Spinal Cord Injury in a Child After Single-Shot Epidural Anesthesia

Spinal Cord Injury and Complications Related to Neuraxial Anaesthesia Procedures: A Systematic Review

The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to anaesthetic practice (Anaes-SCI) are rare events but remain a significant concern for many patients undergoing surgery. This systematic review aimed to identify high-risk patients summarise the causes, consequences, and management/recommendations of SCI due to neuraxial techniques in anaesthesia. A comprehensive search of the literature was conducted in accordance with Cochrane recommendations, and inclusion criteria were applied to identify relevant studies. From the 384 studies initially screened, 31 were critically appraised, and the data were extracted and analysed. The results of this review suggest that the main risk factors reported were extremes of age, obesity, and diabetes. Anaes-SCI was reported as a consequence of hematoma, trauma, abscess, ischemia, and infarction, among others. As a result, mainly motor deficits, sensory loss, and pain were reported. Many authors reported delayed treatments to resolve Anaes-SCI. Despite the potential complications, neuraxial techniques are still one of the best options for opioid-sparing pain prevention and management, reducing patients' morbidity, improving outcomes, reducing the length of hospital stay, and pain chronification, with a consequent economic benefit. The main findings of this review highlight the importance of careful patient management and close monitoring during neuraxial anaesthesia procedures to minimise the risk of spinal cord injury and complications.

Comparison of landmark and real-time ultrasound-guided epidural catheter placement in the pediatric population: a prospective randomized comparative trial

Background

Epidural block placement in pediatric patients is technically challenging for anesthesiologists. The use of ultrasound (US) for the placement of an epidural catheter has shown promise. We compared landmark-guided and US-guided lumbar or lower thoracic epidural needle placement in pediatric patients.

Methods

This prospective, randomized, comparative trial involved children aged 1–6 years who underwent abdominal and thoracic surgeries. Forty-five children were randomly divided into two groups using a computer-generated random number table, and group allocation was performed by the sealed opaque method into either landmark-guided (group LT) or real-time ultrasound-guided (group UT) epidural placement. The primary outcome was a comparison of the procedure time (excluding US probe preparation). Secondary outcomes were the number of attempts (re-insertion of the needle), bone contacts, needle redirection, skin-to-epidural distance using the US in both groups, success rate, and complications.

Results

The median (interquartile range) time to reach epidural space was 105.5 (297.0) seconds in group LT and 143.0 (150) seconds in group UT (P = 0.407). While the first attempt success rate was higher in the UT group (87.0% in UT vs. 40.9% in LT; P = 0.004), the number of bone contacts, needle redirections, and procedure-related complications were significantly lower.

Conclusions

The use of US significantly reduced needle redirection, number of attempts, bone contact, and complications. There was no statistically significant difference in the time to access the epidural space between the US and landmark technique groups.

Large central disc herniation causing cauda equina syndrome in an adolescent. A case report

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Cauda equina syndrome is a surgical emergency that requires early diagnosis and prompt intervention.

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Cauda equina syndrome is an extremely rare condition in the pediatric population with horrible complications if the diagnosis is delayed or missed.

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Lumbar disc herniation is relatively uncommon in children.

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In this age group, this is the first paper in the English written literature reporting a case of lumbar disc herniation complicated by CES in an adolescent.

Background

Cauda equina syndrome is a surgical emergency that requires early diagnosis and prompt intervention. It is a challenging diagnosis with a wide variety of clinical presentations that may delay the diagnosis and result in complications that severely affect the patient’s quality of life.

Case report

We present a case of a 15-years-old child affected with acute cauda equina syndrome (CES) secondary to an acute disc herniation after lifting a heavy object. The patient was treated with decompressive laminectomy and discectomy that resulted in significant neurological improvement.

Discussion

Etiologic factors of CES in the pediatric population include tumors, trauma, iatrogenic injuries, spinal dysraphism, constipation and inferior vena cava syndrome. This case is being reported for the rarity of this syndrome in pediatric population especially when the etiological factor is acute disc herniation, which is also rare in this particular population.

Conclusion

This report is thought to increase the index of suspicion of CES in this age group especially in the presence of inciting event allowing early diagnosis and better outcomes.

The relationship between current intensity for nerve stimulation and success of peripheral nerve blocks performed in pediatric patients under general anesthesia

BACKGROUND

We evaluated the relationship between the lowest current amperage used to obtain a motor response, the success rate and the incidence of neurological complications with peripheral nerve blocks (PNB) in pediatric patients under general anesthesia.

