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ANESTH ANALG
1 YXS.67.17i9
MD,
Tzilenty-one h i d r e d eighty two consecutizle lzirribar epidural injections zcwe studied to determine the incidence of
iriaiiziertent subdural hlock retrcispectiuel!/. A sitbtliiral
block is defined as an estensiz1e neurd block in the absence
of S I ~ J U Y ~ C pzriicturc,
~ ~ J O ~ ~ that is out of proportion to the
amount of local anesthetic injected. Siibdural injection is a
Kathy Kristof,
BSN,
Olga Ivankovich,
MD,
Methods
During the 30-month study period (March 1984September 1986), 2182 lumbar epidural steroid injections were performed at the Pain Center for various
forms of low back pathology. During this period any
patient whu exhibited any untoward or unpleasant
176
LUBENOW ET AL.
ANESlH ANALG
1988:67 1 7 5 9
side effects from the injection (e.g., headache, hypotension, nausea, motor or extensive sensory block)
was identified for follow-up. The patients ranged in
age from 17 to 86 years and each received a single
epidural injection via a lumbar interspace, between
L1 and L5. The blocks were performed by an attending anesthesiologist or a supervised resident using
bupivacaine, 4-6 cc of 0.25% or 6-8 cc of 0.125%, in
combination with methylprednisolone acetate 80-120
mg (Depo Medrol, Upjohn Company, Kalamazoo,
Michigan). The epidural space was identified by the
loss-of-resistance technique. After a careful negative
aspiration test, injections were performed with disposable 17- or 18-gauge Touhy point needles. Aspiration was routinely done before, during, and after
each injection. After the injections, the patients were
observed for approximately 1 hour before discharge
from the center.
Records were evaluated in the following manner
for the presence or absence of clinical findings consistent with subdural injection. I n any patient exhibiting a complication as mentioned above, a detailed
description of the complication and clinical findings
was obtained and recorded in the patients chart at
the time of occurrence. Clinical findings were classified into two levels of criteria, major and minor.
Findings considered major criteria were: 1)a negative
aspiration test, or 2) an unexpected widespread sensory block after epidural injection. The three minor
criteria were: 1)a delayed onset of 10 minutes or more
of a sensory or motor nerve block, 2) a variable motor
blockade occurring, despite use of low doses of
bupivacaine, or 3 ) sympatholysis out of proportion to
the administered dose of local anesthetic. A positive
subdural injection was judged to have occurred in
both of the major criteria and at least one minor
criteria were present. With the criterion of negative
aspiration test we excluded any patient who had a
wet tap before the apparent successful epidural injection. All of these records of morbid events were then
retrospectively evaluated by one reviewer (TL) to
determine if criteria for a subdural block were
present. From 38 potential subdural injections, 18
were judged by an additional investigator (ADI) as
having met the criteria for a subdural injection.
Results
Eighteen patients met the criteria for a subdural
block, establishing an incidence of 0.82%. One patient exhibited all three minor criteria, while an
additional seven patients displayed two of the minor
criteria (Table 1).
Discussion
Epidural nerve blocks occasionally exhibit an atypical
pattern of spread. This may be caused by relative
overdose or accidental injection into the subdural or
subarachnoid spaces. Several investigators have
demonstrated radiological confirmation of catheters
present in the subdural space, especially in cases of
massive epidurals (8,12). A recent report describes
the ease of intentional subdural puncture and further
suggests that accidental subdural puncture may occur
in attempted epidural block even in experienced
hands (13). Consequently, it appears that accidental
subdural injection probably occurs more frequently
than previouslv recognized.
ANESTH ANALG
177
1988,67 175-9
0.25
T12-Ll
T4
0.25
L4-5
L2
0.25
L34
T4
0.125
L34
T2
5
6
0.125
0.125
8
8
L34
L34
T10
TI2
0.125
L34
T6
8
9
0.125
0.125
8
8
L34
L45
TI2
T8
10
0.125
L2-3
T10
11
14
0.125
0.25
0.125
0.125
8
6
8
8
L M
L34
L1-2
L4-5
L10
T10
T6
T10
15
0.125
L2-3
T4
16
0.125
L34
T9
17
0.25
0.25
6
6
L45
L3-4
c4
T2
12
13
18
Onset
time Recovery
(min) time (hr)
Motor
block
Degree of
hypotension
Dense, LE
bilateral
Dense, LE
bilateral
Moderate,
LE bilateral
Moderate,
LE bilateral
None
Mild LE
bilateral
Dense, LE
bilateral
None
None
40%)
10
3.5
None
10
50%
Mild, LE
bilateral
None
None
None
Dense, Le
bilateral
Moderate,
LE bilateral
Dense, LE
bilateral
None
None
Previous
back
surgery
Major Minor
criteria criteria
met
met
2
4.0
Yes, fusion
L 4 5 , 5-s1
No
-7
10
3.0
NO
50%
20
6.0
No
-7
None
None
5
5
3.0
2.0
No
No
None
3.0
No
30%
50%
30
30
2.0
2.0
None
10
4.0
No
Yes, LAM
x 2
Yes, LAM
None
30%
404
None
10
5
20
5
2.0
1.5
3.0
3.0
Yes, LAM
No
Yes, LAM
No
2
2
2
1
1
2
I
50%
3.0
No
None
2.0
N0
50%
50%
10
15
3.0
3.5
No
No
1
1
2
2
1
2
178
ANESTH ANALG
1988.67:17'59
LUBENOW ET A1
surgery are more prone to accidental subdural injection. This is likely because the anatomy may be
altered secondary to scarring and retraction, producing a thin epidural and wide subdural space.
Epidural blocks seem more likely to produce accidental subdural injection than do spinal blocks. This
may be due to differences in technique and the type
of needle used. Epidural injections use a large, blunttipped, long-bevel needle that is introduced very
slowly, sometimes a millimeter at a time. In contrast,
for a subarachnoid puncture, a thinner, sharper needle is introduced, usually at a much faster rate. It is
more likely that the blunt needle tip will pierce the
dura without piercing the arachnoid. The large opening of the epidural needle may straddle the subdural
and epidural, allowing part of the local anesthetic to be
injected into the subdural space while some of it could
be deposited in the epidural space (Fig. 1). This
partitioning of anesthetic may explain the difference in
degree of symptoms. Patients experiencing profound
sensory and motor block obviously would have had
more anesthetic deposited in the subdural space.
Another explanation regarding the difference in
symptomatology may relate in part to the anatomic
distribution of sensory, sympathetic, and motor
nerve fibers. The anterior nerve roots carry motor and
sympatlietic nerve fibers, while sensory fibers are
within posterior nerve roots. Because the subdural
space has more potential capacity posteriorly and
laterally, one should expect a sensory block. Meanwhile, a motor or sympathetic block would be present
only if local anesthetic traveled anteriorly within this
ANESTH ANALG
19SS;h7 175-9
179
References
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