Lumbar Epidural Space Research Articles

Using cross-linked hyaluronic acid gel to prevent postoperative lumbar epidural space adhesion: in vitro and in vivo studies.

Hyaluronic acid prevents tissue adhesion after different surgeries. Physical barriers and inflammatory regulation have been suggested to be involved in the mechanism of these clinical effects. However, the molecular mechanism by which hyaluronic acid prevents epidural adhesion has not yet been reported. In the current in vivo studies, we investigated cross-linked hyaluronic acid gel in the regulation of scar gene expression, the accumulation of fibroblasts in scar tissue, and the prevention of epidural adhesion. The effect of cross-linked hyaluronic acid gel on the secretion of inflammatory factors was observed in vitro. In addition, to ensure the accuracy and reliability of the in vivo gene expression results, we used a cell model to detect the target genes in vitro. The expression levels of TGFβ1 and COL1A1 mRNA were decreased in the cross-linked hyaluronic acid gel-treated group, and the protein expression of levels TGFβ1 and COL1A1 were also reduced, as detected by Western blotting in vitro and in vivo (P < 0.05). Histomorphometry results demonstrated that the number of fibroblasts in the experimental group was significantly lower than that in the control group 2weeks postoperatively. Micro-CT scans showed that the cross-linked hyaluronic acid gel could reduce adhesion in the epidural space after laminectomy. Additionally, the cross-linked hyaluronic acid gel could inhibit IL-6 secretion. These results indicate that cross-linked hyaluronic acid gel can prevent epidural adhesion by inhibiting inflammatory factors, such as IL-6, and downregulating TGFβ1 and COL1A1 mRNA expression. These slides can be retrieved under Electronic Supplementary Material.

The Posterior Lumbar Epidural Space: Three-Dimensional Reconstruction of High-Resolution MRI: Real and Potential Epidural Spaces and Their Content In Vivo.

Our aim was to study the posterior lumbar epidural space with 3D reconstructions of magnetic resonance images (MRIs) and to compare and validate the findings with targeted anatomic microdissections. We performed 3D reconstructions of high-resolution MRIs from seven patients and normal-resolution MRIs commonly used in clinical practice from 196 other random patients. We then dissected and photographed the lumbar spine areas of four fresh cadavers. From the 3D reconstructions of the MRIs, we verified that the distribution of the posterior fat pad had an irregular shape that resembled a truncated pyramid. It spanned between the superior margin of the lamina of the caudad vertebra and beyond the inferior margin to almost halfway underneath the cephalad lamina of the cranial vertebra, and it was not longitudinally or circumferentially continuous. The 3D reconstructions of the high-definition MRI also consistently revealed a prelaminar fibrous body that was not seen in most of the usually used low-definition MRI reconstructions. Targeted microdissections confirmed the 3D reconstruction findings and also showed the prelaminar tissue body to be fibrous, crossing from side to side anterior to the cephalad half of each lamina, and spanning from the dural sac to the laminae. Three-dimensional reconstructions and targeted microdissection revealed the unique appearance of posterior fat pads and a prelaminar fibrous body. The exact consistency, presence, prevalence with age, presence in other regions, and function of this body are unknown and require further research.

Effectiveness of Mixture of Xylocaine, Bupivacaine and Buprenorphine for Lumbar Blockade by Epidural Approach

