Use of tissue adhesive to secure spinal epidural stimulating electrodes: technical note.

Securing spinal cord stimulating electrodes (SCS) within the epidural space is often a challenging task. Complications of the technique include development of cerebrospinal fluid leaks and electrode migration. We report four patients who underwent a limited laminectomy for placement of epidural spinal cord stimulating electrodes to relieve pain and/or spasticity. Suturing electrodes to the dura was not possible, and a tissue adhesive was used. Two-year follow-up shows no migration of the electrodes. Tissue adhesive of "fibrin glue" is a viable alternative for securing epidural SCS electrodes.     

Combined spinal epidural anaesthesia: a new technique

A new technique is described for delivering combined spinal epidural anaesthesia. The disadvantages of the needle-through-needle technique and the two-needle techniques are discussed. The new technique is a modification of the two-needle technique. The spinal needle is introduced and once cerebrospinal fluid is seen at the hub of the needle, the stylet is replaced. The epidural space is then identified and the epidural catheter placed. The spinal needle obturator is then removed and intrathecal injection performed. This technique avoids problems associated with placing an epidural catheter after an intrathecal injection and the potential problem of placing a spinal needle when an epidural catheter has already been placed. This technique requires further evaluation.     

Evaluation of a spinal needle locking device for use with the combined spinal epidural technique

Success of the 'needle-through-needle' technique for combined spinal epidural analgesia requires the immobilisation of the spinal needle during intrathecal injection. A device that achieves this was evaluated in 200 labouring women, randomly allocated to receive a combined spinal epidural using the CSEcure(R) (SIMS Portex, UK) locking needle or a conventional, non-locking technique. Data collection included the incidence of dural click as the spinal needle penetrated the dura mater, presence of cerebrospinal fluid in the spinal needle hub and the number of technical failures with the spinal component. Successful dural punctures with the spinal needle were similar for locking and non-locking needles (99.0 vs. 98.0%; p = 0.55), despite a small but significant reduction in dural click with the locking needle compared with the non-locking technique (97. 0 vs. 84.7%; p < 0.01). Although not statistically significant, there was a higher number of technical failures, mainly due to spinal needle movement, in the non-locking group (9.1 vs. 3.1%; p = 0.08). The locking needle device may be a useful alternative to conventional methods for combined spinal epidural analgesia.     

Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis

STUDY DESIGN: A prospective review of patients undergoing epidural catheter placement after anterior spinal fusion and instrumentation for adolescent scoliosis was performed. Data were collected using visual analog pain scores reflecting the patients' perception of their pain control. OBJECTIVES: To present the authors' technique for epidural catheter placement and dosing protocol, and to demonstrate the results from postoperative pain control after anterior spinal instrumented fusion for 10 consecutive patients. SUMMARY OF BACKGROUND DATA: The literature regarding the benefits of epidural catheters after spinal surgery is contradictory, even with controlled studies comparing epidural catheters with intravenous morphine patient-controlled anesthesia. The authors believe that this lack of consensus stems from varied epidural dosing protocols and techniques in catheter placement, which they have witnessed anecdotally at their own institution. This prompted the authors to develop and refine a standardized dosing and catheter placement protocol for pain control after spinal surgery. METHODS: Epidural catheters were placed intraoperatively before wound closure, then removed on postoperative Day 5. Dosing consisted of fentanyl (1 microg/kg) and hydromorphone (5 microg/kg) diluted in preservative-free saline (0.2 mL/kg). After surgery, dosing consisted of 0.1% ropivacaine and hydromorphone (10 microg/ml) continuously infused at 0.2 mL/kg/hour. Postoperative pain control was assessed on each postoperative day using a visual analog pain scale with choices ranging from 0 to 10. RESULTS: The arithmetic mean of the median pain scores after surgery was 2.1. The mean of the maximum pain scores for the 5 days was 4.1. Three patients required an epidural bolus and a 20% increase in the epidural infusion rate. One patient was judged to be excessively sleepy, so the epidural infusion rate was decreased by 20%. Pruritus requiring diphenhydramine developed in three patients. No other adverse effects related to epidural analgesia were noted. No catheters were accidentally pulled out or disconnected. CONCLUSION: By following the dosing protocol described, epidural catheters can be used safely and effectively to control postoperative pain after anterior instrumentation and spinal fusion for adolescent scoliosis.     

