• The Korean Journal of Pain
• /
• 제8권1호
• /
• pp.159-163
• /
• 1995

Accidental high epidural block is a rare but serious complication. It can result from many factors, which include the volume and concentration of drug, posture, puncture site, age, pregnancy or intra-abdominal mass, and patients' height and weight. We had a case of accidental high epidural block recently. This is a case report which was confirmed by an epiduragram. A healthy 50-year-old woman with a huge uterine myoma was scheduled for a total abdominal hysterectomy under continous epidural analgesia. Epidural catheterization was carried out smoothly. However, an unexpected hypotension was noticed after an epidural injection of 2% lidocaine 25 ml. Thereafter, the patient was intubated and her respiration was controlled during the operation. Using the 5mg of ephedrine, her blood pressure and pulse were well maintained. The scheduled operation was carried out for one hour uneventfully, but after the operation, she felt paresthesia on her hands in the recovery room. To differentiate between the high epidural and the subdural blocks. We injected 5 ml of a water soluble Niopam 300 through the catheter postoperatively. It was observed on the epiduragram that the catheter was placed in the epidural space. It was suggested that the high epidural block was induced from the widespread diffusion through the narrowed epidural space due to the engorgement of the epidural venous plexus by the patient's huge uterine myoma.

• The Korean Journal of Pain
• /
• 제9권1호
• /
• pp.264-267
• /
• 1996

Cervical epidural block can be useful in the management of acute and chronic pain of the head, neck, shoulder, and arm, for selected patients. In spite of the widespread use of cervical epidural blocks for pain, there is limited published data on the specific technique and complications regarding the procedure. High levels of epidural block do not appear to be associated with clinically significant circulatory or ventilatory changes unless the concentrations of local anesthetics used are great enough to produce paralysis of intercostal and phrenic nerves. However, high level of epidural block is associated with sympathetic block which may affect responses of circulatory and ventilatory systems. Accordingly, the possibility of major complications of cervical epidural block must be borne in mind. We experienced two cases of respiratory arrest during cervical epidural block with bupivacaine. This is a report regarding complications of cervical epidural block.

• The Korean Journal of Pain
• /
• 제10권2호
• /
• pp.285-290
• /
• 1997

Horner's syndrome is a well-recognized complication of regional analgesia of neck and shoulder region, and not often a complication of lumbar or low thoracic epidural block. Recently we experienced right Horner's syndrome accompanying paralysis of right upper extremity following lumbar epidural block in for an obstetric patient. Epidurography and MRI was performed to clarify the cause of unilateral high epidural block and cervical sympathetic block. Radiologic study demonstrated a loop formation of the epidural catheter and tip of catheter was located in right anterior epidural spaced(L1-2). The initial epidurogram revealed unilateral spreading of dye in the cervical region in right epidural space. A second epidurogram, 10 minutes following, showed dye filling in left epidural space, however spread of dye in left side was limited to lumbar and low thoracic region. We concluded the most probable cause of this unilateral high epidural block was due to misplacement of the catheter into the anterior epidural space.

• The Korean Journal of Pain
• /
• 제6권2호
• /
• pp.265-269
• /
• 1993

Subdural block is a rare but well recognized complication of epidural anesthesia. The placement of local anesthetics into the subdural space can lead to potentially life-threatening conditions. A healthy 46-year-old women underwent total abdominal hysterectomy under continuous lumber epidural anesthesia. The technical procedure for continuous epidural catheterization went smoothly without a single problem. However, signs of high epidural block such as apnea, cranial nerve paralysis and pupil dilatation developed gradually, about 20 minutes after the epidural injection of 2% lidocaine 20 ml through the epidural catheter. Such extensive segmental block can only be explained as the result of injection into subdural space even if it was not confirmed radiologically.

• The Korean Journal of Pain
• /
• 제9권1호
• /
• pp.260-263
• /
• 1996

High spinal block is a rare complication during epidural block, but it may result in serious events. 56-year-old man with gall stones was scheduled for cholecystectomy under general anesthesia. After operation, lumbar epidural catheterization was done at $T_{8-9}$ interspace for postoperative pain control. At the recovery room, initial bolus drug (0.1% bupivacaine 10 ml containing fentanyl $100{\mu}g$) was administered via epidural catheter and observed carefully. 15 minutes later, hypotension and bradycardia ouccurred. Hartman' solution was administered rapidly and ephedrine 5 mg was injected. 30 minutes after drug administration, loss of consciousness and respiratory arrest developed. Tracheal intubation was done immediately. Cardiovascular and respiratory functions were monitored continuously. The location of intrathecal catheter was confirmed by cerebrospinal fluid (CSF) seen in syringe after aspiration of catheter. The patient recovered gradually and was placed in the ward 4 hours after drug administration, without any problems. He was discharged 1 week later in good health.

• The Korean Journal of Pain
• /
• 제14권1호
• /
• pp.104-109
• /
• 2001

We describe the accidental injection of local anesthetics containing steroid into the subdural space during an attempted lumbar epidural injection for intractable radiculopathy in a patient with failed back surgery syndrome. A 24-year-old man complained of severe radiating pain to left lower extremity and showed a walking disturbance and severe lumbar scoliosis. The MRI finding was a left paramedian recurred disc herniation on L4-5 in a laminectomy state. Several therapeutic modalities such as epidural steroid injection, transforaminal injection, L2 root block, medication, and exercise therapy, etc failed. Initially, during epidural block at L4-5 under fluoroscopic guidance, a railroad track appearance appeared on epidurogram suggesting the presence of a subdural space. A second epidural block was tried at L5-S1. Following confirmation of epidural space upon epidurogram, 6 ml of 0.5% lidocaine including triamcinolone 40 mg was injected. The patient showed signs of the subdural injection including an unexpectedly high sensory block (T2) and a motor weakness of both lower extremities. Following this event, the severe radiculopathy and lumbar scoliosis were improved. Therefore, we conclude that subdural injection of steroid could be helpful in intractable radiculopathy, especially in the failed back surgery syndrome. However, it must be used cautiously with careful patient selection.

