Neuraxial Blockade in Patients with Spinal Stenosis: Between a Rock and a Hard Place

Epidural Anesthesia With Low Concentration Ropivacaine and Sufentanil for Percutaneous Transforaminal Endoscopic Discectomy: A Randomized Controlled Trial

Introduction: Percutaneous transforaminal endoscopic discectomy is a simple and effective treatment for lumbar intervertebral disc herniation, and local anesthesia is often applied in this kind of surgery in many developing countries, including China. However, many patients still feel excruciating pain under this condition. Epidural anesthesia with low-concentration ropivacaine has no impact on muscle strength, and patients might follow the surgeon well during operation. We hypothesize that epidural anesthesia is feasible for percutaneous transforaminal endoscopic discectomy.

Methods: Two hundred patients with disc herniation who underwent percutaneous transforaminal endoscopic discectomy were randomized to receive either epidural anesthesia or local infiltration anesthesia. Primary outcome measures included the pain score, the cooperation degree, and patients' satisfaction. Mean arterial pressure and heart rate were also recorded.

Results: Compared with the local anesthesia group, visual analog scale scores, mean arterial pressure, and heart rate were significantly lower in the epidural anesthesia group (P < 0.05), and patients' satisfaction was higher. There were no significant differences in the total operation time or blood loss between two groups.

Conclusions: Epidural anesthesia with low-concentration ropivacaine and sufentanil is safe and effective for percutaneous transforaminal endoscopic discectomy.

Clinical Trial Registration:ClinicalTrials.gov, identifier: ChiCTR-IOR-17011768.

Reducing risk of spinal haematoma from spinal and epidural pain procedures

Background and aims:

Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory.

Methods:

We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures.

Results and recommendations:

Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients’ comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur.

Conclusions:

When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH.

Implications:

There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts’ experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.

Acute epidural haematoma following epidural steroid injection in a patient with spinal stenosis

Extradural haematoma is a rare but known complication of neuraxial procedures. Although the literature quotes an incidence of 1:150,000 and 1:220,000 after epidural and spinal procedures, respectively, there is only a limited number of case reports described in pain practice. This case report describes an unusual occurrence of thoracic extradural haematoma following a lumbar epidural steroid injection. An entirely unique feature was its occurrence at a level distant to the site of injection, which has not been reported previously unless associated with catheterisation. We would like to highlight this report as it raises several pertinent and challenging questions; both for regional anaesthesia and pain practice.