Epidural fever

Epidural analgesia (EPA) is the most eff ective method of intrapartum pain relief and is considered to be very safe. Recently, it has been used in up to 34% of parturients with EPA and is also associated with maternal temperature elevations during labor. The mechanism of this epidural-associated fever remains incompletely understood. The most likely etiology seems to be non-infectious infl ammation caused by an epidural catheter. However, some authors deny this association. They theorize it is caused by selection bias only, as EPA is more often required by women with more painful and prolonged or more complicated labor, where temperature elevation is due to other causes. They point out that in some studies, fever was correlated to EPA only with concurrent placental infl ammation. Maternal fever, despite the cause, either infectious or non-infectious origin, carries important clinical and public health implications. Further research that evaluates maternal epidural status and its infl uence on maternal or neonatal fever could improve sepsis evaluation and lead to worldwide decrease of unnecessary antibio tic exposure. Key words: epidural fever – epidural analgesia – thermoregulation

Evaluation of Dexmedetomidine Co-Administered with Neostigmine and Bupivacaine for Postoperative Epidural Analgesia in Lower Limb Orthopaedic Surgeries – A Study from Maharashtra, India

BACKGROUND Addition of adjuvants to the neuro axial blocked helps prolongate the duration and quality of analgesia and anaesthesia. The safety and efficacy of drugs dexmedetomidine and neostigmine have been less commonly studied. We wanted to compare post-operative analgesia, haemodynamics, and side effects if any in this study. METHODS Combined spinal - epidural anaesthesia was performed in 60 patients who underwent lower limb surgeries of less than 2 hrs. The patients were given the drug epidurally post-surgery. Group I, II and III were given 10 ml of 0.25 % bupivacaine alone, with 1 microgram per kg of neostigmine and with 0.5 milligram per kg of dexmedetomidine and 1 microgram per kg of neostigmine, respectively. 50 mg tramadol intravenous was kept as rescue analgesic. Parameters which predict haemodynamics, assessment of pain, period of analgesia, demand for rescue analgesia and the chances of side effects were noted over the next ten hrs. RESULTS To conclude, epidural analgesia is the most preferred analgesia these days in management of lower limb orthopaedic surgery’s post-operative pain. When bupivacaine was combined with neostigmine and dexmedetomidine as a neuraxial adjuvant, it prolonged the post-operative analgesia significantly without increasing the side effects of those drugs. The combination of two drugs proved better than the use of single drug alone. CONCLUSIONS Combination of neostigmine and dexmedetomidine when used as a neuraxial adjuvant, significantly prolonged the duration of post-operative analgesia by 274.13 4.539 in lower limb orthopaedic cases compared to neostigmine alone that was 176.23 ± 3.441. KEY WORDS Epidural, Neostigmine, Dexmedetomidine, Orthopaedic Surgeries, Post-Operative Analgesia

Case of an Epidural Hematoma Following a Lumbar Epidural Steroid Injection in a Patient Taking Aspirin and Duloxetine

Background: Epidural hematoma (EDH) formation is one of the most feared complications associated with epidural steroid injections (ESI) as persons may experience permanent neurological deficits including paraplegia. The risk of developing an EDH following an ESI is expectedly increased in the context of concomitant anticoagulant and/or antiplatelet agent usage. While there exists significant evidence for the risks associated with anticoagulant and anti-platelet agents in epidural procedures, the anti-platelet effects of serotonin reuptake inhibitors medications (SRIs) in particular have received less attention. Case Report: A 70-year-old female with numerous cardiovascular comorbidities (on aspirin 81 mg daily for primary prevention of coronary artery disease) and fibromyalgia (on duloxetine 60 mg daily) underwent a fluoroscopically guided L3-L4 level interlaminar ESI for lumbar radiculopathy. Starting 6 hours post-procedure, the patient started to manifest severe back pain, bowel and bladder incontinence, and paraplegia. Magnetic resonance imaging (MRI) of the thoracic and lumbar revealed a large epidural fluid collection compressing the spinal cord and cauda equina. Unfortunately, a delay in care prevented the patient from receiving neurosurgical decompression. Conclusion: SRI associated coagulopathy may predispose to EDH formation by diminishing platelet aggregation. Therefore, weaning these medications, as dictated by the latest guidelines, should be highly considered, if possible and reasonable, to ensure favorable safety profiles for ESI procedures, especially in persons with multiple risk factors. Regardless of appropriate strategies to mitigate ESI associated bleeding risks, proceduralists should always maintain a healthy index of suspicion for EDH formation in the post-procedural phase as early diagnosis and intervention may prevent devastating neurological outcomes. Key words: Epidural hematoma, paraplegia, aspirin, duloxetine