• The Korean Journal of Pain
• /
• 제23권3호
• /
• pp.202-206
• /
• 2010

Magnetic resonance image (MRI) is the most sensitive imaging test of the spine in routine clinical practice. Unlike conventional x-ray examinations and computed tomography scans, high-quality magnetic resonance images can be assured only if patients are able to remain perfectly still. However, some patients find it uncomfortable to remain still because of pain. In that condition, interlaminar cervical epidural injections can reduce pain and allow the procedure. When using air with the "loss of resistance" technique in epidural injections to identify the epidural space, there is the possibility of injected excessive air epidurally to mimic a herniated disc. We describe a case report of epidural air artifact in a cervical MRI after cervical epidural injections.

• The Korean Journal of Pain
• /
• 제25권1호
• /
• pp.43-46
• /
• 2012

The superior hypogastric plexus block (SHPB) is used for treating pelvic pain, especially in patients with gynecological malignancies. Various approaches to this procedure have been reported due to the anatomic obstacles of a high iliac crest or large transverse process of the $5^{th}$ lumbar vertebra. Here, we report a new technique of superior hypogastric plexus block using a unilateral single-needle approach to block the bilateral superior hypogastric plexus with a Tuohy needle and epidural catheter. We have confidence that this new technique can be another option in performing the SHPB when the conventional bilateral approach is difficult to perform.

• The Korean Journal of Pain
• /
• 제23권4호
• /
• pp.254-257
• /
• 2010

Background: Epidural steroid injection is an established treatment modality for intervertebral disc prolapse to radiculopathy. In cases where two levels of radiculopathy are present, two separate injections are warranted. Herein, we present our experience of management of such cases with a single epidural injection of local anaesthetic, tramadol and methylprednisolone, and table tilt for management of both radiculopathies. Methods: 50 patients of either sex aged between 35-65 years presenting with features of cervical and lumbar radiculopathic pain were included and were subjected to single lumbar epidural injection of local anaesthetic, tramadol and methylprednisolone, in the lateral position. The table was then tilted in the trendelberg position with a tilt of 25 degrees, and patients were maintained for 10 minuted before being turned supine. All patients were administered 3 such injections with an interval of 2 weeks between subsequent injections, and pain relief was assessed with a visual analogue scale. Immediate complications after the block were assessed. Results: Immediate and post procedural complications observed were nausea and vomiting (20%), painful injection site (4%), hypotension (10%) and high block (4%). Pain relief was assessed after the three injections by three grades: 37 (74%) had complete resolution of symptoms; 18% had partial relief and 8% did not benefit from the procedure. Conclusions: This technique may be used as an alternative technique for pain relief in patients with unilateral cervical and lumbar radiculopathies.

• The Korean Journal of Pain
• /
• 제2권1호
• /
• pp.66-71
• /
• 1989

It has been standard practice in many institutions to use a combination of a light general anesthesia and an epidural block for lower abdominal and pelvic surgery. This combination of a balanced anesthesia can provide various benefits to the patient such as less bleeding in the surgical field, the use of a lower concentration of general anesthetics, less muscle relaxant, and post operative pain management. However, there are several problems associated with hemodynamics such as bradycardia and hypotension etc. In order to block the pain of the high surgical area with a lumbar epidural puncture postoperatively, a large volume of local anesthetic is required and consequently an extensive blockade of sympathetic, sensory and motor functions can occur causing motor weakness, numbness and postural hypotension. Therefore, the patient is unable to have early ambulation postoperatively. In this study, thoracic epidural catheterization was undertaken to locate the tip of the catheter exactly at the surgical level for upper abdominal surgery, and was followed by general anesthesia. Twenty-one patients scheduled for upper abdominal surgery were selected. Fifteen of them had hepatobiliary operations and the remaining 6 had gastrectomies. Thoracic epidural punctures were performed mostly at T9-T10 (57.1%) and T8-T9. Neuromuscular blocking agents were not used in half of the cases and the, mean doses of relaxant were $3.5{\pm}1.0mg$ in gastrectomies, and $2.7{\pm}0.9mg$ in cases of hepatobiliary operation. Epidural morphine was injected 1 hour before the end of the operation for postoperative pain control. Eight patients did not require additional analgesics and the mean dose of epidural morphine was $2.2{\pm}0.9mg$, and 13 cases were given 0.125% epidural bupivacaine when patients complained of pain. Their initial doses of epidural morphine were $1.9{\pm}0.4mg$ and the mean duration of bupivacaine was 6 hours 20 minutes${\pm}40$ minutes. In conclusion. thoracic epidural analgesia is valuable to reduce postoperative pain in patients with upper abdominal surgery, However, it is not easy to maintain this balanced anesthesia with high epidural analgesia-and light general anesthesia for upper abdominal surgery because of marked hemodynamic changes. Therefore, further practice will be required.