Background: Pain is one of the most compelling experience for human beings. Pain is the most difficult one to define and assess, as it is a purely subjective sensation experienced only by the sufferer. Present study was done in which Buprenorphine was given epidurally along with Bupivacaine and Xylocaine as a single shot technique to evaluate its potency, duration of analgesia and other side effects. Subjects and Methods: Fifty adult patients of ASA risk I/II undergoing lower abdominal surgery, lower limb - orthopaedic surgery, surgery involving perineal region and gynaecological procedures were selected for our study. The patients were divided into two groups consisting of 25 patients each. In group I, patients were given Inj. Bupivacaine 0.5% 20 cc + xylacaine in lumbar epidural space. In group II, patients were given Bupivacaine 0.5% 20 cc + xylacaine 0.5% 20 cc mixed with Inj. Buprenorphine 0.2 mg (2 ml) in same syringe in lumbar epidural space. Duration of total analgesia was measured with help of pain scorre, which were measured throughout operative period and in postoperative period. All the statistical tests will be performed in SPSS version 15 software. Results: In study group majority patients complain of pain at around 16 to 20 hours. Most of the patients in group-I are in 0-4 hours and in group – II are 20-24 hours. Maximum respiratory depression was around 12% (2/min). It was observed that hypotension was seen in 4 cases and bradycardia in 4 cases – intraoperatively and postoperatively no patient had bradycardia or hypotension in study group. Conclusion: Buprenorphine if given epidurally along with local anesthetic solution for various surgical procedures can provide excellent pain free period lasting up to 24 hours without any disturbances to normal physiology life and notable side effects.

Surgical Indications and Operative Results of Lumbosubarachnoid-Lumboepidural Shunting in 29 Patients with Idiopathic Normal Pressure Hydrocephalus under Local Anesthesia.

This study consisted of 29 patients with idiopathic normal pressure hydrocephalus (iNPH) who underwent lumbosubarachnoid-lumboepidural (L-L) shunting under local anesthesia in accordance with our surgical indications of L-L shunting. (1) CSF absorption within the lumbar epidural space and shunt clearance were confirmed in all patients after operation. (2) Shunt responders (R) were 25 of 29 cases (86.2%) 3 months after surgery. Among the R, symptom exacerbation was confirmed in three patients (12%) within the follow-up period (mean, 25.1 months). In each of these patients, shunt function were maintained and remained unchanged even with pressure resetting, the cause being an intracranial/extracranial disease other than iNPH. (3) The initial pressure setting for this method was 8 cmH2O, with gradual change to higher pressures, such that the setting for Patient 11 and thereafter became 20 cmH2O. (4) As postsurgical complications, subcutaneous cerebral spinal fluid collection (SCC) was confirmed in five patients (17.2%). In high-pressure resetting and follow-up observation, SCC was not observed in all patients. Epidural catheter displacement was confirmed in three patients (10.3%). No recurrence was noted after the secure fixation of the catheter at the fascia insertion portion and 2 days’ postsurgical bed rest. Hence, L-L shunting is an effective shunt therapy for iNPH.

Skin-to-epidural distance in the Southeast Asian paediatric population: multiethnic morphometrics and international comparisons.

Paediatric epidurals can present technical challenges due to wide variations in age and weight among children, ranging from neonates to teenagers. This study evaluated the skin-to-epidural distance in the thoracic and lumbar regions to determine the relationship between age, weight and ethnicity and depth to the epidural space in our Singapore paediatric population. Data from the Acute Pain Service was prospectively collected over 16 years. Details included patient demographics, level of epidural performed and distance from skin to epidural space. Multivariable regression analysis was performed to determine the association of weight, age, ethnicity and gender with the depths to the thoracic and lumbar epidural spaces. A simple linear regression was calculated to predict the depth to both thoracic and lumbar epidural spaces based on body weight. Equations were formulated to describe the relationship between weight and depth of epidural space. A total of 616 midline epidurals were studied. Regression analysis was performed for 225 thoracic epidurals and 363 lumbar epidurals. Our study revealed a clear correlation between skin-to-lumbar epidural distance and weight in children. The best correlation was demonstrated between skin-to-lumbar epidural distance and body weight (R2 = 0.729). This relationship was described by the formula: depth (mm) = (0.63 × weight [kg]) + 9.2. Skin-to-lumbar epidural distance correlated with weight in children. Our results highlighted the clinical significance of differences between Southeast Asian paediatric populations when compared to other populations.

In vivo images of the epidural space with two- and three-dimensional optical coherence tomography in a porcine model.

