Lumbar Epidural Block Research Articles

Práctica de la anestesia regional en Chile: encuesta online

To conduct a survey to profile the practice of regional anesthesia in Chile and determine the limitations on its use. A link to an online questionnaire was sent by e-mail to anesthesiologists who were members of their national professional association (Sociedad Chilena de Anestesiologia). The survey was processed anonymously. Multiple choice items elicited responses concerning general demographic information, professional experience as an anesthetist, academic degree, hospital size, and the use of regional anesthesia in clinical practice (number of procedures and types of techniques). Finally, the questionnaire focused on the use of nerve and plexus blocks. A total of 209 completed questionnaires were received, for a response rate of 54%. Regional anesthesia was part of routine practice for 97% of the respondents; 68% reported that regional techniques were used in more than 30% of their caseload. Most performed neuraxial techniques: 98.1% were spinal blocks, 96.2% lumbar epidural blocks, and 66.9% thoracic epidural blocks. Routine use of peripheral nerve blockade was reported by 73.7%. Upper limb anesthesia was provided significantly more often than lower limb anesthesia (P =.011). The most common technique involved use of a peripheral nerve stimulator (64%). Skills were mainly acquired through residency programs (68.9%) and self-teaching (20.1%). Peripheral nerve blocks were never performed by 26.3% of the respondents; the reason given most often was lack of training. Although regional anesthesia is commonly used in Chile, neuraxial blocks remain the most frequently used types. Peripheral nerve blocks are used fairly often, mostly on an upper limb. Training should stimulate attempts to promote more widespread use of all forms of regional anesthesia.

Accidental Subarachnoidal Injection of Neo Vitacain® during Lumbar Epidural Block: A Report of Two Cases

Accidental Subarachnoidal Injection of Neo Vitacain® during Lumbar Epidural Block: A Report of Two Cases

Estimating lumbar epidural space depth in infants and children of Korea.

Lumbar epidural block is now a popular technique for anesthesia and post operative analgesia. It may be helpful for prevention of complication during this procedure to know the depth from the skin to the lumbar epidural space before the procedure. This study was undertaken to evaluate the depth from the skin to the lumbar epidural space and to determine any potential relationship between a patient's data (age, weight, and height) and the measured depth in Korean children. We investigated the electronic records of 662 Korean children who were received urologic surgeries with epidural catheterization for postoperative analgesia. The patients' gender, age, weight, height and epidural depth were recorded and analyzed with multiple linear regression test using SPSS 13.0 (SPSS Co., Ilinois, USA). The patient's age and weight were significantly correlated to the skin-epidural space depth in Korean children. Body weight was more significant variable than age on the epidural depth. The empirical formula derived from the results was as follow; epidural depth (mm) = 9 + 0.5 x body weight (kg) - 0.2 x age (months). We suggest that the depth of skin-lumbar epidural space can be estimated with the empirical formula based on body weight and age.

Spinal cord stimulation in a patient with pain in both legs due to spinal metastasis of lung cancer: A case report.

Spinal metastasis is common in patients with cancer, as the spine is the third most common site for metastasis of lung cancer. A 58-year-old woman was suffering from pain in her both legs due to spinal metastasis of lung cancer. She was treated with various nerve blocks including lumbar epidural block, and continuous epidural block with morphine, subarachnoid alcohol block, and with opioid medication. None of these treatments were effective for the pain, but spinal cord stimulation produced excellent results.

Comparison of lumbar plexus block and epidural block for elderly patients undergoing intertrochanteric femoral fracture surgery

