Lumbar Epidural Anesthesia Research Articles

Developments in labour analgesia and their use in Australia.

Since the introduction of chloroform for labour analgesia in 1847, different methods and medications have been used to relieve the pain of labour. The use of heavy sedative medication in the early 1900s was encouraged by enthusiastic doctors and by women empowered by the women's suffrage movement in America. Nitrous oxide by inhalation has been used in Australia since the 1950s and improved methods of administration have made this method of analgesia safe and practical. Caudal epidural analgesia and lumbar epidural analgesia were first made popular in America and by the 1970s these techniques were more widely available in Australia. In 1847, physicians and the public were unsure whether relieving labour pains was the 'right' thing to do. However, many medical and social changes have occurred thanks to the clinical connection between Australia and the United Kingdom and those first settlers to land on Australian shores. Thanks to this historical connection, in today's Australia there is no question that women should use analgesia as a pain relief if they wish. Currently, the majority of women worldwide use some form of analgesia during labour and different methods are widely available. This paper discusses the four milestones of the development of obstetric analgesia and how they were introduced into patient care in Australia.

PP10.7 – 2603: A spinal cord injury after epidural anesthesia: An idiosyncratic reaction

Objective Regional anaesthesia is associated with reduction in mortality and serious complications in comparison with general anaesthesia. Spinal cord injuries associated with epidural anaesthesia in children is limited to a few case reports. We aim to describe a paediatric case of spinal injury associated with epidural anaesthesia and its possible causes. Case review and results 12 years old girl with Ohdo syndrome had lumbar epidural anesthesia performed under general anesthesia for her abdominal surgery. The epidural needle was introduced a T11 and T12 interspace without any complication. 20hr post surgery, she developed sensory disturbance below T11 and paraparesis with no movement of lower extremities. Her ASIA impairment scale is B (Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5). MRI spine revealed focal area of non-specific T2 signal abnormality within the spinal cord at the level of T11. Day2 MRI spine showed that the abnormal T2 signal extended from T10 to T12. No radiological evidence of haemosiderin deposition to suggest traumatic injury to spinal cord, abscess formation, or vascular abnormalities. The radiological appearance was not typical for an autoimmune process or demyelination. Extensive investigations including inflammatory, metabolic and autoimmune markers, e.g. anti-NMO and anti-MOG, were all negative. Further pharmaceutical and manufacturer's investigations excluded technical problems with epidural pump, epidural bolus and infusion solutions. MR imaging after 3 months showed focal myelomalacic changes at T11. Despite intensive spinal rehabilitation, she has residual spastic paraparesis (GMFSC level 3). Her bladder and bowel dysfunction resolved 3 months later. Conclusion This is one of a few reported paediatric cases of spinal cord injury after non-traumatic epidural injections. After exclusion of other causes of spinal cord injuries, idiosyncratic reaction related to epidural anesthetic agent is the most likely diagnosis; and identifying those patients at risk remain uncertain.

Anaesthetic management of a rare case of single ventricle heterotaxy syndrome for emergency caesarean section.

Heterotaxy syndromes refer to disorders of lateralisation whereby the arrangement of abdominal and thoracic viscera differ from normal and are mirror-images of normal.[1] They are classified into two main subgroups, right-sided isomerism with asplenia, and left-sided isomerism with polysplenia. The patients of right-sided isomerism with asplenia have more severe congenital heart diseases and lateralisation defects when compared with left-sided isomerism.[2] We present a primigravida with single ventricle heterotaxy syndrome for emergency caesarean section managed under graded lumbar epidural anaesthesia.

Subdural Hematoma Revealing Spontaneous Intracranial Hypotension: Diagnosis and Management. A Report of Four Cases

The subdural hematoma (SDH) could be a serious complication of the spontaneous intracranial hypotension (SIH) that is a rare but well-known entity. We reported four illustrative cases of subdural hematomas revealing SIH. Three women and a man with mean age of 58.5 years. In three cases we noted sudden headaches, progressive and postural in one. CT scan has diagnosed the subdural hematomas that were thin and bilateral in three cases. Magnetic resonance imaging (MRI) confirmed the diagnosis of associated SIH. None has undergone an invasive exploration. Two patients were operated for clinical worsening. All of our patients were treated by epidural lumbar blood patch with very good outcome. author highlights the strategy of diagnosis and management of this underestimated pathology by showing different practical situations.

Regional analgesia techniques for total knee replacement.