BackgroundNo reports exist concerning in vivo optical coherence tomography visualization of the epidural space and the blood patch process in the epidural space. In this study, we produced real-time two-dimensional and reconstructed three-dimensional images of the epidural space by using optical coherence tomography in a porcine model. We also aimed to produce three-dimensional optical coherence tomography images of the dura puncture and blood patch process.MethodsTwo-dimensional and three-dimensional optical coherence tomography images were obtained using a swept source optical coherence tomography (SSOCT) system. Four laboratory pigs were intubated and ventilated after the induction of general anesthesia. An 18-gauge Tuohy needle was used as a tunnel for the optical coherence tomography probe to the epidural space. Two-dimensional and three-dimensional reconstruction optical coherence tomography images of the epidural space were acquired in four stages.ResultsIn stage 1, real-time two-dimensional and reconstructed three-dimensional optical coherence tomography of the lumbar and thoracic epidural space were successfully acquired. In stage 2, the epidural catheter in the epidural space was successfully traced in the 3D optical coherence tomography images. In stage 3, water injection and lumbar puncture were successfully monitored in all study animals. In stage 4, 10 mL of fresh blood was injected into the epidural space and two-dimensional and three-dimensional optical coherence tomography images were successfully acquired.ConclusionsThese animal experiments suggest the potential capability of using an optical coherence tomography-based imaging needle in the directed two-dimensional and three-dimensional visualization of the epidural space. More investigations involving humans are required before optical coherence tomography can be recommended for routine use. However, three-dimensional optical coherence tomography may provide a novel, minimally invasive, and safe way to observe the spinal epidural space, epidural catheter, lumbar puncture hole, and blood patch.

Lumbar Epidural space depth has better relations to the Weight than Height of the Patient

This study was carried out on one hundred and fifty male patients undergoing TURP and Cystoscopy under lumbar epidural anaesthesia in urology department mayo hospital with age between 30 years to 100 years with mean 64.29 years, weight 37kg to 96kg with mean 59.21kg and height between 140cm to 187cm with mean 165.34cm. All patients were administered single shot-lumbar epidural anesthesia with tuohy needle no 16 with bupivacain 0.5% volume ranging 15cc to 20cc at level of L3-4 or L4-5 level. Two patients developed lumbar puncture and managed conservatively. The lumbar epidural space ranged between 3.5cm to 6.5cm with mean depth 4.38±0.563. It was concluded statistically that lumbar epidural space depth had better relation to the weight of patients than height.

The influence of patient position on withdrawal force of lumbar epidural catheters after total knee arthroplasty: A randomized trial

Study objectiveElderly patients with degenerative knee disease may have accompanying degenerative spine conditions. There are no studies on lumbar epidural catheter withdrawal forces in these patients. The aim of this study was to investigate withdrawal forces and possible associated risk factors in patients undergoing total knee arthroplasty (TKA). DesignProspective randomized trial. SettingOperating room and ward in a university hospital. PatientsSeventy-eight patients aged 65 to 80years who were undergoing TKA and combined spinal epidural anesthesia were enrolled. InterventionsLumbar epidural catheterization was performed in a lateral position before surgery and the patients were randomly allocated to one of 3 positions for removal: flexed lateral (L), prone (P), and sitting (S). On the third postoperative day, the lumbar epidural catheters were removed by a single investigator with the patient in the assigned position. MeasurementsWe measured the peak tension during catheter withdrawal and evaluated the factors affecting peak tension. Main resultsThe forces required to remove the catheters were considerably greater in the sitting and prone than in the flexed lateral position: group P (3.9N [0.28-10.36]), group S (4.1N [0.04-11.57]), and group L (1.3N [0.07-3.65]) (P<.001). There was a positive correlation between the length of catheter in the epidural space and peak tension (P=.0026, β coefficient=.223). ConclusionsFor ease of removal of catheters from the lumbar epidural space, the flexed lateral position is recommended for elderly patients undergoing TKA. When placing the epidural catheter, the physician should be careful not to insert a catheter that is excessively long.