To compare the anesthesia efficacy, hemodynamics, recovery of passage of gas by anus and bladder function in elderly patients with operation of intertrochanteric femoral fracture with epidural or lumbar plexus block. Sixty patients with intertrochanteric femoral fracture, aged 65-97, were randomly divided into 3 equal groups: lumbar plexus group (Group A, undergoing posterior lumbar plexus block) and epidural group (Group B, undergoing epidural block at L(1-2) interspace). The block onset time, anesthesia efficacy, transfusion amount during operation, blood pressure and heart rate change 1 h after anesthesia, and recovery after anesthesia were observed. The block onset time on femoral nerve, lateral cutaneous nerve of thigh, obturator nerve, and saphenous nerve of Group A were (2.7 +/- 2.0) min, (3.1 +/- 3.4) min, (3.5 +/- 3.3) min, and (3.7 +/- 3.1) min respectively, all significantly shorter than those of Group B [(13.5 +/- 2.1) min, (13.5 +/- 2.1) min, (13.5 +/- 2.1) min, and (13.5 +/- 2.1) min respectively, all P < 0.01]. The duration of postoperative analgesia of Group A was (420 +/- 152) min, significantly longer than that of Group B [(204 +/- 44) min, P < 0.05]. There were no significant differences in the change of blood pressure and heart rate between these 2 groups. The blood pressure decreased significantly 10 - 60 min after anesthesia in Group B, and remained stable in Group A. The transfusion amount of Group A was (773 +/- 353) ml, significantly fewer than that in Group B [(1483 +/- 444) ml, P < 0.01]. Passage of gas by anus started (1.1 +/- 0.6) h after operation in Group A, a time significantly shorter than that in Group B (5.9 +/- 1.2) h, P < 0.01). Urinary retention was seen in 8 patients of Group B, however, no patient in Group A showed incidence of urinary retention (P < 0.01). Forty-eight patients, 20 in Group A and 28 in Group B got excellent anesthesia effect, and 12 of them, 10 in Group A and 2 in Group B, got relatively good anesthesia (P < 0.05). Both lumbar plexus block and epidural block provide satisfactory anesthetic efficacy for operation of intertrochanteric femoral fracture in elderly patients. Epidural block provide better efficacy, and lumbar plexus block shows faster recovery of digestive system and urinary system after operation.

Adhesiolysis and targeted steroid/local anesthetic injection during epiduroscopy alleviates pain and reduces sensory nerve dysfunction in patients with chronic sciatica

The aim of this study was to evaluate the effect of adhesiolysis followed by the injection of steroid and local anesthetic during epiduroscopy on sensory nerve function, pain, and functional disability in patients with chronic sciatica. Epidural adhesiolysis, using epiduroscopy, followed by the injection of steroid and local anesthetic, was scheduled in 19 patients with chronic sciatica refractory to lumbar epidural block. Sensory nerve function in the legs was tested with a series of 2000-Hz (Abeta-fiber), 250-Hz (Adelta-fiber), and 5-Hz (C-fiber) stimuli, using the current perception threshold (CPT), and CPT values and intensity of pain and Roland Morris Disability Questionnaire (RMDQ) scores were assessed before and 1 and 3 months after the epiduroscopy. At all frequencies, the CPT values in the affected legs of patients before the epiduroscopy were significantly higher than those in the unaffected legs. Epidural adhesiolysis was successfully performed in 16 of the 19 patients. In these patients, the CPT values at 2000 and 250 Hz, and the pain and RMDQ scores 1 and 3 months after the epiduroscopy were significantly lower than those before the epiduroscopy, while the CPT value at 5 Hz did change. Epidural adhesiolysis followed by the injection of steroid and local anesthetic during epiduroscopy alleviated pain, and functional disability, and reduced dysfunction of Abeta and Adelta fibers in patients with chronic sciatica.

Bupivacaine caudal epidural anesthesia: assessing the effect of general anesthetic technique on block onset

The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile. One hundred and thirteen healthy children aged <10 years, scheduled for general or urological surgical procedures were randomly allocated to receive either propofol or sevoflurane induction and maintenance. Children received caudal or lumbar epidural block depending on their weight and expected surgery. Time to onset of surgical anesthesia, intraoperative analgesic effectiveness, residual motor blockade, postoperative pain, and adverse effects were evaluated. To assess the influence of age on these measures children were further divided into three age groups: 0-24, 25-60 and >60 months. The mean time to onset of surgical anesthesia was significantly shorter in the sevoflurane group than the propofol group (3.1 vs 4.7 min, P < 0.01), independent of the type of regional technique employed. Distress on arousal in recovery was increased in children receiving sevoflurane (P = 0.03). There was no significant difference in residual motor blockade between the groups but children between 0 and 24 months receiving sevoflurane had a higher incidence of residual motor blockade 3 h after local anesthetic injection (P = 0.01). This study has demonstrated that general anesthesia with sevoflurane decreases the time to onset of surgical anesthesia relative to propofol anesthesia. This effect was most marked when sevoflurane anesthesia preceded caudal epidural blockade. The basis for this effect is most likely to be related to differential binding of the two anesthetic agents to receptors in the spinal cord that mediate immobility in response to surgical stimuli.

Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS)

A 59-year-old man with amyotrophic lateral sclerosis (ALS) received lumbar epidural and sympathetic ganglion blocks to increase regional blood flow and improve his clinical symptoms. After a lumbar epidural block (0.5% mepivacaine), the skin temperature of his affected lower extremities rose by 7.0 degrees C and became close to that of the intact side, and the distance he was able to walk with his cane increased from 2 to 8 m. The clinical effects produced by the lumbar sympathetic ganglion block (99.5% alcohol) were sustained for approximately 8 weeks after the first block and for approximately 6 weeks after the second block. There were no particular adverse effects or complications associated with these nerve block procedures. Epidural and sympathetic ganglion blocks for an ALS patient, albeit their effects are of a transient nature, may improve related clinical symptoms, and were thought to play a contributory role in improving our patient's quality of life.

The Epidural and Psoas Abscess Recognized after Lumbar Epidural Block: A case report

Epidural block is widely used for the diagnosis and treatment of the acute and chronic pain in pain clinic. But, it has several complications like as headache, spinal injury, epidural hematoma and infection including epidural abscess, meningitis and osteomyelitis. Among them, the simultaneous occurrence of psoas and epidural abscesses is extremely rare. We report a patient diagnosed as epidural and psoas absesses one month after lumbar epidural block and treated successfully with surgical decompression and drainage. (Korean J Anesthesiol 2006; 51: 109~11)

Comparative efficacy of ropivacaine and bupivacaine for epidural block in outpatients with degenerative spinal disease and low back pain

Abstract Background and objectives: It is known that ropivacaine produces a differential block for sensory and motor nerves with lower toxic potential than bupivacaine. This study was carried out to evaluate the comparative efficacy of ropivacaine and bupivacaine for lumbar epidural block in 16 outpatients with degenerative spinal disease. Methods: The study was performed in a prospective, randomized, double blind and crossover fashion. A single injection of 8 ml of 0.375% or 0.2% ropivacaine or 0.25% bupivacaine was given at the L4-5 interspace. Each subject received all of the test solutions at an interval of one week or more. The upper level of analgesia, pain and motor blockade were evaluated by pin prick, visual analogue scale (VAS), and Bromage scale, respectively, and the recovery times to mobilization, ambulation and spontaneous micturition were measured. Results: There was no significant difference in the upper level of analgesia and the reduction of VAS among the three trials. Bromage scale with...

Five cases of far lateral lumbar disc herniations treated conservatively

Abstract Far lateral lumbar disc herniation (FLLDH) compresses the nerve root or dorsal ganglion outside the spinal canal at the same level of the herniation and produces severe pain on the anterolateral thigh. Computed tomography or magnetic resonance imaging (MRI) allow successful diagnosis of FLLDH, though one-third of FLLDH is still overlooked at the initial examination. There have been few reports about conservative therapies for FLLDH. We describe five cases of FLLDH treated recently with success using several kinds of nerve blocks. All the cases complained of severe pain at the gruteal or anterolateral part of lower extremity and four of them could not walk because of pain. The axial view of MRI was useful for the diagnosis of FLLDH. Neither lumbar epidural block nor the root block were effective for pain reduction. However, puncturing of herniated mass using a block needle, and a subsequent interdiscal injection of a steroid and a local anesthetic decreased pain in all cases. FLLDH should be taken...

