Lidocaine Test Dose Research Articles

153. Can cervical transforaminal epidural steroid injections be surgery-sparing?

BACKGROUND CONTEXT Cervical radiculopathy can have a significant effect on patient quality of life. Cervical transforaminal epidural steroid injections (TF ESIs) have come under scrutiny due to risk of the procedure and lack of literature demonstrating long-term effect. PURPOSE To determine whether cervical TF ESIs improve patient-reported quality-of-life outcomes, offer therapeutic benefit, and whether TF ESIs decrease the need for cervical spine surgery. STUDY DESIGN/SETTING Hospital-based outpatient medical spine practice. PATIENT SAMPLE A total of 99 consecutive patients who underwent unilateral cervical TF ESI. Of those, 82 patients were available for analysis who underwent cervical injection between 12/11/2013 and 11/8/2017. Average age was 51.3 (SD = 11.5 years) with 51.2% male, 48.8% female. Levels included 45.1% performed at C5-6, 31.7% at C6-7, and 23% at other cervical levels. Median duration of symptoms was seven months. OUTCOME MEASURES We evaluated data using validated outcomes measures – PHQ9, PDQ, and PROMIS-Physical. METHODS Retrospective review of single practitioner's outcomes after all patients undergoing cervical TF ESIs from 2014-2017. RESULTS Of the 99 patients, 25 went on to have cervical surgery; 90.2% patients had diagnostic benefit considered to at least 80% immediate relief 4 hours after injection. Only one patient had a complication: a less than 1 minute seizure with lidocaine test dose. History of spine surgery was the only statistically significant predictor to long-term benefit after cervical TF ESI. Patients who had prior spine surgery had a hazard of postinjection surgery that was 4.2 times larger, compared to patients who did not have prior spine surgery (P = 0.001). None of the other predictors were significantly associated with time from injection to surgery. Patients who had duration of symptoms of 1 year or more had higher postinjection PDQ scores than patients who had duration of symptoms 3 months or less, and patients who had history of spine surgery had higher postinjection PDQ scores. Overall Mean Visual Analog Score (VAS) decreased mean 7.6 to 4.09 at 3 months (n=82), (P CONCLUSIONS Cervical TF ESIs can be done safely with minimal morbidity and significant benefit at 6 months. In more than 2/3 of the patients, surgery was not needed due to diagnostic and therapeutic benefit from cervical TF ESI. FDA DEVsICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Accidental Dural Puncture Management: 10-Year Experience at an Academic Tertiary Care Center.

The use of spinal catheters for extended periods after accidental dural puncture (ADP) and administration of intrathecal saline via spinal catheters have been advocated to decrease the incidence of postdural puncture headache and the subsequent need for epidural blood patch (EBP), with mixed results observed. We reviewed the medical records of 218 patients with ADP who either had the epidural resited or had a spinal catheter (with or without the administration of intrathecal saline). We compared the incidence of headache and the need for blood patch between these groups. We also assessed complications when a standard lidocaine epidural test dose was administered intrathecally and compared this with complications when a solution normally used for labor combined spinal epidurals was administered. There was no difference in the incidence of postdural puncture headache between the resited epidural group and the spinal catheter group, 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0-2.9; P = 0.07). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4-7.6; P < 0.001) and when compared with spinal catheters with intrathecal saline, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3-35.4; P < 0.001). There was a significant difference in the number of blood patches between normal body mass index patients and morbidly obese patients, 55.2% versus 25.0% (OR, 3.7; 95% CI, 1.2-11.2; P = 0.02). Complications (hypotension prompting pressors, high spinal, and emergency cesarean delivery because of nonreassuring fetal status) occurred more frequently when a lidocaine test dose was immediately administered after ADP versus administering a labor combined spinal epidural solution. Insertion of spinal catheters after ADP and administration of intrathecal normal saline via spinal catheters reduce the need for EBP compared with resiting the epidural. Administration of the standard epidural test dose intrathecally is associated with frequent and significant complications.

Digital Subtraction Angiography Does Not Reliably Prevent Paraplegia Associated with Lumbar Transforaminal Epidural Steroid Injection

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.