Lateral deviation of four types of epidural catheters from the lumbar epidural space into the intervertebral foramen

BackgroundDuring epidural anesthesia, the catheter tip occasionally deviates from the epidural space into the intervertebral foramen, resulting in inadequate anesthesia.MethodsDuring postoperative plain radiography, iohexol was injected via the epidural catheter to determine its position and to observe the spread of the material. After exclusion of seven patients with catheters that migrated into the subcutaneous area and 25 patients with no evidence of the contrast medium, 415 patients were evaluated. We retrospectively compared patients to determine whether the incidence of deviation into the intervertebral foramen differed between four types of epidural catheters. We also investigated the load applied to the catheter tip using a Shimadzu Autograph AG-X-500 N-111 universal testing machine.ResultsDeviation of the epidural catheter into the intervertebral foramen was observed in eight and 33 patients in the Hakko and Perifix Soft tip catheter groups, respectively. The incidence of deviation was higher in the Perifix Soft tip catheter group, and lower in the FlexTip Plus and Perifix FX catheter groups. A rapid increase was observed in the force exerted on the tips of the Hakko and Perifix Soft tip catheters, while the force transmitted to the tips of the FlexTip Plus and Perifix FX catheters gradually increased and then reached a plateau at a low level.ConclusionsThe incidence of deviation was significantly lower with spiral-type catheters than with other types of catheters. This might be attributable to the gradual transmission of a lower level of force to the tip in spiral-type catheters.

Influence of Physical Characteristics on Skin to Lumbar Epidural Space Distance in Nigerian Adults

Influence of Physical Characteristics on Skin to Lumbar Epidural Space Distance in Nigerian Adults

Catheter-Based Trans-Epidural Approach to Aspirate Cervical and Thoracic Epidural Abscesses: A Cadaveric Feasibility Study.

Approaching and aspirating cervical and high thoracic epidural abscesses through a trans-epidural route from the lumbar region access represents an alternative method for selected patients. We determined the feasibility of catheter-based manipulation and aspiration using the trans-epidural route. A custom designed infusion-suction catheter system that includes an outer suction catheter and inner infusion catheter in concentric relation with radio-opaque marker bands was tested in a cadaveric preparation to determine (1) the ability to place an aspiration catheter over a guidewire using a percutaneous approach within the posterior lumbar epidural space; (2) the highest vertebral level a catheter can be advanced within the epidural space; and (3) the ability to aspirate artificial purulent-like material placed in the cervical and thoracic level epidural space. We were able to advance two infusion-suction catheter systems from a 14G Touhy spinal needle inserted via an oblique parasagittal approach at the L2-L3 intervertebral space. The infusion-suction catheter was advanced up to the level of the cervical vertebral level of C2 within the epidural space under fluoroscopic guidance. We were able to aspirate artificial purulent-like material directly injected with a 22G Quincke spinal needle at vertebral levels C4-C5 and at vertebral levels T10-T11 by aspiration and manipulation of the outer catheter within the epidural space at levels C3-C7 and T9-L1, respectively. Our observations support the further exploration of a percutaneous catheter-based trans-epidural approach to treat epidural abscesses. The trans-epidural approach may be used alone or as a staged or concurrent approach with open surgical treatment.

Paragangliomas of the Spine.

Paragangliomas of the spine are rare tumors. Clinical presentations and courses of spinal paragangliomas are varied, and there are no standard principles of treatment to date. The purpose of this study was to explore the diagnosis, treatment and prognosis of spinal paragangliomas. The clinical data of 7 consecutive cases, with complete medical records and follow-up results that were treated in our institutions from October 2000 to October 2011, was retrospectively reviewed. There were 6 males and 1 female with a mean age of 40 years (range, 16?61). The follow-up period ranged from 40 to 98 months (mean, 72 months). Of the 6 primary spinal paragangliomas, one lesion was in the cervical intradural extramedullary space, one in the thoracic epidural space and four in the lumbar intradural extramedullary space. All tumors were totally resected and no recurrence was detected during the follow-up period. Of the metastatic case, the lesion of the spine was located in the first lumbar epidural space and vertebra. The patients underwent surgical resection two times with radiotherapy, but the tumor recurred and the patient suffered from the paraplegia of lower limbs and urine and stool incontinence during the follow-up period. No patient died. Spinal paragangliomas are rare lesions and seldom considered in the presurgical differential diagnosis due to its rarity and non-specific clinical symptoms and imaging features. Clinical follow-up was necessary to determine the outcome. Complete resection is necessary to prevent recurrence. The role of radiotherapy in the management of these lesions needs further assessment.

