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Kang SY, Cho HS, Yi J, Jung SC, Kim HS, Jang IT, Kang H. Epidural, Inadvertent Subdural, and Combined Epidural-Subdural Anesthesia in Lumbar Spine Surgery: A Retrospective Analysis. J Pers Med 2024; 14:486. [PMID: 38793068 PMCID: PMC11122072 DOI: 10.3390/jpm14050486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
This study aimed to categorize contrast media images associated with epidural, subdural, and combined epidural-subdural anesthesia in patients who had undergone fluoroscopy-guided epidural anesthesia using contrast media combined with monitored anesthesia care (MAC) targeted at deep sedation, incorporating capnography over 5 years. Additionally, a correlation was established between the anesthetic effects and radiographic findings according to the categorized imaging appearances. This study included 628 patients who underwent endoscopic, open, or fusion surgery under epidural anesthesia at Nanoori Hospital in Gangnam between March 2018 and September 2023. Fluoroscopy-guided epidural anesthesia using contrast media combined with MAC and capnography was used. The dataset included detailed radiographic imaging, nursing, and anesthesia records. Distinct patterns of anesthesia administration were observed, with 49%, 19.6%, and 31% of patients receiving epidural, subdural, and combined epidural-subdural anesthesia, respectively. The incidence and duration of motor block were significantly different among the three groups. Additionally, subdural anesthesia displayed a higher incidence of motor block and a prolonged motor deficit duration than epidural anesthesia. Fluoroscopic guidance using a contrast medium for epidural and subdural anesthesia ensures precise space identification and prevents serious anesthetic complications. Our findings suggest the potential to achieve stable anesthesia, particularly using subdural and combined epidural-subdural anesthesia.
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Affiliation(s)
- Seung Youn Kang
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul 06048, Republic of Korea; (S.Y.K.); (H.S.C.); (J.Y.); (S.C.J.)
| | - Hae Sun Cho
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul 06048, Republic of Korea; (S.Y.K.); (H.S.C.); (J.Y.); (S.C.J.)
| | - Jihwan Yi
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul 06048, Republic of Korea; (S.Y.K.); (H.S.C.); (J.Y.); (S.C.J.)
| | - Sung Chan Jung
- Department of Anesthesiology and Pain Medicine, Nanoori Hospital Gangnam, Seoul 06048, Republic of Korea; (S.Y.K.); (H.S.C.); (J.Y.); (S.C.J.)
| | - Hyeun Sung Kim
- Department of Neurosurgery, Cheongdam Harrison Hospital Gangnam, Seoul 06084, Republic of Korea;
| | - Il Tae Jang
- Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul 06048, Republic of Korea;
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chungang University College of Medicine, Seoul 06974, Republic of Korea
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Madhavan AA, Liebo GB, Baffour F, Diehn FE, Maus TP, Murthy NS, Rhodes NG, Tiegs-Heiden CA. A review of epidural and non-epidural contrast flow patterns during fluoroscopic and CT-guided epidural steroid injections. Interv Neuroradiol 2024:15910199231221857. [PMID: 38179603 DOI: 10.1177/15910199231221857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Epidural steroid injections are commonly performed using fluoroscopic or CT guidance. With both modalities, the injection of contrast material is necessary before steroid administration to ensure adequate epidural flow and exclude non-epidural flow. While fluoroscopic guidance is conventional, CT is utilized at some centers and can be particularly helpful in the setting of challenging or postoperative anatomy. It is important for proceduralists to be adept at evaluating contrast media flow patterns under both modalities. The goal of this review article is to describe and provide examples of epidural and non-epidural flow patterns on both conventional fluoroscopy and CT. Specific non-epidural patterns discussed include intrathecal flow, intradural/subdural flow, vascular uptake, flow into the retrodural space of Okada, inadvertent facet joint flow, and intradiscal flow.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Greta B Liebo
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Francis Baffour
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Timothy P Maus
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Naveen S Murthy
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Nicholas G Rhodes
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Christin A Tiegs-Heiden
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Assessing the impact of adding bupivacaine on immediate and delayed post-procedure pain scores in interlaminar epidural steroid injections. Skeletal Radiol 2022; 51:161-169. [PMID: 34136939 DOI: 10.1007/s00256-021-03817-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE A local anesthetic is frequently administered as part of a lumbar epidural steroid injection (LESI); however, there is a rare potential for this to result in transient paralysis if administered incorrectly. The purpose of this retrospective study is to determine if the addition of bupivacaine significantly improves patient-reported pain scores. MATERIALS AND METHODS This retrospective review includes patients undergoing LESI over an approximately 1 year time span. Pre-procedure, immediate post-procedure, and 1-week integer scaled pain scores were recorded. Ordinal regression was used to compare the distributions of the aggregated ordinal pain score categories between bupivacaine- and non-bupivacaine-injected patients. RESULTS Two hundred fifty-eight patients met the inclusion criteria (126F:132 M, mean age 64.7 years) with 164 receiving bupivacaine and steroids and 94 receiving steroids alone. The relative frequency distributions for pre-injection pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.114). Similarly, the relative frequency distributions for immediate and 1-week post-procedure pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.293 at immediate time point and p = 0.306 at 1-week time point). Odds ratios comparing pain severity change between the bupivacaine and non-bupivacaine patients also were not significantly different at either the immediate post-procedure (p = 0.769) or 1-week (p = 0.203) time points. CONCLUSION The lack of a significant downward shift in the bupivacaine patients' post-procedure pain scores compared to the non-bupivacaine patients' post-procedure pain scores raises doubts about bupivacaine's utility as a standard component of a lumbar epidural injection.