Accidental subdural injection during attempted lumbar epidural block may present as a failed or inadequate block: radiographic evidence

Background and objectives Until now, case reports after accidental subdural injection during attempted epidural block have usually described extensive neuraxial blocks with a delayed onset, after low doses of local anesthetic, with a characteristic radiographic appearance on contrast injection. Our radiographic investigation of atypical “epidural” blocks has revealed that subdural injection may go unrecognized clinically and may be a cause of inadequate blocks. The mechanism is explored. Case reports A radiographic study of 35 cases of atypical or inadequate blocks for cesarean delivery has unexpectedly revealed four instances of subdural contrast injection. On imaging, only localized posterior spread of subdural contrast was detected in these 4 cases, unlike the more widespread distribution previously reported after extensive neuraxial blocks. Recent findings on the ultrastructure of the subdural space are reviewed and related to the new clinical findings, which include inadequate blocks and pain developing on postoperative reinjections. Conclusions Accidental subdural injection may now be added to the list of causes of failed or inadequate “epidural” block. Clinicians should be aware of the diagnosis of a possible subdural injection, if a poor quality block with restricted spread and slow onset is associated with pain on postoperative reinjection of the catheter.

Left Leg Paralysis after Lumbar Epidural Block -A case report-

A lumbar epidural block is widely performed to treat low back and lower extremity pain. Though there is a very low incidence of neurological complications after lumbar epidural block, there have been some reports of neurological complications after a lumbar epidural block. We report a case of left leg paralysis following a lumbar epidural block in a patient who had lower back pain and intermittent neurological claudication. After the neurological complications occurred, severe herniated lumbar disc disorders were found on the lumbar magnetic resonance image.

The Epidural Depth in Geriatric Patients

Background: Nowadays the number of geriatric patients continues to increase, and lumbar epidural blocks are frequently requested for operation in geriatric patients. The depth of the epidural space varies from patient to patient, and also varies at different levels of the spinal column in the same patient. We studied the distance from the skin to the lumbar epidural space in geriatric patients to determine whether there is any systematic relationship between physical parameters and distance from the skin to the epidural space. Methods: We measured epidural depth in 602 geriatric patients when the block was done successfully. Height, weight, and age were obtained from medical records. Physical parameters such as body mass index (BMI), Broca's index and weight/height were calculated. Pearson's correlation analysis and regression testing were used to analyze relations between epidural depth and physical parameters. Results: The epidural depths at the intervertebral spaces were cm, respectively. A significant correlation was found between the epidural depth and, weight, BMI, Broca's index, and the weight/height ratio. Conclusions: No disparity was found between epidural depth in geriatric patients and young adults, and significant correlations were found between epidural depth and BMI, weight, Broca's index and weight/height ratio. BMI showed the highest correlation coefficient with epidural depth.

Accidental Subdural Injection During Attempted Lumbar Epidural Block May Present as a Failed or Inadequate Block

Accidental Subdural Injection During Attempted Lumbar Epidural Block May Present as a Failed or Inadequate Block

Neuraxial blockade in children

Epidural blockade in children has become more popular for postoperative analgesia in recent years owing to increased experience, greater confidence and the development of appropriate equipment. In the UK, about 2000 lumbar epidural and continuous caudal blocks are performed each year. Spinal anaesthesia remains popular for babies at risk of postoperative apnoea, but is increasingly being superseded by light general anaesthesia with desflurane or sevoflurane combined with caudal blockade, which produces more rapid recovery from anaesthesia. Contraindications to neuraxial blockade are the same as for adults (patient or parental refusal, coagulation abnormalities, septicaemia, raised intracranial pressure, meningitis, infection at the entry site, allergy to local anaesthetics) but also include myelomeningocele (spina bifida) and, for a caudal epidural, abnormal sacral anatomy.