Spinal Capillary Hemangioma Involving the Lumbar Epidural and Paraspinal Spaces: A Case Report

Spinal Capillary Hemangioma Involving the Lumbar Epidural and Paraspinal Spaces: A Case Report

Epidural administration of neostigmine-loaded nanofibers provides extended analgesia in rats.

BackgroundIn this study, neostigmine-loaded electrospun nanofibers were prepared and then their efficacy and duration of analgesic action were studied after epidural administration in rats by repeated tail flick and formalin tests.MethodsThe neostigmine poly vinyl alcohol (PVA) nanofibers were fabricated by electrospinning methods. The nanofibers (1 mg) were injected into the lumbar epidural space (L5-L6) of rats (n = 6). Cerebrospinal fluid samples of rats were collected 1, 5 and 24 hours after injection and then were sampled once weekly for 4 weeks. Free-neostigmine concentration was measured in the samples spectrophotometrically. Rat nociceptive responses were evaluated by repeated tail-flick and formalin tests for 5 weeks after the nanofibers (1 mg) injection. Locomotor activity of rats was measured in the open-field at the same period.ResultsThe cerebrospinal fluid concentration of free neostigmine reached 5 μg/ml five hours after injection and remained constant until the end of the experiments. The tail-flick latency of treated rats was significantly (p < 0.01) increased and remained constant up to 4 weeks. Pain scores of the rats in both phases of formalin test were significantly (p < 0.01) reduced during the same periods, Epidural injection of the nanofibers had no effect on locomotor activity of rats in an open-field.ConclusionsOur results indicate that the neostigmine nanofibers can provide sustained release of neostigmine for induction of prolonged analgesia after epidural administration. High tissue distribution and penetration of the nanofibers in dorsal horn can increase thermal and chemical analgesia duration without altering locomotor activity in rats for 4 weeks.

An Unusual Case of Extradural Primary Ewing Sarcoma of Lumbar Spine in an Adult

Ewing sarcoma (ES) is a malignant neoplasm of bones with mesenchymal origin that rarely occurs in extraosseous sites, most frequently presents in the pediatric population and is extremely rare in the adult population, with only 30 extradural spine cases reported in the literature. We present a case of an extraskeletal ES that belongs to the primitive neuroectodermal tumor/ES family occurring in the lumbar epidural space. A 46-year-old woman was admitted to neurosurgery department with the complaint of 1 month of worsening leg pain. Lumbosacral magnetic resonance imaging revealed the presence of a large, enhancing, extradural mass lesion at the level of L4 without any bony involvement. The patient underwent laminectomy and total tumor resection. ES diagnosis arising in the lumbar epidural space was confirmed by histopathologic examination. The patient received both chemotherapy and radiotherapy after the operation. Hereby, we report an extremely rare case of primary ES in adult patient with regard to tumor resection, prevention of recurrence, and metastasis.

Le positionnement d’un cathéter péridural thoracique stimulant par voie lombaire provoque des lésions importantes à la moelle épinière sur un modèle porcin

Continuous thoracic epidural analgesia is a valuable and common technique for analgesia but involves risk to the spinal cord. There is significant pediatric experience safely placing thoracic epidurals via a caudal approach. The use of a stimulating catheter offers the advantage of real-time confirmation of appropriate catheter placement. We hypothesize that the tip of a stimulating epidural catheter can be reliably advanced to the thoracic epidural space with lumbar insertion in a porcine model. This prospective experimental porcine study evaluated the feasibility of placing the tip of a stimulating epidural catheter to a predefined thoracic epidural location after percutaneous lumbar epidural access in six live pigs. After the lumbar epidural space was accessed, a stimulating epidural catheter was advanced until the targeted thoracic myotome was stimulated. The final position of the catheter in relation to the targeted location was determined by fluoroscopy. All animals were euthanized at the end of the experiment, necropsy and spinal cord histology were then performed to assess the extent of spinal cord damage. In all animals the epidural catheter tip could be accurately advanced to the targeted thoracic myotome. Gross subdural bleeding occurred in three of the six animals and deep spinal damage was observed in two of the six animals. In one animal, the catheter was placed in the subarachnoid space. Accurate access to the thoracic epidural space is possible via a lumbar approach using a stimulating epidural catheter. Based on gross and histopathological examination, this technique resulted in frequent complications, including subdural hemorrhage, deep spinal cord damage, and subarachnoid catheter placement.