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Gill J, Simopoulos T, Orhurhu V, Nagda J, Aner M. Lumbar Epidural Contrast Spread Patterns for the Interlaminar Approach: Three-Dimensional Analysis Using Antero-Posterior, Lateral, and Contralateral Oblique Views. PAIN MEDICINE 2021; 21:747-756. [PMID: 31609385 DOI: 10.1093/pm/pnz256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe and analyze lumbar epidural contrast spread patterns in antero-posterior (AP), lateral, and contralateral oblique (CLO) views. METHODS Lumbar epidural contrast spread patterns after interlaminar injection were prospectively collected in AP, lateral, and several CLO views and analyzed for multiple variables; three-dimensional mapping was also performed. RESULTS Epidural contrast patterns were prospectively analyzed in 28 subjects. The median volume of contrast injected was 2 mL; the AP view was more sensitive than the lateral view to detect foraminal uptake (13/28, 46%, 95% confidence interval [CI] = 27-66%, vs 7/28, 25%, 95% CI = 11-45% subjects). CLO view demonstrated the most consistent location for epidural contrast spread, with contrast contacting the ventral laminar margin in 28/28 (100%, 95% CI = 87-100%) patients. The most common location of contrast spread in the lateral view was at the facet joint lucency, with only 8/28 (29%, 95% CI = 13%-49%) subjects showing contrast contacting the spinolaminar junction. Lateral view was more sensitive than the CLO view in ventral epidural contrast spread detection. The extent and distribution of the spread did not bear any relationship to the volume injected or to the needle location in AP view. CONCLUSIONS CLO view provides the most consistent landmark for lumbar epidural contrast spread, and lateral view is most suited to confirming ventral epidural spread. The AP view may be the most optimal for determining target access when considering access to the dorsal root ganglia; in an individual patient, the volume injected and needle location in AP view do not reliably predict target access. The volume to be injected and the need to re-access or obtain multisite access must be prospectively determined, based upon observation of the spread.
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Affiliation(s)
- Jatinder Gill
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas Simopoulos
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vwaire Orhurhu
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jyotsna Nagda
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Moris Aner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Shlapak DP, Kim DK, Diehn FE, Benson JC, Lehman VT, Liebo GB, Morris JM, Morris PP, Verdoorn JT, Carr CM. Time to Resolution of Inadvertent Subdural Contrast Injection during a Myelogram: When Can the Study Be Reattempted? AJNR Am J Neuroradiol 2020; 41:1958-1962. [PMID: 32855185 DOI: 10.3174/ajnr.a6725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Inadvertent subdural contrast injections can occur during any myelogram. Currently, there are no guidelines defining when residual subdural iodinated contrast will be cleared and no longer interfere with subsequent procedure and imaging. We investigated the time to resolution of subdural contrast using a 2-day lateral decubitus digital subtraction myelogram and associated CT myelogram data in patients undergoing evaluation for spontaneous intracranial hypotension. MATERIALS AND METHODS Retrospective review of 63 patients with lateral decubitus digital subtraction myelograms from September 4, 2018, to October 1, 2019, was performed. Patients with 2-day lateral decubitus digital subtraction myelograms on 2 consecutive days, with or without a same-day CT myelogram on day 1 and with a same-day CT myelogram on day 2, were included. Patients with next-day CT covering at least the abdomen and pelvis after either-day injection were also included. In cases of subdural injection, next-day CT scans were evaluated for residual subdural contrast. RESULTS Of 49 included patients, 5 had subdural injection on day 1, with the second-day CT myelogram available for review. One of these 5 patients had subdural injections on 2 different days and subsequently had chest/abdomen/pelvis CTA a day after the second subdural injection. In all 6 cases of subdural injections, there was complete resolution of subdural contrast on the next-day CT, with the shortest time to resolution of approximately 20.5 hours (range, 20.5-28.5 hours). CONCLUSIONS Our study suggests that resolution of inadvertently injected subdural contrast occurs within 1 day, and the myelogram can be reattempted as early as the next day.
