Cervical Epidural Anesthesia Research Articles

Comparison of Cervical Epidural Anesthesia and General Anesthesia for Thyroid Surgery

ABSTRACTIntroductionNational trends are showing statistically significant increase in the thyroid surgeries being performed by otorhinolaryngologist surgeons. There is a rising interest among the otorhinolaryngology surgeons subspecializing in head and neck surgeries to increase the horizons in the advancements in thyroid surgeries. Cervical epidural anesthesia (CEA) for thyroid surgeries is gaining popularity over general anesthesia (GA) for the various advantages it offers.ObjectiveThis prospective study was designed to evaluate the effectiveness and ease of thyroidectomy under CEA as compared to GA.Materials and methodsA prospective study of total of 30 patients undergoing thyroid surgery from two teaching hospitals. They were randomly allotted into CEA and GA groups of 15 members each.ResultsIn the CEA group, postoperative comfort and economic feasibility were found to be better compared to GA group. The blood volume loss was lesser in the CEA group. The CEA group also offered the added advantage of vocal cord monitoring by voice contact during the surgery. Both the CEA and GA group maintained hemodynamic stability. There were no complications in both the groups.ConclusionEven though thyroid surgery is currently being performed mostly under GA, CEA must be considered for thyroid surgeries routinely. CEA offers a number of advantages of GA in selected cases. This study has proved that CEA has distinct advantages over GA in thyroidectomies. Considering the ease and effectiveness of CEA, it is as good as GA, if not better, even in routine thyroidectomies.

A case of combined thoracic epidural anesthesia-interscalene block application in high-risk mastectomy patients: a case report

Recent advances in surgical and anesthetic techniques have facilitated general anesthesia and surgical possibilities in the higher-risk patient group. Although general anesthesia is the only preferred approach for breast surgery, there have been many clinical trials about breast surgery that has been achieved with regional anesthesia techniques. It is known that regional anesthesia application decreases the preoperative stress, postoperative morbidity and mortality. Additionally, this application positively affects the early start of feeding and mobilization. Regional anesthesia techniques like high thoracic epidural anesthesia, cervical epidural anesthesia and paravertebral block have been applied successfully in mastectomy operations. Combined thoracic epidural anesthesia-interscalene block technique may also be a good alternative to general or cervical, high thoracic epidural anesthesia. We aimed herein to present a case who underwent successful mastectomy and axillary dissection under combined thoracic epidural anesthesia-interscalene block.

Suspected migration of cervical epidural catheter into the brainstem after a difficult catheter insertion

We report a case of diplopia during continuous epidural injection presumably caused by catheter migration. A 61-year-old woman underwent shoulder surgery under general anesthesia with cervical epidural anesthesia. The epidural catheter was placed in the C6-C7 epidural space with some difficulty before general anesthesia. The depth of the catheter placed under the skin was 10cm. On POD 2, the patient noticed diplopia and developed dysarthria despite of good pain control so far. She complained of sudden headache after the rate of continuous epidural infusion was increased to relieve postoperative pain. Computed tomography and T2-weighted cerebral magnetic resonance imaging revealed an air image and surrounding edema in the pons. Diplopia and dysarthria disappeared after ceasing continuous epidural injection. A 15-cm-long mark under the skin and leak of colorless clear fluid from the puncture site were noted at removal of the catheter. On POD 13, diplopia recurred, which improved gradually. On the 9-month radiologic follow-up, we considered that the symptoms on POD 2 were caused by migration of the epidural catheter into the pons and that her later diplopia was induced by intracranial hypotension syndrome. One should be aware that such an unexpected migration of the catheter can occur following a difficult insertion.