Pain following total knee arthroplasty is a challenging task for healthcare providers. Concurrently, fast recovery and early ambulation are required to regain function and to prevent postoperative complications. Ideal postoperative analgesia provides sufficient pain relief with minimal opioid consumption and preservation of motor strength. Regional analgesia techniques are broadly used to answer these expectations. Femoral nerve blocks are performed frequently but have suggested disadvantages, such as motor weakness. The use of lumbar epidurals is questioned because of the risk of epidural hematoma. Relatively new techniques, such as local infiltration analgesia or adductor canal blocks, are increasingly discussed. The present review discusses new findings and weight between known benefits and risks of all of these techniques for total knee arthroplasty. Femoral nerve blocks are the gold standard for total knee arthroplasty. The standard use of additional sciatic nerve blocks remains controversial. Lumbar epidurals possess an unfavourable risk/benefit ratio because of increased rate of epidural hematoma in orthopaedic patients and should be reserved for lower limb amputation; peripheral regional techniques provide comparable pain control, greater satisfaction and less risk than epidural analgesia. Although motor weakness might be greater with femoral nerve blocks compared with no regional analgesia, new data point towards a similar risk of falls after total knee arthroplasty with or without peripheral nerve blocks. Local infiltration analgesia and adductor canal blockade are promising recent techniques to gain adequate pain control with a minimum of undesired side-effects. Femoral nerve blocks are still the gold standard for an effective analgesia approach in knee arthroplasty and should be supplemented (if needed) by oral opioids. An additional sciatic nerve blockade is still controversial and should be an individual decision. Large-scale studies are needed to reinforce the promising results of newer regional techniques, such as local infiltration analgesia and adductor canal block.

Case Report: Pneumocephalus after labor epidural anesthesia

Lumbar epidural anesthesia is commonly used for labor analgesia. The 'loss-of- resistance' to air technique (LORA) is generally employed for recognition of the epidural space. One of the rare complications of this technique is pneumocephalus (PC). Here we describe the case of a parturient who developed a frontal headache when locating the epidural space using LORA. On the second day after epidural injection, the patient exhibited occipital headaches with gradual worsening. Computed tomography scans of the brain indicated PC. Following symptomatic treatment, our patient was discharged on the 13th day. We concluded that the amount of air used to identify the epidural space in LORA should be minimized, LORA should not be used after dural puncture and the use of saline avoids PC complications.

小児の仙骨ならびに胸腰部硬膜外麻酔への超音波の有用性について

米国では理論上，超音波下の仙骨硬膜外穿刺がスタンダードとされている．しかし本邦では，超音波装置本体および小児で必要なホッケースティック型プローブの普及が十分ではなく，また保険適用ではないことから滅菌袋などのコストを確保しにくいことなどもあり，さらに小児では穿刺部位が解剖学的に浅くわかりやすいことから仙骨麻酔は盲目下で行うことが多い．本稿ではその危険性に焦点を当てながら，われわれの臨床研究にも触れたい．

ANAESTHESIOLOGY AND INTENSIVE CARE The influence of epidural anesthesia on the electrical activity of heart atria

IntroductionHigh thoracic epidural anesthesia (TEA) causes blockade of sympathetic fibers involved in innervation of the heart (segments T1-T4), which results in changes of cardiac electrophysiology. The anti-arrhythmic effects of TEA on supraventricular arrhythmias, mainly atrial fibrillation, are controversial.The aim of the studyThe aim of the study was to assess the influence of epidural anesthesia on the electrical function of heart atria, including proven markers of increased risk of perioperative atrial fibrillation, such as P wave dispersion and P wave maximum duration.Material and methodsThe study involved 50 male patients, without a history of previous heart diseases, scheduled for elective surgical procedures. Patients received thoracic epidural anesthesia (group T, n = 25) or lumbar epidural anesthesia (group L, n = 25). The measurements were obtained from a continuous recording of ECG before epidural anesthesia and after the detection of blockade (T1 or T8 segment sensory block in groups T and L, respectively).ResultsThe statistical analysis of electrocardiographic parameters, including the maximum, minimum and mean P wave duration; P wave dispersion; the maximum, minimum and mean PR interval duration; and PR interval dispersion, did not show any inter- or intragroup differences at selected time points.ConclusionsRegardless of its location, epidural anesthesia and sympathetic blockade associated with this procedure do not significantly affect the electrical functions of the cardiac atria reflected in superficial ECG, including the electrocardiographic parameters that are considered to be markers of increased risk of perioperative atrial fibrillation, such as P wave dispersion and its maximum duration.