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Affiliation(s)
- D P Shlapak
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - D K Kim
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - F E Diehn
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - V T Lehman
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - G B Liebo
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - J M Morris
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - P P Morris
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - J T Verdoorn
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - C M Carr
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
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Affiliation(s)
- Jatinder S Gill
- Division of Pain Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Beth Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Maus T. Expert Opinion #1. PAIN MEDICINE 2017; 18:1182-1183. [DOI: 10.1093/pm/pnx074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Spinal subdural abscess following repeat lumbar microdiscectomy: A case report of imaging findings for a rare infection. Clin Imaging 2017; 44:74-78. [PMID: 28482336 DOI: 10.1016/j.clinimag.2017.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/17/2017] [Accepted: 04/25/2017] [Indexed: 11/22/2022]
Abstract
Spinal subdural abscess is a rare central nervous system infection with just over a hundred cases reported. It is much less common than spinal epidural abscess. While most case reports have focused on route of infection and treatment options, there have not been any reports that focused on the unique MRI findings of spinal subdural abscess. We describe a case of spinal subdural abscess diagnosed by MRI in a 33-year-old male who presented with headaches after undergoing a microdiscectomy procedure, and review the underlying anatomic features of the spinal meninges which produce the appearance of a spinal subdural abscess.
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Collier CB, Reina MA, Prats-Galino A, Machés F. An Anatomical Study of the Intradural Space. Anaesth Intensive Care 2011; 39:1038-42. [DOI: 10.1177/0310057x1103900609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We have previously postulated that it is possible to accidentally insert an epidural needle or catheter into the substance of the dura during attempted epidural block, creating an intradural space. It appears that injection of local anaesthetic into an intradural space leads to an initially inadequate neuraxial block but further doses may produce an extensive life-threatening block. In the laboratory, 54 samples of human thoraco-lumbar dura were obtained from six cadavers and prepared for scanning electron microscopy. Images from these dehydrated specimens were assessed for the presence of spaces within the dura, and attempts were made to insert an epidural catheter, under optical microscopy, into the substance of the dura in 32 cases. Electron microscopy revealed the concentric laminae that compose the dura and the presence of artefactual spaces between some of these. It was possible to insert an epidural catheter into the substance of the dura in eight specimens, creating intradural spaces which remained following catheter removal. If this represents the clinical situation, it may help to explain previously reported cases of atypical neuraxial block and their associated radiological findings.
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Affiliation(s)
- C. B. Collier
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute, CEU San Pablo University School of Medicine, Madrid and Human Anatomy and Embryology Unit, Barcelona University School of Medicine, Barcelona, Spain
- Obstetric Anaesthesia. Prince of Wales Private Hospital
| | - M. A. Reina
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute, CEU San Pablo University School of Medicine, Madrid and Human Anatomy and Embryology Unit, Barcelona University School of Medicine, Barcelona, Spain
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute
| | - A. Prats-Galino
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute, CEU San Pablo University School of Medicine, Madrid and Human Anatomy and Embryology Unit, Barcelona University School of Medicine, Barcelona, Spain
- Human Anatomy and Embryology Unit, Faculty of Medicine, Barcelona University
| | - F. Machés
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute, CEU San Pablo University School of Medicine, Madrid and Human Anatomy and Embryology Unit, Barcelona University School of Medicine, Barcelona, Spain
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Yun JS, Kang SY, Cho JS, Choi JB, Lee YW. Accidental intradural injection during attempted epidural block -A case report-. Korean J Anesthesiol 2011; 60:205-8. [PMID: 21490823 PMCID: PMC3071485 DOI: 10.4097/kjae.2011.60.3.205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 09/16/2010] [Accepted: 10/14/2010] [Indexed: 12/03/2022] Open
Abstract
Several cases of accidental subdural injection have been reported, but only few of them are known to be accidental intradural injection during epidural block. Therefore we would like to report our experience of accidental intradural injection. A 68-year-old female was referred to our pain clinic due to severe metastatic spinal pain. We performed a diagnostic epidural injection at T9/10 interspace under the C-arm guided X-ray view. Unlike the usual process of block, onset was delayed and sensory dermatomes were irregular range. We found out a dense collection of localized radio-opaque contrast media on the reviewed X-ray findings. These are characteristic of intradural injection and clearly different from the narrow wispy bands of contrast in the subdural space.
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Affiliation(s)
- Joo Sun Yun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Youn Kang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Youn-Woo Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institude, Yonsei University College of Medicine, Seoul, Korea
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Feigl G, Dorn C, Bornemann-Cimenti H. Does an intradural space really exist? Int J Obstet Anesth 2010; 20:89; author reply 89-90. [PMID: 21131194 DOI: 10.1016/j.ijoa.2010.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 09/06/2010] [Indexed: 10/18/2022]
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