Comparison of continuous spinal and epidural analgesia for pain relief in labour

We have compared continuous spinal analgesia with continuous epidural analgesia for pain relief in labour. Twenty-six women were randomly allocated to receive either epidural 0.25% bupivacaine 5-10 ml via a 20 gauge catheter inserted through a 16 gauge Tuohy needle or intrathecal 0.25% bupivacaine 0.5-1.0 ml via a 32 gauge catheter inserted through a 24 gauge Sprotte needle. This was supplemented with fentanyl 5-10 mcg (spinal) or 1 mcg per kg (epidural) if analgesia was unsatisfactory. Outcome was measured by the success and timing of the procedure, time to analgesia, amount of drug given, visual analogue scoring of pain relief by the patient and an observer and degree of motor block. Onset time and dosage were significantly reduced in the continuous spinal group. Two catheters failed to feed in the spinal group. One catheter became displaced in each group. Pain relief was satisfactory in all patients and none had post-dural puncture headache. Continuous spinal analgesia may offer significant advantages over epidural analgesia but technical difficulties remain with the present equipment. The reasons for the withdrawal of the spinal catheters in the United States of America are discussed.     

Epidural infusion pressure in degenerative spinal disease before and after epidural steroid therapy.

The analgesic mechanism of epidural steroids in reducing pain associated with degenerative spinal disease (DSD) is poorly understood. We report increased inline epidural infusion pressure in patients with DSD and assess whether this phenomenon is affected by administration of an epidural steroid injection. We collected data during epidural placement for routine surgery or epidural steroid therapy. Using a 17-gauge Tuohy needle, with patients in the right lateral decubitus position, loss of resistance to 2 mL of saline identified the epidural space. Two minutes later the needle was attached to saline-filled tubing connected to a pressure transducer (Baxter PX 260 pressure monitoring kit with Truwave TM disposable pressure transducer). In the first part of the study, 4 successive boluses of 3 mL of local anesthetic were administered at a rate of 6 mL/min to 15 patients (age 47 +/- 6 yrs) with radicular back pain and magnetic resonance imaging (MRI) or computed tomography (CT) evidence of DSD, and to 8 control patients with no history of back pain (age 44 +/- 5 yr) while inline epidural infusion pressure was measured. In the second part of the study 44 patients with low back pain and MRI or CT evidence of DSD presenting to the pain clinic were infused with 8 mL of 0.125% bupivacaine and 40 mg of methylprednisolone (20 mg/mL) at a rate of 6 mL/min while inline epidural infusion pressure was measure and recorded. This was repeated 3 wk later. Initially, DSD patients had significantly increased infusion pressures over normals, which most likely reflects outflow resistance or obstruction. A significant decrease in inline epidural infusion pressure was observed after epidural steroid treatment. This change in pressure may indicate efficacy from epidural steroid injection. IMPLICATIONS: During injection into the epidural space we observed increased resistance in patients with degenerative spinal disease. This resistance was significantly less when measured 3 wk after an epidural steroid injection. This change in pressure may indicate efficacy from epidural steroid injection.     

Combination therapy of radiofrequency lumbar facet joint denervation and epidural spinal cord stimulation for failed back surgery syndrome

An 81-year-old woman with failed back surgery syndrome (FBSS) was treated using a combination of percutaneous radiofrequency (RF) lumbar zygapophysial joint denervation and epidural spinal cord stimulation (SCS). She had undergone a staged laminectomy for narrowing of the spinal canal from L1 to S1 and degenerative spondylolisthesis at the L3-4 level. Postoperatively, in addition to low back pain (LBP) induced by dynamic motion, she began to experience intractable leg pain with a burning sensation, presumably caused by damage to the cauda equina. She initially underwent RF lumbar zygapophysial joint denervation for the LBP and subsequently underwent SCS via dual electrode leads for the leg pain. This combination therapy of RF denervation and SCS relieved the LBP almost entirely and relieved the leg pain by approximately 50%. The combination of these two minimally invasive interventions is particularly effective for severe leg pain and LBP in elderly patients or medically compromised cases with contraindications against general anesthesia, as well as in patients with FBSS.     

Revision of a spinal column stimulator lead without lead replacement

OBJECTIVE: The objective of this case report is to describe a technique for percutaneous spinal column stimulator (SCS) revision without lead replacement. CASE REPORT: A 35-year-old woman with a single-lead SCS implanted for control for left lower extremity pain underwent revision of her SCS lead because of loss of stimulation paresthesia in the area of pain. Using the method described, the lead was revised without lead replacement. CONCLUSION: SCS leads can be revised without placement of a new lead.     