Accidently Discovered Postpartum Pituitary Apoplexy after Epidural Anesthesia

Anesthetic consideration of obstetric patients with pituitary disorders is an important topic to deal with. Few cases were reported with accidently discovered pituitary tumor complications especially in the postpartum period. A 26 years old primigravida lady with 39 weeks gestational period was reported to have severe headache and sudden loss of conscious after normal vaginal delivery with lumbar epidural anesthesia. Accidently discovered pituitary adenoma was proved after neurology, endocrine and ophthalmology consultations. Hence, undiagnosed pituitary adenomas should be taken in to consideration with unexplained postpartum generalized weakness and loss of conscious especially after exclusion of epidural anesthesia complications.

Intentional Unilateral Sacral Epidural

Background: Unilateral block by lumbar epidural and caudal anesthesia is a rare event, although, from time to time, it becomes essential for aged patients to minimize the drug effect and to have full benefits of epidural anesthesia. Aims: This study is scheduled to get a way to achieve unilateral lower limb block with the help of the sacral epidural anesthesia. Method: 25ml of 0.5% Ropivacaine were injected into sacral epidural space in the lateral position with slight head down tilt. The patient was kept in the same position on the operation table for 15 minutes after completion of sacral epidural anesthesia on the surgical side with the nerve stimulator needle used for detection of the epidural space. Result: All patients expect five developed unilateral lower limb block, placed on the operation table and projected for surgery. Other five patients developed bilateral block. Conclusion: The sacral epidural through its dorsal foramen in lateral position of the patient is highly capable of providing the unilateral block on dependent lower limb for projected surgeries without hemodynamic fluctuation.

Neuraxial block, death and serious cardiovascular morbidity in the POISE trial

BackgroundThis post hoc analysis aimed to determine whether neuraxial block was associated with a composite of cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal cardiac arrest within 30 days of randomization in POISE trial patients. MethodsA total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were randomized to β-blocker or placebo. Neuraxial block was defined as spinal, lumbar or thoracic epidural anaesthesia. Logistic regression, with weighting using estimated propensity scores, was used to determine the association between neuraxial block and primary and secondary outcomes. ResultsNeuraxial block was associated with an increased risk of the primary outcome [287 (7.3%) vs 229 (5.7%); odds ratio (OR), 1.24; 95% confidence interval (CI), 1.02–1.49; P=0.03] and MI [230 (5.9%) vs 177 (4.4%); OR, 1.32; 95% CI, 1.07–1.64; P=0.009] but not stroke [23 (0.6%) vs 32 (0.8%); OR, 0.76; 95% CI, 0.44–1.33; P=0.34], death [96 (2.5%) vs 111 (2.8%); OR, 0.87; 95% CI, 0.65–1.17; P=0.37] or clinically significant hypotension [522 (13.4%) vs 484 (12.1%); OR, 1.13; 95% CI, 0.99–1.30; P=0.08]. Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [86 (12.1%) vs 119 (5.4%); OR, 2.95; 95% CI, 2.00–4.35; P<0.001]. ConclusionsIn patients at high risk of cardiovascular morbidity, neuraxial block was associated with an increased risk of adverse cardiovascular outcomes, which could be causal or because of residual confounding.

Fatal bupivacaine overdose through intrathecally positioned epidural catheter

ABSTRACT We describe a fatality due to an intrathecally positioned epidural catheter and an infusion rate of bupivacaine set 10 times higher than planned. The undetected misplacement, despite safety routines, is discussed along with the toxicological findings and new information on the intrathecal distribution of bupivacaine. From a clinical point of view, the human factor, in combination with an indistinct decimal point on the pump, was considered as the reason for the unfortunate overdose. In continuous epidural infusion of local anesthetics, the importance of guidelines and informed staff in managing complications of epidural lumbar infusion as well as careful monitoring of the vital functions is essential. Guidelines are also vital during the procedure of insertion of epidural catheters. When using combined spinal and epidural anaesthesia, we believe that an epidural catheter should be inserted, and its position tested, prior to spinal anesthesia. The case also illustrates the need of innovative investigation techniques to confirm the suspicion of unusual manifestations of inadvertent drug effects. Segmental analysis, together with analyses in a control case, enabled us to elucidate the high and varying tissue concentrations in the central nervous system.