Síndrome compartimental en miembros superiores por picadura de abejas: reporte de caso

IntroductionThe upper limb compartment syndrome is considered an emergency. It may cause necrosis and loss of functionality of the hand. The principal treatment is fasciotomies. However, there are therapeutic possibilities that may help or avoid surgery, provided there is always the option to do a fasciotomy when conservative treatment fails. ObjectiveTo assess the clinical response and treatment safety with stellate ganglion block and cervical epidural anesthesia in a patient with compartment syndrome of both upper limbs. Methods and materialsDescriptive longitudinal prospective study in a case report format, of a patient with compartment syndrome of both upper extremities that underwent a stellate ganglion block and cervical epidural anesthesia for treating her condition. The patient was followed for 7 days. The recovery of sensitivity and the mobility were assessed on both hands, in addition to pain intensity and bilateral distal cyanosis improvement. ResultsThe patient evolved satisfactorily with evidence of recovery of sensitivity and mobility in both hands, adequate pain control and immediate and bilateral improved distalcyanosis. ConclusionsSympathetic block and epidural cervical analgesia are a treatment option for the comprehensive approach of the compartment syndrome, as long as the patient receives constant monitoring of any alarm signs and a surgeon is immediately available to do fasciotomies if the intervention therapy fails.

Compartment syndrome of the upper limbs after bee sting: Case report

IntroductionThe upper limb compartment syndrome is considered an emergency. It may cause necrosis and loss of functionality of the hand. The principal treatment is fasciotomies. However, there are therapeutic possibilities that may help or avoid surgery, provided there is always the option to do a fasciotomy when conservative treatment fails. ObjectiveTo assess the clinical response and treatment safety with stellate ganglion block and cervical epidural anesthesia in a patient with compartment syndrome of both upper limbs. Methods and materialsDescriptive longitudinal prospective study in a case report format, of a patient with compartment syndrome of both upper extremities that underwent a stellate ganglion block and cervical epidural anesthesia for treating her condition. The patient was followed for 7 days. The recovery of sensitivity and the mobility were assessed on both hands, in addition to pain intensity and bilateral distal cyanosis improvement. ResultsThe patient evolved satisfactorily with evidence of recovery of sensitivity and mobility in both hands, adequate pain control and immediate and bilateral improved distal cyanosis. ConclusionsSympathetic block and epidural cervical analgesia are a treatment option for the comprehensive approach of the compartment syndrome, as long as the patient receives constant monitoring of any alarm signs and a surgeon is immediately available to do fasciotomies if the intervention therapy fails.

Continuous Thoracocervical Epidural Analgesia for Management of Perioperative Pain in an Adolescent with Osteosarcoma: A Case Report.

Osteosarcoma, an aggressive spindle-cell neoplasm, is the most common bone malignancy in children and young adults, with an incidence of 1 in 100,000 persons1. The presenting symptoms are pain and swelling of the affected extremity. The cause of pain is twofold: mass effect limiting motion and direct nerve involvement of the proximal neurovascular bundles. Osteosarcoma causes complex unrelenting pain, resulting in high opioid requirements. Because the treatment of osteosarcoma is neoadjuvant chemotherapy and resection, it is understandable that adequate pain control is an integral component of the multidisciplinary care required by these patients. There are multiple modalities to address upper-extremity cancer pain, including continuous systemic opioids, peripheral nerve blocks, and cervical epidural anesthesia, each with unique benefits and drawbacks. To the best of our knowledge, no study has been identified that addresses the early intervention (longer than seventy-two hours) of cervical epidural analgesia for preoperative pain control in this population, with continued use during and after surgery. We present a case in which we used cervical epidural anesthesia with 0.375% bupivacaine without opioids to provide effective perioperative pain control in a pediatric postpartum patient scheduled for a forequarter amputation because of osteosarcoma of the left humerus. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A fifteen-year-old girl (gravida 1, para 0 in the third trimester) presented to the emergency room with left shoulder and arm pain. A radiograph identified a mass in the left humerus. The patient was lost to follow-up and subsequently returned to the hospital late in her third trimester with progression of pain and an evident shoulder mass. She was diagnosed with osteosarcoma of the proximal part of the humerus with brachial plexus involvement, but there was no evidence of metastasis. During this hospitalization, the …

Cervical Epidural Anesthesia Is Associated With Increased Cancer-Free Survival in Laryngeal and Hypopharyngeal Cancer Surgery