SAT0411 Visualization of the Lumbar Epidural Space by Ultrasonography

BackgroundEpidural steroid injections are a common method used for the treatment of patients with sciatica. They are usually performed without imaging guidance using anatomical landmarks. However, injections are sometimes challenging...

Lumbosubarachnoid–Lumboepidural Shunting in Patients With Idiopathic Normal-Pressure Hydrocephalus: Surgical Procedures and Follow-up Study of Five Cases

The objective of the study is to introduce the surgical procedure of the lumbosubarachnoid-lumboepidural (L-L) shunting performed as treatment for idiopathic normal-pressure hydrocephalus (iNPH) and its follow-up. The subjects were five patients with probable iNPH (aged 78-85 years; mean age 81 years; four males and one female) who were judged to be at high risk from general or lumbar anesthesia due to their systemic complications and age. The L-L shunt operation was performed for all the patients under local anesthesia using Codman-Hakim Programmable Valve(®) (Codman & Shurtleff, Inc., Raynham, Massachusetts, USA). The initial pressure for all patients was set at 8 cmH2O. The evaluation of shunt efficacy and the lumbar epidural space cerebrospinal fluid (CSF) absorption test (injection of contrast media into epidural space) were performed both on the operation day and during follow-up period (9-12 months). The shunt operation was judged to be effective in four out of five patients (regarded as shunt responders), whereas no improvement in symptoms was seen in one patient (regarded as shunt nonresponder) where the shunting had no effect after the initial pressure was changed to 4 cmH2O. The lumbar epidural space CSF absorption test both on the operation day and during the follow-up period confirmed absorption in all patients. The L-L shunting is useful for patients with probable iNPH who are at high risk from general or lumbar anesthesia due to their systemic complications and age. CSF was continuously absorbed in the lumbar epidural space during postoperative follow-up period. A longer follow-up is required to establish this surgical procedure.

Effects of ozone applied by spinal endoscopy in patients with chronic pain related to failed back surgery syndrome: a pilot study.

IntroductionIn the last two decades, ozone has emerged as a treatment for low back pain, applied by means of minimally invasive techniques.ObjectiveThe aim of this study is to assess the effect and safety of ozone therapy applied in the epidural space for chronic pain related to failed back surgery syndrome.MethodsThe investigators studied 13 sequential patients of both sexes, between 18 and 70 years old, with persistent chronic pain (more than six months) in the lumbar region and in the lower limbs related to failed back surgery syndrome (FBSS). Pain was classified as neuropathic and non-neuropathic regarding the topography (lumbar and lower limb), based on the DN4 (Douleur Neuropathique 4) questionnaire. The patients received the ozone gas in the lumbar epidural space via spinal-sacral endoscopy. Clinical evaluation was performed before, immediately after (24 hours), and 1, 3, and 6 months after intervention with visual analog scale and Oswestry Disability Index (ODI).ResultsOverall, the patients had 43.7% reduction of lumbar pain, 60.9% reduction in leg pain in six months followed by 44.0% of improvement in ODI. The reduction of pain and in the disability index was markedly greater in patients with non-neuropathic predominant pain, 95.2%, 80.6%, and 75.3% improvement in lumbar, leg pain, and ODI respectively, while neuropathic predominant pain patients experienced only 12.5%, 42.4%, and 20.9% improvement, also respectively. No neurological or infectious complications were observed acutely or during the follow-up. The present data suggests that epidural ozone might be a therapeutic option for persistent low back pain, especially in non-neuropathic predominant pain patients, but double-blind controlled studies are still required to prove its efficacy.

Effect of Ethnicity and Body Mass Index on the Distance From Skin to Lumbar Epidural Space in Parturients

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