Spinal cord stimulation for a woman with complex regional pain syndrome who wished to get pregnant

A woman with complex regional pain syndrome (CRPS) in the right lower extremity who wished to discontinue medications to get pregnant underwent implantation of a spinal cord stimulation system (SCS). An electrode lead was placed at Th_10–11 in the epidural space, accessed via the L_2–3 interspace with a paramedian approach, and a pulse generator was implanted in the left buttock. She kept the SCS on 24 h a day. After she had experienced several chemical abortions, finally she got pregnant via artificial insemination. She had an uneventful delivery of a healthy baby by cesarean resection under spinal anesthesia. In a patient with CRPS who has an implanted SCS system and wishes to get pregnant, the electrode lead into the low thoracic epidural space should be accessed via the high lumbar intervertebral space in consideration of a future requirement for spinal or epidural anesthesia for cesarean section. The generator should be placed in the buttock to prevent impairment of the SCS system being caused by the enlarged abdomen during pregnancy. Although we were apprehensive of adverse effects owing to the electromagnetic field force and change of blood flow in the pelvic viscera, our patient had a successful delivery. SCS is a favorable option for patients with CRPS who wish to get pregnant.     

Epidural injection of lidocaine reduces the response to dural puncture accompanying spinal needle insertion when performing combined spinal-epidural anesthesia

During placement of needles for combined spinal-epidural anesthesia (CSEA), patients may experience pain, pressure, paresthesia, or discomfort during skin and deeper injection of local anesthetic, needle impingement on periosteum, dural puncture by the spinal needle, and insertion of the epidural catheter. We investigated the incidence of perception of and spontaneous verbal and motor responses to insertion of a spinal needle through the dura mater and pia mater and the effect of injecting lidocaine into the epidural space through the epidural needle before inserting the spinal needle through the meninges. Forty-three patients presenting for elective cesarean delivery under CSEA were studied. After localization of the epidural space using loss of resistance to air using a 17-gauge Tuohy needle, either 3 mL preservative free normal saline or 3 mL lidocaine 2% plus epinephrine 1:200,000 was injected through the Tuohy needle. "Needle through needle" dural puncture was performed 1 min later using a 27-gauge Whitacre pencil-point needle. At the moment of dural puncture, 2 (9%) parturients given lidocaine and 17 (81%) parturients given saline (P < 0.005) responded to dural puncture by spontaneously moving (33%), spontaneously vocalizing (62%), or, in response to direct questioning, by acknowledging (76%) having perceived sensation during thecal penetration. This study reveals that dural puncture by a Whitacre 27-gauge pencil-point needle inserted through a Tuohy epidural needle sited using loss of resistance to air causes involuntary movement, spontaneous vocalization, or is perceived by the majority of patients presenting for cesarean delivery under CSEA and that lidocaine injected into the epidural space before dural puncture largely eliminates these responses and sensations.     

Labor epidural placement in a woman with a cervical spinal cord stimulator

A 37-year-old female, gravida 1 para 0, in active labor at term, with a cervical spinal cord stimulator in situ, presented for epidural analgesia for labor. She had received the cervical spinal cord stimulator some 30 months before, to treat chronic regional pain syndrome I. She was taking no medication, and was thin but otherwise healthy. The cervical spinal cord stimulator electrodes entered the C7-T1 interspace, and their end was in the epidural space at the C3 level. The electrodes were fixed to a cervical spinous process, crossed the midline high in the back and then went down the left side of her back parallel to her spine to the generator, which was in her buttock. The electrode cable could be felt high on the left side of her back, but not in her lumbar region. After consultation, it was felt safe and reasonable to proceed with labor epidural anesthesia. The procedure took place with the patient sitting, using a standard reusable 17-gauge Tuohy needle. Subsequent analgesia was acceptable. The patient also observed about 20 min after receiving the epidural medication that suddenly she could move her right hand more easily and that it felt warm. Her labor and delivery proceeded uneventfully. The spinal cord stimulator continued to function well throughout the entire process. She noticed that the feeling in her right hand returned to baseline after the delivery.     

Huge epidural hematoma after surgery for spinal cord stimulation

Summary Objective and importance. Spinal epidural haematoma (SEH) following implantation of an epidural spinal cord electrode is a very rare complication but one that must not be overlooked. This case is unusual because of the almost holocord extension of the haematoma and the excellent recovery obtained by prompt surgical treatment.Clinical presentation. A 69 years old man with normal serum coagulation parameters was submitted to spinal cord stimulation (SCS) for chronic pain syndrome. After a minimal L1 laminotomy the patient developed paraplegia due to a large haematoma at D4-L2.Intervention. Surgical removal of the entire clot by a D4-L2 laminectomy was performed immediately.Conclusion. Large epidural haematoma can result from SCS and this complication may be cured by appropriate and prompt surgery.     