Regional anesthesia preserves perioperative immune competence and may reduce the risk of recurrence and metastasis after cancer surgery. Cervical epidural anesthesia provides adequate analgesia for head and neck cancer surgery, but its impact on cancer recurrence is unknown. This study was a single-center retrospective cohort study of patients undergoing larynx or hypopharynx cancer surgery between January 1984 and December 2008. One hundred eleven patients had general anesthesia combined with intraoperative and postoperative cervical epidural; 160 had general anesthesia alone with postoperative morphine. From this cohort, matched pairs were selected using a propensity score to balance potential confounders of receiving epidural anesthesia. The primary end point was the length of cancer-free survival after surgery until September 2009. Propensity-based matching produced 65 pairs. Matching was effective in achieving balance between groups for each of the preoperative variables collected. Combined epidural and general anesthesia (68% 5-year cancer-free survival; 95% confidence interval [CI], 57%-82%) was associated with significantly increased cancer-free survival compared with general anesthesia alone (37% 5-year cancer-free survival; 95% CI, 25%-54%) with a corresponding adjusted hazard ratio of 0.49 (95% CI, 0.25-0.96; P = 0.04). Patients in the epidural group had an increased overall survival compared with the non-epidural group (P = 0.03). The association between cervical epidural anesthesia and increased cancer-free survival found in this retrospective study should be an important hypothesis to further investigate in head and neck cancer surgery.

A Study of Comparison of Cervical Epidural Anaesthesia with General Anaesthesia for Thyroid Surgery

Background: To compare cervical epidural anaesthesia (CEA) technique with general anaesthesia in thyroid surgeries. Method: Fifteen patients were randomly selected to be operated under CEA for thyroid surgeries and their results were compared with 15 other patients who underwent the same surgery under conventional GA technique. Results: CEA was found to be comparable to GA in thyroid surgeries Conclusion: We conclude that cervical epidural anaesthesia can be safely used for thyroid surgery.

Doxorubicin-induced dilated cardiomyopathy for modified radical mastectomy: A case managed under cervical epidural anaesthesia

Doxorubicin (Dox) is an antineoplastic agent used in a wide variety of malignancies. Its use is limited because of a cumulative, dose-dependent irreversible cardiomyopathy. We report a case of Dox induced cardiomyopathy, posted for modified radical mastectomy. The patient had poor LV function along with moderate pulmonary hypertension. Regional anaesthesia was planned as the risk associated with general anaesthesia was more. A cervical epidural was placed and a block adequate for surgery could be achived. The haemodynamic parameters as measured by esophageal doppler showed a stable trend. The surgery could be managed well under cervical epidural and also provided a good postoperative pain relief.

Cervical epidural anaesthesia for shoulder arthroscopy and effective postoperative physiotherapy for a frozen shoulder: a case study

Shoulder arthroscopy is used to treat various diseases of the shoulder, including refractory adhesive capsulitis. Effective postoperative pain relief is critical for these patients, as the success of surgery largely depends on early and regular physiotherapy. Although traditionally, various methods of postoperative analgesia have been described, each has its own disadvantages. We report a case of adhesive capsulitis, for which arthroscopic capsular release was carried out under cervical epidural anaesthesia with general anaesthesia, resulting in excellent intraoperative and postoperative analgesia, with a better patient compliance for physiotherapy, and a significant improvement in the range of movement at the shoulder joint.

Comparison of three different formulations of local anaesthetics for cervical epidural anaesthesia during thyroid surgery

Background:To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery.Methods:In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications.Results:Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups.Conclusion:We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.