METHODS

We reviewed the regional anesthesia database at The Children's Hospital of Philadelphia and included all pediatric patients who received a single-injection PNB under general anesthesia with the aid of a peripheral nerve stimulator between October 2002 and July 2006. Data analyzed included age, sex, type of block, stimulation threshold, presence of sensory and motor blockade, and neurological complications.

RESULTS

Six-hundred sixty patients received a PNB during the study period. The average age of the patients was 13.8 yr (range = 2-18 yr). All the blocks were performed using a current ranging between 0.2 and 1 (median = 0.5 mA, interquartile range: 0.45-0.55 mA). The overall success rate was 96%. There was no difference in success rate between blocks performed using a stimulation threshold of < or =0.5 or >0.5 mA (96.3% vs 95.9%; P = 0.793). There was no correlation between the success rate and sex, type of block performed or intensity of current used. Two patients reported prolonged nerve blockade of the great toe and dorsum of the foot after a sciatic nerve block, which lasted for 72 h. No long-term sequelae were noted in our patients.

CONCLUSION

In this study, a similar PNB success rate was observed with both a low (*0.5 mA) and a high stimulation threshold (>0.5 mA). Therefore, it may not be necessary to perform needle manipulations to achieve a low stimulation threshold (< or =0.5 mA), as this may increase the risk of intraneural injection.

Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique

BACKGROUND

We report a prospective, randomized study to evaluate ultrasound guidance for epidural catheter placement in children 0-6 yr of age.

METHODS

Epidural catheters were placed at lumbar or thoracic cord levels in 64 children undergoing major surgery, using either ultrasonography or loss-of-resistance (LOR) for guidance. Using a 5-10 MHz linear ultrasound probe, the neuraxial structures were identified, the skin-epidural depth and epidural space was measured, the advancing epidural catheter visualized, and the spread of local anaesthetic verifying catheter position was confirmed. Epidural placement procedures were analysed for bone contacts and speed of execution. Children under 6 months were analysed separately.

RESULTS

Epidural placement involved bone contacts in 17% of children in the ultrasound group and 71% of children in the LOR group (P<0.0001). Epidurals were executed more swiftly in the ultrasound group [162 (75) s vs 234 (138) s; P<0.01]. Children under 6 months revealed a 0.9 correlation between skin-epidural depth and body weight.

CONCLUSIONS

Ultrasonography is a useful aid to verify epidural placement of local anaesthetic agents and epidural catheters in children. Advantages include a reduction in bone contacts, faster epidural placement, direct visualization of neuraxial structures and the spread of local anaesthetic inside the epidural space. Ultrasound guidance requires additional training and good manual skills, and should only be used once experience in ultrasound-guided techniques of regional anaesthesia has been acquired.

The threshold current in the intrathecal space to elicit motor response is lower and does not overlap that in the epidural space: a porcine model

PURPOSE

Using electrical epidural stimulation, a current of 1 to 10 mA is required to confirm the presence of the tip of an epidural catheter in the epidural space. The purpose of this study was to examine the hypothesis that the threshold current required to elicit a motor response in the intrathecal space is significantly lower than that in the epidural space in a porcine model.

METHODS

Four 20-kg pigs were used in this experiment. Eighteen gauge, insulated, Tuohy needles were advanced into the epidural space using the loss of resistance technique at five different spinal levels in each pig. When the epidural space was entered, an electrical current was applied to the needle and increased progressively until a motor response was elicited. The needle was then further advanced until cerebrospinal fluid (CSF) was observed or until the needle had been advanced a maximum of 1 cm. At this point, the current was reapplied and increased until motor activity was evident.

RESULTS

A total of 20 needles were inserted in four pigs. The current required to produce a motor response in the epidural space was 3.45 +/- 0.73 mA (mean +/- SD). The current required to produce a motor response in the intrathecal space (entry confirmed by the presence of CSF) was 0.38 +/- 0.19 mA (mean +/- SD). Two needles were advanced 1 cm without obtaining CSF but the current thresholds were similar to those obtained when CSF was evident (0.4 mA and 0.3 mA, respectively).

CONCLUSION

The threshold current of an insulated needle required to elicit a motor response in the intrathecal space, was significantly (P < 0.01) lower than that in the epidural space in a porcine model.