Interventional Spine Considerations for Radiosensitivity in a Patient with Ligase IV Syndrome

Background: Patient selection plays a critical role in any interventional pain practice. Rare conditions may not always have clearly established guidelines for interventional pain procedures. Ligase IV (LIG4) syndrome is a rare inherited condition with a wide variety of features, including radiosensitivity.. Case Report: A 36-year-old woman with a known history of LIG4 syndrome presented with an acute on chronic left L5 and S1 radiculopathy from a large L5-S1 central disc herniation. In an effort to minimize radiation exposure, an ultrasound (US)-guided caudal epidural steroid injection was used to help manage her radicular leg pain. Conclusion: Interventional spine providers should be aware of rare radiosensitive conditions and strive to offer appropriate treatment alternatives. While limitations do exist, emerging US-guide spine procedures hold a distinct advantage for patients with radiosensitivities. Key words: Epidural steroid injection, Ligase IV syndrome, radiculopathy, radiology, radiosensitivity, ultrasound

Comparison of Epidural Pressure Decrease Pattern According to Different Lumbar Epidural Approaches

Background: During lumbar epidural injection (LEI) using a midline approach, we might encounter failure of identifying the epidural space owing to an equivocal or absent loss of resistance (LOR) sensation. The reason for such absence of LOR sensation has been suggested as paucity of midline ligamentum flavum, paravertebral muscle, and cyst in the interspinous ligament of the lumbar spine. Despite its low specificity, LOR is the most commonly used method to identify the epidural space. Objectives: The purpose of this study was to analyze lumbar epidural pressure decrease patterns and identify factors contributing to this pressure decrease. Study Design: Prospective randomized trial. Setting: An interventional pain management practice in South Korea. Methods: This prospective study included 104 patients receiving LEI due to lumbar radiculopathy. A midline or paramedian approach of LEI was determined with randomization. Among various factors, gender, age, body mass index (BMI), and diagnosis were analyzed using a subgroup that included 60 cases of only a paramedian approach. Results: Grades I, II (abrupt decrease), and III (gradual decrease) were found as patterns of epidural pressure decrease. Abrupt pressure decrease was more frequently observed in the paramedian group (P < 0.001). Age, gender, BMI, and diagnosis did not show any significant difference in frequencies between abrupt and gradual pressure decrease. Limitations: We could not match LOR sensation with epidural pressure decrease shown in the monitor. Conclusions: This study demonstrates that abrupt pressure decrease occurs more frequently with the paramedian approach. However, age, gender, BMI, or diagnosis did not affect the incidence of epidural pressure decrease. Key words: Epidural, paramedian, midline, pressure decrease

Pre-Contrast Injection Multiple Needle Placement Technique: An Alternative Method for Performing Challenging Transforaminal Epidural Steroid Injections for Radicular Pain

A subpedicular transforaminal epidural steroid injection (TFESI) at the L5-S1 level can be technically challenging due to lumbar spondylosis. As described in the cases below, in challenging cases, placing multiple needles (normally 2 needles, occasionally 3 needles) before injecting the radiocontrast dye can improve the chances of depositing the steroid in the area of pathology responsible for pain. This will, of course, add to the risk of the procedure due to multiple needles being close to the nerve root. On balance, however, it may be less risky than not placing the steroid at the appropriate pathological site, which may fail to provide pain relief leading to unnecessary suffering and, in some cases, surgical intervention. However, if the spread of contrast medium and the subsequent steroid injection through the first needle is satisfactory, then the other needles can be removed without injecting. The “pre-contrast injection multiple needle placement” technique has been used by the author on multiple occasions and 3 cases are described below. Key words: Epidural steroid injection, transforaminal epidural injection, sciatica, radicular pain, multiple needle technique