Two Cases of Horner Syndrome After Administration of an Epidural Test Dose That did not Recur With Subsequent Epidural Activation

We describe 2 cases of Horner syndrome after epidural test dose injections in thoracic surgery patients. The Horner syndrome was transient and did not recur with full epidural activation and infusion. Two patients undergoing thoracic surgery procedures received preoperative midthoracic epidural catheters for postoperative analgesia. Following the 3-mL 1.5% lidocaine test dose, a unilateral Horner syndrome was observed. No other signs and symptoms of high epidural blockade were seen, and the Horner syndrome subsequently resolved. After epidurogram confirmation of proper catheter position and at the conclusion of surgery, the epidural was activated with an appropriate bolus and infusion dose without recurrence of the Horner syndrome. Two cases of Horner syndrome presenting after administration of an epidural test dose are reported. This uncommon initial finding could not be reproduced with subsequent epidural activation, perhaps suggesting that initial conditions within the epidural space had been altered. Successful utilization of neuraxial regional analgesia was achieved with careful postoperative monitoring of the patients.

Comparison of three doses of epidural fentanyl followed by bupivacaine and fentanyl for labor analgesia

Epidural fentanyl 100 microg after lidocaine-epinephrine test dose has been shown to provide adequate analgesia in early labor. This investigation determines the effect of three different bolus doses of epidural fentanyl on duration and quality of analgesia during early first stage of labor. In this prospective, double-blind study, 103 laboring nulliparous at cervical dilation <5 cm were enrolled. After an epidural test dose of lidocaine (60 mg) with epinephrine (15 microg), parturients received, randomly, bolus of epidural fentanyl 50, 75, or 100 microg, followed by a continuous infusion of epidural bupivacaine 0.0625% and fentanyl 3 microg/ml at a rate of 10 ml/h. Pain scores and maternal sedation, pruritus, nausea, and vomiting were recorded 10, 20, and 30 min after fentanyl, and every 30 min thereafter until first request for additional analgesia. Adequate analgesia was achieved in 87% (28/32), 94% (35/38), and 94% (31/33) in the fentanyl 50, 75, and 100 microg groups within 20 min. Mean duration of analgesia before re-dosing was significantly longer in fentanyl 100 and 75 microg groups (185.6+/-82.9 and 188.5+/-82.2 min, respectively) as compared with fentanyl 50 microg group (133.6+/-46.2 min, P<0.016). There was no difference in the incidence of maternal side effects or neonatal Apgar scores among the three groups. After a test dose of lidocaine-epinephrine, the three epidural fentanyl doses produced similar effective labor analgesia. However, epidural fentanyl 75 microg followed by epidural infusion of dilute bupivacaine and fentanyl produced longer duration of analgesia than fentanyl 50 microg followed by the same infusion, with no further prolongation when the dose of fentanyl was increased up to 100 microg.

Spinal and Epidural Anesthesia.