Treatment of spontaneous intracranial hypotension: evolution of the therapeutic and diagnostic modalities

Magnetic resonance imaging in patients affected by orthostatic headache often allows the diagnosis of spontaneous intracranial hypotension (SIH). Nevertheless, in the last 5 years, the diagnostic and therapeutic strategy for spontaneous intracranial hypotension (SIH) has been significantly modified. Specifically, all invasive techniques aimed at localization and demonstration of "spontaneous" spinal fistulas (myelography, isotopic cisternography, and so on) have been progressively abandoned. Also myelo-MR, although not an invasive exam, is no longer considered necessary to establish the most appropriate treatment. This change is due to the development and demonstration of a pathogenetic theory which considers the cerebrospinal fistula not as the primary cause of intracranial hypotension, but as the consequence of an imbalance between epidural and cerebrospinal fluid (CSF) pressures. In a consecutive series of 80 patients, we performed a standardized epidural lumbar injection of a dense compound aimed to raise the epidural pressure irrespective of the presence and site of CSF leaks. The technique used, the long-term results of this treatment and the diagnostic pathways will be discussed.

Abstract No. 312 - Initial clinical experience with a quadrupol butterfly coil for spinal interventions in an open vertical MRI at 1.0 Tesla

Purpose In vertical open MRI systems, near real-time spinal injection procedures usually need to be performed in lateral decubitus position because the needle artifact is often impaired in prone position. The purpose of this study was to report our initial clinical experience with a coil, allowing for interventions in prone position. Materials and Methods 15 patients (7 women, 8 men; mean age 42 y) were treated in a 1.0 Tesla Panorama High Field Open (HFO) MRI system (Panorama HFO) using a quadrupol butterfly coil (Bfly), and matched by 15 patients of similar sex, age and MR intervention performed in conventional lateral decubitus position with the Multipurpose L coil (MPL; all devices Philips Medical Systems, Best, The Netherlands). A near real time PD TSE image sequence (TR/TE/flip angle/ta: 200-1000ms/5.7- 90ms/90°/3-4.4 s/image) and a MRI-compatible 20-G Chiba needle (10 or 15 cm; Cook [Bloomington, IN]) was used for intervention. Qualitative and quantitative image analysis was performed including signal intensity, SNR, CNR, contrast measurement and Full Width at Half Maximum (FWHM) determination of the needle. Results All 15 interventions (12 lumbar and 1 cervical periradicular, 1 lumbar facet joint and 1 epidural lumbar infiltration) were performed successfully. Subjective image quality and intervention time were comparable to the conventional MR intervention. Quantitative analysis yielded significant results for contrast between the needle and musculature (Bfly 0,27/MPL 0,17) as well as the periradicular fat tissue (0,13/0,24) during the intervention (both, p=0,029). CNR between musculature and needle was significant (10,61/5,23; p=0,010) although FWHM values were not (2,4/2,2; p=0,754). Needle signal intensity during intervention (1152,9/793,2; p=0,006) and post interventional SNR values of subcutaneous fat (15,3/28,6; p=0,007), musculature (6,6/11,8; p=0,011) and CNR between these tissues (8,7/17,5; p=0,004) were statistically significant. Conclusion The new quadrupol butterfly coil is a feasible alternative for MR guided interventions, especially when patients cannot (or prefer not to) be in a lateral decubitus position, or if prone positioning yields better access to the target zone.

The Effect of Anesthetic Technique on Cardiac Troponin-T and Systemic Inflammatory Response after Major Abdominal Cancer Surgery

Objectives: this study aims at assessment of acute inflammatory response; measured by high sensitivity C-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients undergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar epidural anesthesia. Methods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk factor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned into 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia (G2). Pain severity, time to first request of rescue analgesic, analgesic consumption, hemodynamics and side effects were recorded in first 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3 days postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery. Results: The mean VAS scores were significantly reduced in G2 allover time in comparison to G1 (p 0.03ng/ml. Regarding ECGs changes there were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in the form of depressed ST segment >1mm. Conclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing major non-cardiac surgery is associated with less perioperative acute inflammatory response, less post-operative pain and can reduce the perioperative myocardial damage.

Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain

Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.

