Fig 1 - uploaded by Seokyung Shin
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Lateral view of thoracolumbar X-ray taken after radiocontrast dye injection. A thin posterior column of dye is seen within the subdural space.
Citations
... When the local anesthetics reach the brain stem, they lead to apnea and unconsciousness [14]. Several cases of subdural injection, but no controlled studies, have been reported [13,14,16,28,29]. Lubenow and colleagues [15] reported subdural incidence in 18 out of 2182 patients (0.82%) treated by lumbar epidural injection. ...
Persistent or recurrent back and leg pain following spinal surgery, known as failed back surgery syndrome (FBSS), significantly limits daily life activities. A lumbar epidural injection can reduce adhesions, inflammation, and nerve compression, although the epidural space can be distorted due to dura mater and epidural tissues changes after spinal surgery. This study analyzed subdural injection during lumbar epidural injection in FBSS patients. We retrospectively analyzed data from 155 patients who received a lumbar interlaminar epidural injection to manage FBSS. We grouped the patients based on the injected contrast medium appearance in the subdural (group S) or epidural spaces (group E) in fluoroscopic contrast images. Demographic, clinical, surgical and fluoroscopic data were recorded and evaluated, as were the pain scores before and after injection. There were 59 patients (38.1%) in the subdural group. Injection distance from the surgery level differed between the groups. Risk of subdural injection at level 1 distance from the surgery level had an odds ratio of 0.374, and at level ≥2, it was 0.172, when compared to level 0. Subdural incidence differed with the distance from surgical site. Physicians should strive to reduce subdural incidence when the injection is planned at surgery site in FBSS.
... An inadvertent intrathecal placement could result in a high spinal in the larger volume group and a subdural placement of such large volumes could be dangerous. [20,21] We had used a commercial preparation of 2% lignocaine with adrenaline that is higher than the recommended test dose. The large volume of saline that was used was based on the saline volumes with LOR to saline technique [9] or the pre-distension of epidural space in the obstetric population. ...
Background and aims:
Epidural analgesia is widely used for pain relief but confirmation of accurate epidural placement is poorly understood. We proposed that sensory blockade to cold sensation would predict the accurate placement of epidural. The primary outcome was the assessment of sensory blockade at 5 and 10 min with a standard epidural test dose versus test dose with additional saline. We looked at haemodynamic changes following administration as secondary outcomes.
Methods:
Following Ethics Committee approval, 161 patients presenting for elective abdominal surgery needing epidural analgesia with general anaesthesia were randomly allocated into Group 1 receiving standard test dose (3 ml of 2% lignocaine with 1:2,00,000 adrenaline) or Group 2 (standard test dose with 6 ml of saline) epidurally. The blockade to cold sensation was assessed at 5 and 10 min. The heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure (MAP) were recorded at baseline, 1, 5, and 10 min following epidural dosing. Statistical analysis was performed with Chi-square test for categorical and Student's t-test for continuous variables.
Results:
The sensory blockade at 5 min was 69.5% versus 82.3% (P = 0.059), and at 10 min 85.4% versus 97.5% (P = 0.01) in Groups 1 and 2, respectively. The MAP at 5 min (P = 0.032) and the HR and MAP at 10 min (P = 0.015, 0.04) were significantly lower in Group 2.
Conclusion:
An epidural test dose of 3 ml followed by additional 6 ml saline accurately predicted sensory blockade to cold at 10 min in comparison to the standard dose of 3 ml but was associated with a decrease in the HR and MAP.
... Subdural placement of an epidural catheter is a rare complication that may lead to life-threatening consequences. However, it is difficult to detect owing to the variability of symptoms and signs and insufficient diagnostic guidelines [2]. We are reporting a case of suspected subdural deposition of local anesthetic in a patient who was administered combined spinal epidural anesthesia for rectopexy surgery and postoperative pain relief. ...
... In the presence of certain conditions such as spinal stenosis, previous lumbar disc surgeries, and history of back trauma, epidural catheter placement can be difficult and pain control may be less than adequate. If the catheter is placed in the subdural space or within the thecal sac, dangerous outcomes may arise when clinically relevant epidural doses of medications are subsequently administered [2]. ...
... These patterns include a smooth layering of contrast against the inside of the dural sac; and a lack of solution passage into the intervertebral foramina [4]. Radiologic visualization of the neuraxial catheter may be helpful when clinical symptoms make the situation difficult to assess [2]. ...
Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion.