Blockade of spinal nerves attenuates myocardial apoptosis in acute myocardial ischaemia/infarction in rats

Evidence showed involvement of neural activity in acute myocardial ischaemia but the knowledge about the role in the pathology is still limited. The objective of this study was to examine whether low cervical and upper thoracic epidural anaesthesia could reduce apoptosis of the myocardium induced by 3-h and 6-h permanent coronary artery occlusion (CAO) in rats. The left anterior descending branch of coronary artery was ligated in anaesthetized Sprague-Dawley rats with and without precondition of epidural anaesthesia at the level of upper thoracic segments. Apoptosis of the myocardium insulted by acute myocardial ischaemia and infarction was assessed using terminal deoxynucleotidyl transferase-mediated dUTP nick endlabelling and caspase assay. The apoptotic rates of the myocytes were 16.90 +/- 1.38 and 19.75 +/- 1.47% in the groups of CAO 3 h and CAO 6 h, respectively, whereas in the epidural groups, 10.25 +/- 1.07 and 13.05 +/- 1.19% of the apoptotic rates were detected at 3 and 6 h of CAO, significantly lower than that in the time-matched CAO animals without epidural anaesthesia (P < 0.01). Lower caspase-3 activity was observed in epidural anaesthesia group, 1.41 +/- 0.11 folds of the sham (versus 1.86 +/- 0.14 folds in CAO-3 h group) and 2.0 +/- 0.18 folds (versus 2.87 +/- 0.20 folds in CAO-6 h group) at 3 and 6 h of CAO, respectively, which were statistically significant (P < 0.05). The findings may indicate blockade of spinal nerves could reduce apoptosis of myocardium in acute myocardial ischaemia and infarction.

Awake Upper Airway Surgery

The need to compromise between surgical and anesthetic access in airway surgery is an important clinical problem. We wanted to determine the feasibility of performing upper airway surgery under awake anesthesia and spontaneous respiration. This was a prospective, clinical feasibility study. Patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomized local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction. Twenty consecutive patients with idiopathic (n = 4) or postintubation (n = 16) complete (n = 3) or severe (>80%, n = 17) subglottic (n = 12) or upper trachea (n = 8) stenosis were enrolled. Operations included 12 subglottic and 8 segmental resections with primary anastomosis. Permissive hypercapnia was well tolerated. Median length of resection was 4.5 cm (range, 2 to 6 cm), and 12 releases (8 thyrohyoid, 4 suprahyoid) were required. One patient required a nasotracheal tube for 36 hours. All but 1 were able to cough and talk immediately, and to swallow fluids and solids, and were fully mobilized at 6 hours. There were no early complications. Median hospitalization was 3.1 days (range, 2 to 15). Patients had excellent (n = 16) or good (n = 4) functional (n = 20) outcomes, with no early relapse of stenosis. Median self-reported satisfaction at median 12 months was 9.5 +/- 1.0 (scale, 0 to 10). All patients indicated that they would be happy to repeat the procedure. Awake and tubeless upper airway surgery is feasible and safe, and has a high level of patient satisfaction. If supported by randomized controlled trial, this method will change the way airway stenosis surgery is approached by both surgeons and anesthesiologist.

Cervical Epidural Anesthesia for Arteriovenous Bridge Graft at Upper Arm in Chronic Renal Failure Patients

Purpose: Cervical epidural analgesia is used for pain control in head and neck or upper arm. But it is not commonly used for the purpose of pure regional anesthesia for upper arm surgery. Therefore, we investigated the usefulness of cervical epidural anesthesia (CEA) as a method of regional anesthesia for arteriovenous bridge graft (AVBG) for hemodialysis at upper arm and evaluated the effects of CEA on hemodynamics and respiration. Methods: One hundred-fifty chronic renal failure patients scheduled for AVBG were randomly assigned. In the sitting position, an epidural catheter was inserted at C6-7 or C7-T1 and 15 ml of 0.375% ropivacaine with fentanyl 20㎍ was injected. Analgesic level, blood pressure and heart rate were measured at 5-minute intervals after injection of the drug. Arterial blood sampling was taken for aBGA before and twenty minutes after CEA. Results: Average anesthetic dermatomalsensory levels were C3.4±1.2∼T5.7±2.8. During surgery, hypotension was noted in 49% of patients. It was treated with ephedrine or phenylephrine i.v. Baseline PaCO₂ changed from 42.4±2.9 ㎜Hg to 44.6±3.6 ㎜Hg. Conclusion: The above results suggest that CEA is suitable for AVBG at upper arm as a regional anesthesia.