Whipple’s Operation Under Lumber Epidural Analgesia and Sedation

Whipple's operation can be carried out either under general anaesthesia or continuous epidural anaesthesia with sedation. We report three cases that were managed successfully and we found that the combination of lumbar epidural analgesia with sedation is safer and beneficial as compared to those who undergo Whipple's operation under general anaesthesia. For the last three decades epidural analgesia has been the part of anaesthesia practice. Epidural analgesia can be a useful method of pain management various situations. It facilitates early mobilization and also avoids perioperative pulmonary complications especially after major thoracic or upper abdominal surgeries. The combination of continuous epidural analgesia with sedation has many advantages in prolonged major upper abdominal surgeries. Keywords- Whipple's operation, general anaesthesia, continuous epidural anaesthesia, sedation, upper abdominal surgery. I. Case Report We present 3 cases where regional anaesthesia technique combined with sedation for whipple's operation was employed successfully. Three patients with obstructive jaundice secondary to periampullary carcinoma posted for whipple's surgery. The diagnosis was confirmed by blood biochemistry, CT scan, ERCP and biopsy. General physical and systemic examination and vital parameters was essentially the same in all the patients. On pre-anaesthetic examination, an informed consent was taken and patients were thoroughly explained about the procedure and technique of lumbar epidural anaesthesia. After taking the patients in operation theater, patient were monitored for HR, BP, ECG, SpO2 and temperature. Intra Venous access was secured with 18 G cannula on the dorsum of hand and preloading was done with ringer's lactate solution 10-15ml kg-1. under full aseptic precaution an epidural catheter was inserted in the epidural space at L1-L2 level. The tip of catheter was advanced to T4. A test dose of 3 ml of 2% xylocaine with adrenaline 5 µg ml-1 was given after insuring correct placement the bolus dose of local anaesthetics (10ml of 2% lignocaine and 10ml of 0.5% bupivacaine and 50 micro g of fentanyl) was given followed by bolus dose of 6ml 0.5% bupivacaine hourly. Central venous cannulation was done and CVP maintained between 8-10 cm of normal saline. Opioids were not used. Urine output monitoring was done and maintained between 1.5-2 ml kg-1 hr-1. Blood loss was adequately replaced by PRBCs, FFP's and other IV fluids. Average blood loss in all 3 cases was 2-3 liters. The duration of surgery was approximately 8 hours. Propofol infusion 10ml hr-1 was used in all cases for sedation along with midazolam @ 2 ml/hour. Vital signs were monitered and maintained through out intraoperative period. All patients were fully conscious, oriented and with stable vitals. Postoperative x-ray Chest was normal in all cases. Postoperative pain relief was given with lumber epidural infusion. Bowel sounds were audible on 3rd postoperative day. Biochemistry, haematological and Blood Gas parameters was within normal limits. Patients remained comfortable, without pain and were discharged on 3-4th postoperative day from the ICU. epidural catheter was removed before discharge. All the 3 patients were ambulatory and with no complaint of pain.

Pediatric Regional Anesthesia

Two articles in this month’s Anesthesia & Analgesia address safety of regional anesthesia and analgesia in pediatrics.1,2 At first glance, one is very reassuring, the other is frightening. In this Editorial, we will recommend a middle ground. Practitioners of pediatric regional anesthesia should be careful and vigilant but can be confident that many types of complications can be made extremely rare by adopting some recommended practice patterns. Over the past 30 years, pediatric applications of postoperative regional anesthesia and analgesia have expanded rapidly.3 There is now a substantial body of studies regarding techniques, pharmacokinetics, and clinical outcomes. Agerelated trends in local anesthetic pharmacokinetics have been characterized, and safe dosing guidelines have been established.4 Most regional anesthesia in adults is performed awake or with doses of sedatives and analgesics that maintain verbal responsiveness, permitting patient reporting of paresthesias, severe pain with needle movement or injection, immediate symptoms of systemic local anesthetic effect, and progression of sensory and motor blockade over the minutes after injections. Textbooks, review articles, and consensus documents often strongly criticize performing most types of major peripheral or neuraxial blocks in adults under deep sedation or general anesthesia.5 In contrast, most, but not all, regional anesthesia in children is performed under either deep sedation or general anesthesia. Advocates of pediatric regional anesthesia have cited a series of retrospective and prospective safety studies to support their contention that the widespread practice of performing regional anesthesia under general anesthesia is safe.6–8 Polaner et al. report on the first 3 years of prospective registry data from PRAN, the Pediatric Regional Anesthesia Network, a consortium of North American pediatric centers. This report has a number of strengths. The data collection and analysis plan was generally thoughtfully constructed. There is a good degree of detail and new information regarding how procedures are performed and regarding most adverse events. The methodology for data gathering is likely to be fairly complete for intraoperative serious adverse events and for events occurring during patients’ inpatient stay. There are several scenarios that could potentially lead to underreporting of peripheral nerve injuries, most notably partial nerve injuries in nonverbal or nonambulatory children that might evade detection by parents and physicians. For example, a thoracic nerve root or an intercostal nerve injury following thoracic epidural or thoracic paravertebral block might not be detected in a preverbal child. In addition, for a patient in a cast, a deficit might not be apparent until days to weeks postoperatively. The methodology for postoperative surveillance in this registry is likely to omit some cases with delayed detection. Despite these possible sources for underreporting, the PRAN investigators make a good case for the overall very good safety of pediatric neuraxial and peripheral blocks as performed by clinicians in these hospitals. In contrast to the conclusion of the PRAN investigators that “nothing really bad happened,” Meyer et al. showed admirable courage and forthrightness in reporting on 4 cases of neurologic injury following epidural anesthesia in children. All 4 cases involve care by experienced anesthesiologists with extensive experience in pediatric epidural analgesia and acute and chronic pain management. Based on the incomplete information available in this case report, we would tend to agree with the authors’ general contention that there was “absence of proof of medical negligence.” A more important question, which the authors have addressed in their discussion, might be phrased as follows: “Based on these cases and other available knowledge, do we have ways to modify our practice to prevent similar complications in the future?” We consider the 4 cases in this light, taking advantage of “20–20 hindsight.” Among the 4 cases, case 1 was perhaps the most frightening, because the patient was healthy and uncomplicated, the epidural catheter placement proceeded uneventfully at a lumbar level below the terminus of the spinal cord, the duration of general anesthesia was short, and there were no hemodynamic clues intraoperatively to raise concerns. The test dose was appropriate (0.1 mL/kg). E EDITORIAL