Virginia Mason Medical Center, Seattle, Washington. michael.mulroy@vmmc.orgSpinal and Epidural Anesthesia. By Cynthia A. Wong, M.D. New York, McGraw-Hill, 2007. Pages: 374. Price: $99.00.Spinal and Epidural Anesthesia , edited by Cynthia Wong, M.D., is a multiauthor, in-depth textbook on neuraxial anesthesia. The authors have targeted a major subspecialty of regional anesthesia and focused on this subject in greater depth than the broader textbooks are capable of doing. Although Drs. Philip Bromage and J. Alfred Lee might disagree with the authors’ assertion that there “are no textbooks devoted solely to the clinical practice of spinal and epidural anesthesia,” it is true that there has not been such a textbook in the past 20 yr, and their offering makes a substantial step in bringing us all up-to-date with the advances in neuraxial technique and applications.The book is well designed, with in-depth chapters on the anatomy, pharmacology, and physiology of neuraxial techniques, complemented by an extensive section on the clinical application of these techniques to various subspecialties. These latter sections include obstetrics and postoperative pain management, as well as the many surgical subspecialties where neuraxial techniques are particularly useful. The chapters all exhibit extensive depth and modern references, although in the process they have omitted some of the classics that have not been surpassed (such as Abraham et al. ’s description of a spinal test dose of lidocaine).1The text is generally clear and well written and supplemented by a generous quantity of black-and-white illustrations and photographs. The lack of colored illustrations is only a minor drawback. The tables and highlights are particularly useful in stressing the key points and guiding the reader through the pertinent sections.The author has assembled an impressive collection of contributors to the various chapters, many of whom are clearly identified as experts in their subspecialty fields. The multiauthor aspect carries the inevitable counterbalance of depth from each author, combined with an unavoidable overlap on several of the important subtopics. And, of course, there is the personal bias of the individual chapter authors as to their favorite techniques. The issue of post–dural puncture headache, for example, is described in one chapter as “increased with youth” but in another as being “rare in pediatric patients.” The corollary discussion of epidural blood patch similarly suffers an unfortunate lack of detail in the discussion of the timing and ideal volume to be injected. Likewise, many of the chapters on subspecialty application of techniques repeat issues of dosage and side effects that are covered in the general chapters.Overall, however, there is excellent depth, despite a few omissions. In the Orthopedic chapter, there is the most fleeting reference to the advantages of peripheral nerve catheters as an alternative to neuraxial techniques when anticoagulation is an issue. The Chronic Pain section claims to address the issue of prevention of chronic pain, but does not address the recent awareness of chronic postsurgical pain that may be reduced by the more aggressive use of neuraxial analgesic techniques. And sometimes the depth is too much. The Acute Pain chapter includes so many options and alternatives, and even multiple recommended dose regimens, that the reader may leave the text with unanswered questions about where to start with a postoperative infusion. But that may be, as the authors point out, because there is no answer!Nevertheless, this text provides an in-depth review of our current understanding of neuraxial anesthesia and its clinical applications. It is a useful resource for both the trainee and the experienced clinician. The dilemma that will face most potential purchasers is the one that the authors identify in the preface: There are several general and regional anesthesia textbooks that already cover similar material in their specialized chapters. And on the other hand, the obstetrics chapters provide an excellent overview, but are they a substitute for a textbook devoted solely to the subject? There is no doubt that this textbook covers the material involved in great depth, and especially the clinical application of the neuraxial blocks. For someone wishing for a greater depth of knowledge and the most recent references in the field, this textbook offers a welcome addition to his or her library.Virginia Mason Medical Center, Seattle, Washington. michael.mulroy@vmmc.org

The Effect of a Lidocaine Test Dose on Analgesia and Mobility After an Epidural Combination of Neostigmine and Sufentanil in Early Labor

The Effect of a Lidocaine Test Dose on Analgesia and Mobility After an Epidural Combination of Neostigmine and Sufentanil in Early Labor

The Effect of a Lidocaine Test Dose on Analgesia and Mobility after an Epidural Combination of Neostigmine and Sufentanil in Early Labor

The Effect of a Lidocaine Test Dose on Analgesia and Mobility after an Epidural Combination of Neostigmine and Sufentanil in Early Labor

Epidural clonidine added to a bupivacaine infusion increases analgesic duration in labor without adverse maternal or fetal effects

Many obstetric patients receiving epidural analgesia are encouraged to ambulate. This current study was designed to determine the potential for maximizing the time to first epidural supplement when adding clonidine to a 0.625 mg.ml(-1) bupivacaine continuous epidural infusion following epidural fentanyl bolus in early labor for patients allowed to ambulate. Maternal and fetal effects secondary to clonidine were also evaluated. Sixty-eight laboring primigravid women received a 3-ml epidural test dose of lidocaine with epinephrine, followed by a fentanyl 100-microg bolus (in a 10 ml-volume). The patients then received a 0.625 mg.ml(-1) bupivacaine continuous epidural infusion, either with or without clonidine (5 microg.ml(-1)), at a rate of 10 ml.h(-1). Pain scores and side effects were recorded for each patient. The overall quality of analgesia was similar in both groups. The mean duration prior to request for additional analgesia was significantly longer in the clonidine group (269 +/- 160 min), compared to the control group (164 +/- 64 min). No patient in either group experienced any detectable motor block; one patient (clonidine group) complained of mild thigh numbness and was not allowed to ambulate. While mean blood pressure was approximately 6 mmHg lower in the clonidine group at 1, 1.5, and 3.5 h, this was not clinically significant. No adverse effects on maternal heart rate or fetal heart rate were noted. In early laboring patients, addition of clonidine prolongs the analgesia duration of a 0.625 mg.ml(-1) bupivacaine continuous epidural infusion following 100 microg epidural fentanyl (after a lidocaine-epinephrine test dose) without a clinically significant increase in side effects.