Continuous cervical epidural analgesia for Isshiki type - I thyroplasty.

Thyroplasty is an operation on the upper airway to improve voice quality in patients with unilateral vocal cord paralysis. It is a difficult anaesthetic procedure that requires sharing the airway with the surgeon. We describe a good anaesthetic technique, which provides a safe airway with excellent operating conditions, using continuous cervical epidural anaesthesia and postoperative analgesia in three patients. The use of a regional anaesthetic technique provides excellent anaesthesia and analgesia while allowing the patient to phonate at the request of the surgeon intraoperatively.

Cervical epidural anaesthesia for neck arm and upper thoracic surgery

Cervical epidural anaesthesia for neck arm and upper thoracic surgery

Drip infusion method as a useful indicator for identification of the epidural space.

Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method. One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only. In all cases, the combined LOR with drip infusion method, identify the epidural space. Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.

Comparison of Methods to Confirm the Cervical Epidural Space

Background: The loss of resistance (LOR) method is most commonly used to identify the epidural space. This method is thought to rely on the penetration of the ligamentum flavum. Unfortunately the exact morphology of the ligamentum flavum is variable at different vertebral lev els. Especially, it has been pointed out that the lower cervical ligamentum flavum may be discontinuous in the mi dline in up to 50% of patients. Thus, the LOR method may be inaccurate to confirm the cervical epidural space . The aim of this study is to determine which method is the safest and most exact for confirming the cervical epidural space. Methods: 100 adult, chronic renal failure patients who were undergoing an arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. During the cervical epidural puncture, we identified the cervical epidural space by subjectively feeling the resistance with using a finger just through the ligamentum flavum, and we also used the drip infusion method, the loss of resistance method using air, and the hanging drop method. By using 5 grades, we classified the extent of whether or not the techniques were effective. Results: Using the drip infusion method, we identify the epidural space in all the patients as ＋/＋＋ grade. The catheter insertion method was also successful in identifying those epidural spaces over a ± grade. The pseudo LOR was over ± grade in 47 patients. Conclusions: The combined LOR/hanging drop with drip infusion method is useful for confirming the cervical epidural space. (Korean J Pain 2009; 22: 158-162)

Regional anaesthesia for carotid endarterectomy: an audit over 10 years

The aim of this retrospective study was to compare the failure rates and the frequency of anaesthesia-related complications of two different methods of regional anaesthesia used for carotid endarterectomy--cervical epidural (CE) anaesthesia and cervical plexus block (CPB). The study included 1828 carotid endarterectomies performed in 1455 patients between 1996 and 2006. A combination of deep and superficial CPB was used for 1166 procedures, whereas in 662 cases surgery was performed under CE anaesthesia. The failure rate of CPB was 3% compared with 6.9% for CE anaesthesia (P < 0.0001). The reasons for failure of the anaesthetic techniques were (1) technical failure, (2) insufficient analgesia, (3) non-compliant patients, and (4) anaesthetic complications. The incidence of complications resulting from CE anaesthesia was significantly higher than with CPB; life-threatening complications--2% compared with 0.3% (P < 0.0001); other anaesthesia-related complications 5.7 vs 4.7%. Serious complications included inadvertant injection into the subarachnoid space or vertebral artery. The frequency of shunt insertion, perioperative stroke, and death from any cause was similar in both groups of patients. Both methods of regional anaesthesia are acceptable for carotid artery surgery. CPB is associated with a significantly lower frequency of anaesthesia-related complications and should therefore be considered the anaesthetic of choice. CE anaesthesia should not be performed except in extenuating circumstances such as variant anatomy or the requirement for more extensive surgery.

Cervical epidural analgesia via a thoracic approach using nerve‐stimulation guidance in adult patients undergoing total shoulder replacement surgery

Continuous cervical epidural anesthesia can provide excellent peri- and post-operative analgesia, although several factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low-current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. After Institutional Review Board approval, adult patients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1-10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch responses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2-8 ml/h) of ropivacaine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8 +/- 2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4-7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.