Https://orthopedicreviews.openmedicalpublishing.org/article/23314-unusual-cause-of-acute-low-back-pain-sudden-annulus-fibrosus-rupture

Despite the good general patient acceptance, high patient comfort, safety and precision in the needle placement, exposure to radiation in computed tomography (CT)-guided spinal interventions remains a serious concern, and is often used to argue against its use. The aim of this study was to determine the technical possibilities of reducing the radiation dose in CT-guided epidural and periradicular injections in lumbar spine. We evaluated the possibilities of reducing radiation dose to the patient and operator during CT-guided injections on the lumbar spine using the following steps: significant reduction of the tube current and energy used for the topogram-acquisition, narrowing the area of interest in spiral CT-mode and reduction of tube current and radiation energy in the final intervention mode. Fifty-three CT-guided spinal injections were performed in the lumbar spine (34 epidural lumbar, 19 lumbar periradicular) using a low-dose protocol in non-obese patients and compared with 1870 CT-guided injections from the year 2010, when a standard dose protocol was used. Technical considerations on radiation dose reduction were provided. An average dose reduction of 85% was achieved using the low-dose protocol in CT-guided epidural and periradicular injections in lumbar spine without showing any effect on safety or precision.

Risk Factors for New-Onset Persistent Low-Back Pain Following Nonobstetric Surgery Performed With Epidural Anesthesia

The aim of this trial was to identify risk factors for persistent low-back pain (LBP) of new onset following nonobstetric surgery performed with lumbar epidural anesthesia. Four-hundred eighty-three patients with no history of LBP were screened for backache 2 days, 10 days, and 13 weeks after nonobstetric surgeries were performed with lumbar epidural anesthesia. Demographic data, details of epidural techniques, and operative data were compared in patients who developed back pain that persisted for 13 weeks with those patients who did not. Multivariate logistic regression analysis was performed to identify predictors of persistent LBP. Ten patients (2.1%) consistently experienced clinically significant LBP at 2 days, 10 days, and 13 weeks after surgery; they were labeled as having persistent LBP. Multivariate analysis showed that higher body mass index (P < 0.001), multiple attempts at epidural placement (P = 0.026), surgery in the lithotomy position (P = 0.013), and duration of surgery exceeding 2½ hrs (P = 0.025) were independent risk factors for persistent LBP. As much as 51% of variation in the outcome measure could be explained by the model (R = 0.51), which had an overall accuracy of 98.1%. Persistent LBP after nonobstetric surgery performed with lumbar epidural anesthesia is rather rare. Independent risk factors for this untoward outcome are higher body mass index, multiple trials at epidural placement, surgery in the lithotomy position, and operative time exceeding 2½ hrs. These results need to be validated by prospective trials using larger cohorts.