The Effect of a Lidocaine Test Dose on Analgesia and Mobility After an Epidural Combination of Neostigmine and Sufentanil in Early Labor

We previously demonstrated the effectiveness of epidural sufentanil and the cholinesterase inhibitor, neostigmine, to initiate selective labor analgesia. Because the traditional lidocaine plus epinephrine test dose (TD) may alter the effect of subsequent epidural drugs, we undertook this investigation to evaluate the impact of a lidocaine TD on analgesia from a combination of epidural neostigmine plus sufentanil administered in early labor. Eighty healthy parturients were randomly allocated to two groups to receive a 3 mL-TD, either lidocaine 2%-epinephrine (1:200,000) or saline-epinephrine (1:200,000), followed 3 min later by epidural neostigmine 500 microg plus sufentanil 10 microg. Pain scores were recorded for 30 min after injection, as was the time elapsed from initial bolus until request for supplemental analgesia. Thirty minutes after injection, adequacy of motor function was evaluated by the parturient's ability to sit, stand up, bend her knees, and walk. Lidocaine TD hastened the onset (5 min vs 15 min) and increased duration (122 +/- 53 min vs 98 +/- 54 min; P = 0.02) of analgesia from epidural neostigmine plus sufentanil bolus. In contrast, the TD did not significantly impair the ability to sit, stand up, or bend the knees. The ability to ambulate, however, was reduced (57% vs 82%; P = 0.04). In conclusion, a traditional lidocaine TD significantly enhances the analgesic effect from the epidural neostigmine plus sufentanil combination, but affects ambulation in early labor.

Transient Profound Neurologic Deficit Associated with Thoracic Epidural Analgesia in an Elderly Patient

Transient Profound Neurologic Deficit Associated with Thoracic Epidural Analgesia in an Elderly Patient

Sympathetic blocks: Therapeutic effects of prolonged stellate ganglion blockade with Botulinum toxin type A (BOTOX) in the treatment of refractory upper extremity complex regional pain syndrome: A pilot study

