Interpleural analgesia: Its use, and a complication, in a quadriplegic patient with chronic benign pain

Abstract

A 49-yr-old woman sustained a cervical spine fracture at the age of 21 yr as the result of a swimming accident. In 1986, she developed syringomyelia and underwent a C2-3 laminectomy, drainage of the syrinx, and placement of a syringo-subarachnoid shunt. At this time, she became ventilator dependent. Pain had been experienced in the right shoulder, neck, and lateral aspect of the forearm for 3 yr. A series of trigger point injections provided short-term relief, as did a series of stellate ganglion b:ocks. Several injections of steroid into the bursa of the shoulder joint also yielded no sustained relief, and further injections were refused. She was maintained on baclofen 100 mg daily, acetaminophen 350 mg four times daily, hydromorphone 3 mg every 3 hr, and amitriptyline 50 mg twice daily, but this regimen failed to provide adequate analgesia. When she came to the Pain Clinic, examination revealed a ventilated patient with a tracheostomy. There was limited range of motion of her neck, especially on rotation to the right. Neck movement was not painful. The neck was obese, and there was a posterior scar as a result of her previous laminectomy. Neurologic examination revealed flaccid quadriplegia, absent sensation ‘below C,, decreased reflexes in both upper and lower extremities, negative Babinski signs bilaterally, and finger contractures of both hands. Cervical spine radiographs showed demineralization of the lower cervical vertebrae, with no focal abnormality. The remainder of the examination was unremarkable. The right scapular pain was thought to be secondary to cervical osteoarthritis, and the shoulder pain was ascribed to bursitis. Cervical cpidural steroid injections were considered, but were then rejected due to the technical difficulties posed by a patient with an obese short neck, limited range of movement, prior neck surgery, and a tracheostomy band around the neck. A trial of interpleural analgesics was planned. With the patient in the left lateral position, a 17-gauge Tuohy needle was advanced at the T7-8 interspace. The interpleural space was identified using a “passive loss of resistance” technique. This method allows l-2 mI, of air from a syringe to be drawn into the interpleural