adhesiolysis using a Fogarty catheter via the transforaminal approach.

Epidural Dexamethasone Decreased Inflammatory Hyperalgesia and Spinal cPLA2 Expression in a Rat Formalin Test

PURPOSE: The aim of this study was to investigate the effect of epidural dexamethasone on analgesia and cytosolic phospholipase A2 (cPLA2) expression in the spinal cord in a rat formalin test. MATERIALS AND METHODS: Epidural dexamethasone injection was performed to Sprague-Dawley rats with a 25 gauge needle under fluoroscopy. Following the epidural injection, a formalin induced pain behavior test was performed. Next, the spinal cords corresponding to L4 dorsal root ganglion was extracted to observe the cPLA2 expression. RESULTS: There were no differences in pain response during phase I among the groups. The phase II pain response in 300 microg of epidural dexamethasone group decreased as compared to control, 30 microg of epidural dexamethasone, 100 microg of epidural dexamethasone, and 300 microg of systemic dexamethasone groups. The expression of cPLA2 decreased in Rexed laminae I-II in 300 microg of the epidural dexamethasone group compared with the ones in the control group. CONCLUSION: Taken together, these results suggest that 300 microg of epidural dexamethasone has an attenuating effect on the peripheral inflammatory tissue injury induced hyperalgesia and this effect is mediated through the inhibition of intraspinal cPLA2 expression and the primary site of action is the laminae I-II of the spinal cord.

Epidural steroid injection

Excessive spine operations is an economic and social problem today in Korea. Proper conservative treatment can reduce the need for surgical treatment by relieving the pain during the acute phase of spinal disease. Epidural steroid injection and a selective nerve root block are relatively safer and easier than other treatments. They may have many advantages such as relief of neck and back pain and of radicular pain, and reducing the gastrointestinal adverse effects caused by long-term NSAID medication or injection. Furthermore, patients in an inoperable state due to old age or other comorbidities and outpatients who want conservative treatment may benefit from epidural steroid injection and a nerve root block. The treatment outcomes differ among reports. The efficacy of temporary pain relief has been described to be excellent, but it gradually decreases as time passes. Recently, transforaminal epidural steroid injection has been widely performed. Epidural steroid injection should be performed for temporary pain relief due to its limited efficacy. In addition, an overuse of epidural and selective nerve root steroid injection can cause serious side effects. Therefore, this procedure should be done with caution, taking into account the technical risks and side effects.

Epidural catheterization with a subcutaneous injection port for the long-term administration of opioids and local anesthetics to treat zoster-associated pain: a report of two cases / 대한마취과학회지

Continuous epidural analgesia has been used for decades to treat acute herpes zoster pain and to prevent postherpetic neuralgia. However, many technical problems can arise during chronic treatment with epidural medications. These complications include catheter dislodgement, infection, injection pain, leakage, and occlusion. Epidural catheter placement utilizing subcutaneous injection port implantation has gained widespread acceptance as a method to overcome such complications. The technique reduces the risk of infection, the most feared complication, compared to the use of a percutaneous epidural catheter. Herein, we present 2 cases in which the continuous thoracic epidural administration of opioids and local anesthetics through an implantable subcutaneous injection port for over 2 months successfully treated zoster-associated pain without any technique- or medication-related complications in patients with risk factors for epidural abscess.

Fluoroscopic analysis of lumbar epidural contrast spread after retrograde interlaminar ventral epidural injection (RIVEI) / 대한마취과학회지

BACKGROUND: Retrograde interlaminar ventral epidural injection (RIVEI) may hypothetically be more effective if the catheter is placed at the ventrocaudal aspect of the exiting nerve. We tested that hypothesis by measuring ventral and dorsal epidural contrast flow during RIVEI. METHODS: To perform RIVEI, a 17 G Tuohy needle was inserted to access the epidural space. A 19 G epidural catheter was inserted and advanced through the needle, passing in a caudal direction to the lower aspect of the contralateral pedicle. Fluoroscopic images were recorded at 1.5 ml increments of contrast. Based on the images of contrast dispersal, the extent of contrast spreading was assessed in 82 patients. RESULTS: All 82 patients (100%) injected with 3.0 ml contrast medium demonstrated ventral epidural spreading. Mean spreading level from the catheter tip was 2.21 +/- 0.93 with 3.0 ml of contrast. Spreading to the superior aspect of the supra-adjacent intervertebral disc was observed in 67/82 (81.7%) of RIVEIs with 3.0 ml of contrast injected into the ventral epidural space. We found that 3.0 ml of contrast reached the inferior aspect of the infra-adjacent intervertebral disc in 95.1% (78/82) of RIVEIs performed. CONCLUSIONS: Our findings imply that a one-level RIVEI may be sufficient in situations where a two-level injection would currently be used.

Relief of Postherpetic Neuralgia with Transforaminal Epidural Injection of Magnesium: A Case Report

Although postherpetic neuralgia (PHN) is a common chronic pain syndrome, the pathophysiology of this disorder is not well known and management is often very difficult. N-Methyl-D-Aspartate (NMDA) receptor antagonists are known to be effective in PHN, and magnesium, a physiological blocker of NMDA receptors, is widely used to treat various chronic pain disorders. Here, we present a case of the PHN refractory to conventional treatment, which was treated successfully with transforaminal epidural injection of magnesium sulphate at the affected dermatome.

Relief of Postherpetic Neuralgia with Transforaminal Epidural Injection of Magnesium: A Case Report

Although postherpetic neuralgia (PHN) is a common chronic pain syndrome, the pathophysiology of this disorder is not well known and management is often very difficult. N-Methyl-D-Aspartate (NMDA) receptor antagonists are known to be effective in PHN, and magnesium, a physiological blocker of NMDA receptors, is widely used to treat various chronic pain disorders. Here, we present a case of the PHN refractory to conventional treatment, which was treated successfully with transforaminal epidural injection of magnesium sulphate at the affected dermatome.

Air Bubbles Mimic Disc Herniation in MRI after Cervical Epidural Block

Magnetic resonance image (MRI) is the most sensitive imaging test of the spine in routine clinical practice. Unlike conventional x-ray examinations and computed tomography scans, high-quality magnetic resonance images can be assured only if patients are able to remain perfectly still. However, some patients find it uncomfortable to remain still because of pain. In that condition, interlaminar cervical epidural injections can reduce pain and allow the procedure. When using air with the "loss of resistance" technique in epidural injections to identify the epidural space, there is the possibility of injected excessive air epidurally to mimic a herniated disc. We describe a case report of epidural air artifact in a cervical MRI after cervical epidural injections.