Confirmation of epidural catheter placement in a quadriplegic patient using a nerve stimulator

Abstract

To the Editor, Autonomic hyperreflexia (AH) may occur in up to 85% of patients with spinal lesions above the spinal level of T6 and manifests itself as marked hypertension, bradycardia, headache, and sweating. The triggers of AH include distention of the bladder, rectum, or cervix, and surgical stimulation below the level of lesion. The use of epidural to treat AH in patients with spinal cord injury has been described. 1 However, as assessment of motor and sensory loss is difficult to elicit in a patient with spinal cord injury, the correct placement of the epidural catheter can be challenging. In 1998, Tsui et al. described low current electrical stimulation (1–10 mA) to confirm epidural catheter placement. 2 This test has shown to have a sensitivity and specificity of 100% and 91.6%, respectively. We describe a case in which the placement of an epidural catheter in a patient with spinal cord injury was confirmed using a nerve stimulator. The authors received the patient’s written permission to report the case. Following a fall, a 30-yr-old female sustained a traumatic complete spinal injury at the level of C4. As a result of this injury, she was quadriplegic with sensory and motor levels of C4 and C6, respectively. Four years later, she presented to our hospital for ileal vesicostomy and creation of a pubovaginal sling. She had had a few episodes of AH triggered by bladder catheter blockage. Due to the intra and postoperative risks of AH, it was agreed that the patient would receive a combined thoracic epidural and general anesthesia. On the day of surgery, the patient’s skin was prepped while she was placed in the right lateral position, and the epidural space was identified in the midline at the T9-T10 level with a 17G Tuohy needle. An Arrow TM Flexi