Upper Extremity Complex Regional Pain Syndrome (UE CRPS) can often be cured with sequential Stellate Ganglion Blocks (SGB's) with local anesthetics (LA's). Unfortunately, many cases are refractory to the commonly used single injection technique. Prolonged blockade with LA's delivered via an indwelling catheter for up to 14 days has been found to be beneficial in some of these cases, but is impractical. Our intent was to determine whether a more practical and effective method of producing prolonged SGB could be provided by applying Botulinum Toxin Type A (BoNT-A) to the ganglion. Six patients were enrolled based on a diagnosis of UE CRPS and failure to exhibit sustained improvement with at least three conventional SGB's. Evaluation included photographs, McGill Pain Questionnaires, and physical exams at appropriate intervals. A C7 approach under fluoroscopic guidance was utilized to minimize the chance of diffusion of BoNT-A into unintended targets. Prior to BoNT-A instillation, a 2cc test dose of lidocaine produced a confirmatory Horner's Syndrome within five minutes. Five of six patients received 30 units of BoNT-A in 0.6 cc's of normal saline (NS); the first patient received 20 units in 0.4 cc's of NS. Evidence of SGB (ptosis, miosis) with BoNT-A appeared in 4-7 days in all patients and persisted 3-6 weeks. Blockade was considered partial in the first subject and nearly complete in the others. Mild, transient dysphagia, the only complication, occurred in one patient. Two patients reported complete and one moderate improvement of pain at week 12. Improved patients exhibited resolution of skin temperature changes and allodynia, and substantial return of function. Two patients showed transient improvement. One failed to improve. In all patients trophic changes persisted. These preliminary findings suggest that prolonged SGB with BoNT-A can provide clinically relevant improvement in some patients with refractory CRPS. Further study is warranted. Upper Extremity Complex Regional Pain Syndrome (UE CRPS) can often be cured with sequential Stellate Ganglion Blocks (SGB's) with local anesthetics (LA's). Unfortunately, many cases are refractory to the commonly used single injection technique. Prolonged blockade with LA's delivered via an indwelling catheter for up to 14 days has been found to be beneficial in some of these cases, but is impractical. Our intent was to determine whether a more practical and effective method of producing prolonged SGB could be provided by applying Botulinum Toxin Type A (BoNT-A) to the ganglion. Six patients were enrolled based on a diagnosis of UE CRPS and failure to exhibit sustained improvement with at least three conventional SGB's. Evaluation included photographs, McGill Pain Questionnaires, and physical exams at appropriate intervals. A C7 approach under fluoroscopic guidance was utilized to minimize the chance of diffusion of BoNT-A into unintended targets. Prior to BoNT-A instillation, a 2cc test dose of lidocaine produced a confirmatory Horner's Syndrome within five minutes. Five of six patients received 30 units of BoNT-A in 0.6 cc's of normal saline (NS); the first patient received 20 units in 0.4 cc's of NS. Evidence of SGB (ptosis, miosis) with BoNT-A appeared in 4-7 days in all patients and persisted 3-6 weeks. Blockade was considered partial in the first subject and nearly complete in the others. Mild, transient dysphagia, the only complication, occurred in one patient. Two patients reported complete and one moderate improvement of pain at week 12. Improved patients exhibited resolution of skin temperature changes and allodynia, and substantial return of function. Two patients showed transient improvement. One failed to improve. In all patients trophic changes persisted. These preliminary findings suggest that prolonged SGB with BoNT-A can provide clinically relevant improvement in some patients with refractory CRPS. Further study is warranted.

The epidural test dose in obstetric anesthesia: it is not obsolete

Many anesthesiologists have called for the abandonment of the epidural test dose in the obstetric patient, citing its lack of sensitivity and specificity. A test dose of lidocaine 1.5% with epinephrine 1:200,000, in combination with aspiration, is highly effective in detecting incorrect placement of an epidural catheter. If the catheter is intrathecal, it requires approximately 2 minutes to obtain a sensory level. For the detection of an intravascular catheter, a positive test dose would result in a sudden increase in the maternal heart rate of 10 beats per minute within 1 minute after injection. It should not be administered during uterine contraction, as labor pain may trigger a tachycardic response. This test dose has been extensively studied and is safe both for both mother and fetus.

A Case on Diplopia after Epidural Catheterization for Postoperative Pain Control: A case report

A 53 year old man with gastric cancer was admitted for radical subtotal gastrectomy. The patient received general anesthesia with epidural analgesia. Epidural catheterization was performed using an 18-gauge Tuohy needle at the T10-11 interspace, and the epidural space was confirmed after a repeated attempt. An epidural catheter was then advanced smoothly 5 cm in cephalad direction without bleeding or CSF leakage. The patient received a test dose of lidocaine and epinephrine and continuous infusion with morphine and lidocaine 30 minutes before operation finished. Vital signs during the operation were stable. Two days after the operation, the patient complained of an orthostatic headache, and relieved ketolorac. On the seventh day, the patient complained of bilateral diplopia. Diffuse pachymeningeal gadolonium enhancement was seen on the brain MRI, and his CSF pressure was 0 mmHg by spinal tapping. We suspected abducent nerve palsy due to CSF hypovolemia and performed an epidural blood patch with 15 ml of autologus blood at the previous puncture site. The patient is receiving regular examinations at the Neurology and Opthalmology department. Abducent nerve palsy completely recovered by the Hess Screen test 6 months after operation, and diplopia disappeared 10 months after the operation.

MEGX disposition in critically-ill trauma patients: subsequent assessments during the first week following trauma.