Particulate Epidural Steroid may not be Detectable on Magnetic Resonance Imaging

Lumbar epidural steroid injections (LESI) have become a staple in the interventional pain physician’s armamentarium. For patients with radicular symptomatology, LESIs provide substantial pain relief with a favorable safety profile. Adverse effects, although rare, can occur as with any procedure. One of the most dreaded complications is the development of an epidural hematoma, which should be readily seen on Magnetic Resonance Imaging (MRI). It has been previously thought that particulate steroid injections should also be seen on MRI potentially obscuring a physician’s clinical judgment. We present two cases where patients underwent an uncomplicated LESI and subsequently went for a lumbar MRI that displayed no injectate in the epidural space. Key words: Epidural steroid injection, magnetic resonance imaging, particulate injection, hematoma

Labor Pain Pathophysiology and Analgesic Options

Regional neuraxial blocks, such as spinal and epidural anesthetics, are used for most women in the United States for labor pain. They are the most effective methods for preserving consciousness and the ability to participate in the second stage of labor. Regional neuraxial blocks may be augmented by combining spinal and epidural techniques, postlabor nonopioids and opioids, distraction therapy, and patient-controlled analgesia. In addition, several alternative analgesic methods have been recently recommended for labor pain without consensus on their respective efficacies, including yoga, exercise during pregnancy, acupuncture, hypnotism, hydrotherapy, and therapeutic massage. This review focuses on current updates and recent trends in labor pain management, the pathophysiology of labor pain, and the basic mechanisms supporting the efficacies of systemic, inhalation, neuraxial, and local analgesia during labor. Key words: epidural, fentanyl, labor pain, local anesthetic, spinal analgesia

Labor Pain Pathophysiology and Analgesic Options

Regional neuraxial blocks, such as spinal and epidural anesthetics, are used for most women in the United States for labor pain. They are the most effective methods for preserving consciousness and the ability to participate in the second stage of labor. Regional neuraxial blocks may be augmented by combining spinal and epidural techniques, postlabor nonopioids and opioids, distraction therapy, and patient-controlled analgesia. In addition, several alternative analgesic methods have been recently recommended for labor pain without consensus on their respective efficacies, including yoga, exercise during pregnancy, acupuncture, hypnotism, hydrotherapy, and therapeutic massage. This review focuses on current updates and recent trends in labor pain management, the pathophysiology of labor pain, and the basic mechanisms supporting the efficacies of systemic, inhalation, neuraxial, and local analgesia during labor. Key words: epidural, fentanyl, labor pain, local anesthetic, spinal analgesia

Lumbar Subarachnoid Hematoma Following an Epidural Blood Patch for Meningeal Puncture Headache Related to the Implantation of an Intrathecal Drug Delivery System

Persistent meningeal puncture headache (MPH) is a known complication following both intentional and unintentional puncture of the dura mater. We present a case of persistent MPH following implantation of an intrathecal drug delivery system (IDDS). Two separate epidural blood patches (EBP) were performed under radiographic guidance with contrast visualization of the epidural space on postoperative days 16 and 28, respectively. The case was complicated by the development of a symptomatic lumbar subarachnoid hematoma diagnosed on postoperative day 35. The patient subsequently underwent a laminectomy, evacuation of the hematoma, and explanation of the IDDS. This case illustrates a potential unique morbidity associated with the EBP in a patient with an IDDS. The report concludes with a brief review of MPH followed by a discussion of possible mechanisms underlying this complication. Key words: Epidural blood patch, post dural puncture headache, meningeal puncture headache, complications, spinal subarachnoid hematoma, intrathecal drug delivery, implantable pain therapies, ziconotide, tinnitus, pain, pain procedures