A case report of CRPS treated with repeated subarachnoid block therapy

The patient was a 42-year-old female with an established diagnosis of Type II complex regional pain syndrome (CRPS) due to multiple operated back (MOB). After 2 repeated operations for lumbar disc herniation at L5/S1, dysesthesia complicated with pain and numbness of the left limb had appeared. Since MRI performed after operation revealed no noticeable anomalies in the lumbar region, lumbar epidural block, lumbar sympathetic ganglion block and spinal cord epidural stimulation were performed. These nerve block therapies were effective with improved symptoms which lasted for 2 hours following the former and for 1-4 months following the latter intervention. Though the stimulation approach was also effective, it could not but discontinue because of metal (platinum) allergy. After repeated lumbar epidural blocking procedures over 4 years more or less, its manipulation became difficult to complete and was thus switched to repeated L4/5 subarachnoid block using 0.3% dibucaine. Her dysesthesia almost disappeared after 3rd subarachnoid blocking procedure, the pain was relieved after 10th and the patient became possible to walk normally after about 18th procedure. Because a painless state began to last for 3-4 weeks on and after 33rd procedure, the subarachnoid block was performed at 3 week intervals thereafter. This procedure has so far been repeated 59 times in total during the past about 4 years with good pain control but no side effects ⁄ complications due to 0.3% dibucaine. When CRPS of type II is considered among various MOB-induced pain episodes, subarachnoid block seemed to be of effective manipulation in those patients who responded good to the previous sympathetic ganglion block even if it was noted temporarily. However, a possible neurotoxicity due to local anesthetics used should be recognized because its repeated procedures are required.

腰椎椎間板ヘルニアに対する選択的神経根ブロックと持続硬膜外ブロックの治療効果の比較

In this study we analyzed 70 patients with lumbar disc herniation treated by blocks since 1996. Fifty-one patients were treated by selective nerve root blocks and 19 were treated by continuous lumbar epidural blocks. The purpose of this paper is to compare the efficacy of the selective nerve root block and continuous epidural block. The functional results were evaluated on the basis of the Japanese Orthopaedic Association (JOA) score, subjective symptoms: 9 points. We assessed the block effectiveness when the JOA score improved by more than 2 points after the blocks. It was effective in 31 patients (60.8%) for selective nerve root blocks and 8 patients (42.1%) for continuous epidural blocks. Selective nerve root block is considered to be superior to continuous epidural block. Selective nerve root block showed better results especially for patients with negative SLR test. The herniated mass was protrusion type and space-occupying ratio was less than 30%.

Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient‐controlled analgesia after total hip replacement

We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1, comparing it with intravenous patient‐controlled analgesia using piritramide in this prospective, randomised, double‐blind study of 24 ASA physical status I–III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient‐controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 at a rate of 5–9 ml.h−1 and an intravenous patient‐controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient‐controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p &lt; 0.01), and on movement 4 h (p &lt; 0.01) and 8 h (p &lt; 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p &lt; 0.001), especially hypotension (p &lt; 0.01) and vomiting (p &lt; 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p &lt; 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 is superior to intravenous opioid by patient‐controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.

Lumbar sympathetic block for pain relief in two patients with interstitial cystitis. (Shimane Medical University, Izumo, Japan) Reg Anesth Pain Med 2001;26:271–273.

This case report discussed the effective treatment of interstitial cystitis (IC) with regard to a 63‐year‐old woman and a 78‐year‐old woman. Medical therapy with nonsteroidal anti‐inflammatory drugs, anticholinergics, and hydrodistention of the bladder failed to improve their symptoms. Subsequently, a continuous lumbar epidural block using 1% mepivacaine was used in these patients. A transient reduction of the symptoms in both patients was achieved. A lumbar sympathetic block with a neurolytic agent produced almost complete and long‐lasting relief of their symptoms. Conclude that lumbar sympathetic block using a neurolytic agent produced long‐lasting pain relief in 2 patients with IC.Comment by Pedro F. Bejarano, M.D. Chronic visceral pain association to the neurovegetative system and to sympathetically‐maintained mechanisms has been well documented nowadays. The multiple neural connections among different abdominal nerve plexus has also been described, and this anastomoses may account for the observed analgesic effects in this case obtained without specific blockade of the superior hypogastric plexus. Despite the reported good results, the use of the lumbar approach may be controversial in this cases, as the uncomfortable peripheral effects of a permanent lumbar sympathetic neurolytic block (i.e.: lower limb vasodilation) favors a more anatomically restricted (visceral) area like that obtained with a superior hypogastric approach.We must remark that the existence of Sympathetically mediated and/or maintained pain is not enough phenomenae to fit the diagnostic criteria of a RCPS, as suggested by the authors, but it is less so in the case of an evidently persistent, organic source of visceral nociception like in the Intersticial Cystitis disease.