The objective of this study was to evaluate MEGX disposition as a surrogate marker in assessing the influence that injury may exert on liver function during the first week after the traumatic event in young vs. elderly patients. The MEGX exposure over time was assessed at 0.25, 0.5, 1, 2, 4 and 6 h after the intravenous administration of a 1 mg/kg lidocaine test dose in 12 young and 7 elderly trauma patients on days 1, 4 and 7 after a severe injury (Apache II score > 10). MEGX plasma concentration-time profiles were consistently different on day 1 in the elderly vs. young, consistent with a statistically significant lower rate of both lidocaine clearance and MEGX formation, and with a considerably longer MEGX elimination in the elderly than in the young. This suggests an impairment of liver blood flow as a result of splanchnic vasoconstriction occurring mainly in elderly trauma patients. A significant improvement in MEGX disposition occurred on days 4 and 7 vs. the day of trauma in most elderly, whereas minor changes were observed in the young. Multiple factors may account for these major changes in the elderly: the more severe status, the major sensitivity to the pathophysiologic changes induced by trauma, and also at least partially the ageing processes. Although referring to a limited number of observations, our findings on MEGX disposition suggest that liver function may be affected by the severity of injury, even if the influence of age should not be underestimated in these patients.

Epidural anaesthesia for arthroscopic knee surgery in a patient with Takayasu's arteritis

Epidural anaesthesia for arthroscopic knee surgery in a patient with Takayasu's arteritis

Propofol Reduces Spinal Motor Neuron Excitability in Humans

Propofol Reduces Spinal Motor Neuron Excitability in Humans

Epidural Anesthesia for Lumbar Spine Surgery

Background: Many anesthesiolosists feel that epidural anesthesia is unsuitable for spinal sugery. However, several articles have been published in which epidural anesthesia is viewed as a good alternative to general anesthesia for spine surgery. The aim of this study was to evaluate effectiveness and complications of epidural anesthesia for spine surgery. Methods: Eighty-two patients undergoing epidural anesthesia for spine surgery was studied prospectively. Epidural anesthesia was performed using 18-gauge Tuohy needles inserted at the L1-2 interspace. A test dose of lidocaine 3 ml was injected to check for a subarachnoid puncture. After a 2-3 minute waiting period, 0.5% bupivacaine 12 ml was slowly injected for 3 minutes. The pain at the operation site and roots, extension of anesthesia, motor blockade and complications were evaluated. Results: Pain at the operation site was minimal in 83% of the patients; however, 44% of the patients complained of moderate to severe root pain. No patient had a new neurologic deficit as a result of the epidural technique. Perioperative complications were minimal and could be easily treated. Conclusions: We concluded that proper administration of epidural anesthesia for spine surgery is a safe and reliable procedure and a good alternative to general anesthesia.

Effect of epidural clonidine added to epidural sufentanil for labor pain management

Labor analgesia with intrathecal sufentanil has been shown to be prolonged by the addition of intrathecal clonidine. The current study was designed to determine if epidural clonidine would prolong labor analgesia provided by epidural sufentanil. Forty laboring primiparous women at less than 5 cm cervical dilation requesting epidural analgesia were enrolled. Following a 3 mL test dose of lidocaine with epinephrine, patients were randomized to receive 10 mL of either sufentanil 20 μg (S) or sufentanil 20 μg with clonidine 75 μg (SC). After administration of the analgesic, pain scores and side-effects were recorded for each patient at 5, 10, 15, 20 and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean duration of analgesia was similar between the S group (153 ± 78 min) and the SC group (178 ± 55 min). Side-effects were similar between the two groups. There was no difference between the two groups in time from sufentanil administration to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 20 μg after a lidocaine test dose provides analgesia comparable to that of sufentanil 20 μg with clonidine 75 μg; there was no significant difference in analgesic duration between the two groups.

Extension of Sensory Blockade after Thoracic and Lumbar Epidural Administration of a Test dose of Lidocaine

Extension of Sensory Blockade after Thoracic and Lumbar Epidural Administration of a Test dose of Lidocaine