Subject(s)
Lower Extremity/anatomy & histology , Lower Extremity/physiology , Nerve Block/methods , Peripheral Nerves/anatomy & histology , Peripheral Nerves/physiology , Humans , Lumbosacral Plexus/anatomy & histology , Lumbosacral Plexus/drug effects , Lumbosacral Plexus/physiology , Nerve Block/adverse effects , Peripheral Nerves/drug effectsABSTRACT
PURPOSE: To report the case of a patient who experienced failed spinal anesthesia following a psoas compartment block (PCB) and discuss its implications. CLINICAL FEATURES: A 70-yr-old male was scheduled for a right total hip arthroplasty. He agreed to a PCB for postoperative analgesia and a spinal anesthetic. The spinal anesthetic was performed after completion of the PCB. Free flow of clear fluid was demonstrated at the beginning and at the end of the presumed intrathecal injection. General anesthesia had to be induced because of failure of the spinal anesthetic. The patient awoke from his general anesthetic with a functional PCB and no evidence of residual neuraxial anesthesia. The possibility of epidural spread of local anesthetic from the PCB impairing the ability to perform spinal anesthesia is discussed and reviewed. We hypothesize that local anesthetic in the epidural space may have falsely reassured the anesthesiologist that the needle was properly placed. CONCLUSION: We describe a case of failed spinal anesthesia following a PCB and discuss its implications.
Subject(s)
Anesthesia, Spinal , Neuromuscular Blockade , Psoas Muscles , Aged , Anesthesia, General , Anesthetics, Local/administration & dosage , Arthroplasty, Replacement, Hip , Epidural Space , Humans , Male , Treatment FailureABSTRACT
BACKGROUND AND OBJECTIVES: To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis). CASE REPORT: A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established. CONCLUSION: We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.