A case of intractable lower limb pain treated successfully by spinal cord stimulation with an electrode inserted retrogradely

We experienced a case of intractable lower limb pain successfuly treated by spinal cord stimulation with an electrode inserted retrogradely. The patient is a 32 year-old-man suffering from intractable lower limb pain on the area innervated by the sciatic nerve from unidentified cause for about 4 years. We tried various treatments such as epidural block, S 1 nerve-root block including thermocoagulation technique, opiate. Nevertheless, his pain became worse further. Therefore, 6 years after the onset of the symptom, we tried to stimulate electrically the nerve with an electrode inserted retrogradely. This method of spinal cord stimulation produced enough pain reduction. The method of retrograde insertion of an electrode for spinal cord stimulation seems to be a good way to treat intractable pain of the area innervated by a single spinal nerve.     

The placement of the epidural catheter at the predicted site by electrical stimulation test

More accurate segmental and sagittal positioning of the epidural catheter tip is required for the success of continuous epidural analgesia, spinal cord monitoring, and percutaneous epidural spinal cord stimulation. We examined the usefulness of an electrical stimulation test for verifying the proper placement of the epidural catheter tip at the predicted site in the posterior epidural space by using a locally developed epidural catheter with electrodes at its tip. The test included the observation of segmental bilateral muscle twitches and the patient's report of feeling in the region stimulated by moving the epidural catheter electrode back and forth and changing the direction of the bevel of the Tuohy needle. The success rate of midline placement at the required spinal segment was significantly more frequent (99%; P < 0.001) in the group (n = 289) receiving the electrical stimulation test compared with the group (n = 277) not receiving the test (success rate 57%). The results indicate the usefulness of this method. We concluded that the electrical stimulation test is effective for verifying the proper placement of the catheter electrode tip. IMPLICATIONS: Ideally the epidural catheter tip should be positioned in the posterior epidural space near the midline. We concluded that the electrical stimulation test is effective for verifying the proper placement of the catheter electrode tip.     

Techniques of epidural block

Epidural blocks are used for relief of chronic pain, labour pain and postoperative pain as well as for surgical anaesthesia. The effect can be targeted at the insertion level which can be from cervical spine level all the way to the sacral hiatus in the case of a caudal epidural block. Catheter insertion means doses can be repeated and the effect maintained. This contrasts with the typical single-shot spinal/subarachnoid injection primarily used for surgical anaesthesia. Specifically avoiding dural puncture also contrasts with the spinal’s simple endpoint of detecting CSF. Accurate epidural needle insertion is therefore technically more difficult. The variety of methods available to identify if the needle tip is in the epidural space highlights this much less certain endpoint. With epidural injections, drug solutions need to physically spread to access each intended nerve root. This makes epidurals less reliable than spinals, where simply depositing the solution in the CSF rapidly enables it to bathe all the nerve roots encountered. Serious risks such as direct damage to nerve tissue, infection and epidural haematoma are shared with spinal anaesthesia but may be more likely with epidural techniques. Epidural needles are wider bore and more likely to damage tissue and vessels. They are sometimes directed close to the spinal cord itself. In-dwelling catheters can move and traumatize vessels and act as a focus for infection. Despite these potential drawbacks, careful selection, skilled placement and management mean patients can safely derive the intended benefits and epidurals and caudal blocks continue to be popular.     

The efficacy of surgically placed epidural catheters for analgesia after posterior spinal surgery

Posterior spinal fusion for correction of scoliosis is a major procedure for which the provision of satisfactory, safe postoperative analgesia is often a problem. One possible solution involves the placement of epidural catheters under direct vision by the surgeon at the end of the procedure, followed by an epidural infusion of local anaesthetic with or without an opioid. Despite its simplicity, this technique has not been reported as being consistently successful. We report an observational study of the analgesia achieved with surgically placed epidural catheters and of the reasons for the failure of the technique. Fourteen consecutive patients undergoing posterior spinal fusion had epidural catheters placed by the surgeon and had radio-opaque dye injected down the catheter 15 min before their routine postoperative chest X-ray. Analgesia was assessed at 0, 6, 12 and 24 h after surgery using visual analogue scores. Five patients had inadequate pain control; none of these patients had dye visible in the epidural space. Seven patients had dye visible in the epidural space; all of these cases had satisfactory analgesia. In two cases, dye was observed in the paravertebral gutters; both of these patients had satisfactory postoperative analgesia. This small pilot study suggests that correctly placed 'surgical' epidural catheters are capable of providing good analgesia after posterior spinal fusion and that misplaced catheters, seen in a large proportion of patients, are associated with inadequate analgesia.     

Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy

Eighteen subjects with intractable pain due to reflex sympathetic dystrophy (RSD) underwent treatment by epidural spinal cord stimulation (SCS). All the patients had previously undergone multiple sympathetic blocks and/or surgical sympathectomy with either no results or only temporary therapeutic effects. Four subjects did not experience any beneficial effects during a 1-week trial and the electrode was removed, and 14 patients had the system internalized surgically. In 4 cases two separate systems (electrode + pulse generator) were implanted, in order to cover distant areas of the body involved by the disease (neck, shoulders, upper extremities, trunk and lower extremities). Follow-up varies from 4 to 14 months. In the implanted group, pain relief was absent in 3 patients, minimal in 1, moderate in 5 and good in 6. Pain relief was strictly limited to the body parts covered by the parasthesiae induced by SCS. In 3 patients, SCS produced visible changes in the swelling of the painful extremities. None of the patients was made neurologically worse. In 7 patients there were technical problems related to electrode breakage or migration, change in the pattern of paresthesiae and poor connection due to body fluid infiltration. All the problems were corrected surgically under local anesthesia. SCS has some value in the management of refractory RSD pain in selected cases. Because of the limited series and follow-up, its value in the comprehensive management of RSD requires further investigation.     

The predictive value of sympathetic block for the success of spinal cord stimulation

OBJECTIVE: The purpose of this study was to assess the predictive value of response to sympathetic blockade (SB) on the success rate of spinal cord stimulation (SCS) in patients with complex regional pain syndrome. METHODS: We performed a retrospective study on 23 patients with complex regional pain syndrome who underwent both SB and subsequent SCS trials in the past 3 years at the Massachusetts General Hospital Pain Center, Boston, MA, and Walter Reed Army Medical Center, Washington, DC. Fifteen of these patients underwent permanent placement of an SCS device, and pain relief at 1- and 9-month follow-up was recorded. RESULTS: Among the 23 patients included in the study, those having transient pain relief with SB were more likely to have a positive SCS trial: all 13 with positive SB had good pain relief during the trial, compared with only 3 of the 10 with negative SB (100% versus 30%, P < 0.001). Among the 10 patients with negative SB, 7 noted poor pain relief during the trial despite adequate coverage, and they did not undergo placement of a permanent device. Among the patients who underwent permanent placement of an SCS device, those who received good pain relief with SB were more likely to have greater than 50% pain relief at 1-month follow-up (100% versus 33%, P = 0.029) and 9-month follow-up (87.5% versus 33.3%, P = 0.15). CONCLUSION: We conclude that patients with good response to SB before SCS are more likely to have a positive response during their SCS trial and long-term pain relief after placement of permanent SCS device.     

Techniques of epidural block

Epidural blocks are used for relief of chronic pain, labour pain and postoperative pain as well as for surgical anaesthesia. Effect can be targeted at the insertion level which can be from cervical spine level all the way to the sacral hiatus in the case of a caudal epidural block. Catheter insertion means doses can be repeated and the effect maintained. This contrasts with the typical single-shot spinal/subarachnoid injection primarily used for surgical anaesthesia. Specifically avoiding dural puncture also contrasts with the spinal's simple endpoint of detecting CSF. Accurate epidural needle insertion is therefore technically more difficult. The variety of methods available to identify if the needle tip is in the epidural space highlights this much less certain endpoint. With epidural injections, drug solutions need to physically spread to access each intended nerve root. This makes epidurals less reliable than spinals, where simply depositing the solution in the CSF rapidly enables it to bathe all the nerve roots encountered. Serious risks such as direct damage to nerve tissue, infection and epidural haematoma are shared with spinal anaesthesia but may be more likely with epidural techniques. Epidural needles are wider bore and more likely to damage tissue and vessels. They are sometimes directed close to the spinal cord itself. In-dwelling catheters can move and traumatize vessels and act as a focus for infection. Despite these potential drawbacks, careful selection, skilled placement and management mean patients can safely derive the intended benefits and epidurals and caudal blocks continue to be popular.     

Spinal cord stimulation for nonspecific limb pain versus neuropathic pain and spontaneous versus evoked pain

OBJECTIVE: To compare the outcome of spinal cord stimulation (SCS) in patients with nonspecific limb pain versus patients with neuropathic pain syndromes and in patients with spontaneous versus evoked pain. METHODS: A retrospective review of 122 patients accepted for treatment with SCS between January 1990 and December 1998 was conducted. All patients first underwent a trial of SCS with a monopolar epidural electrode. Seventy-four patients had a successful trial and underwent permanent implantation of the monopolar electrode used for the trial (19 patients), or a quadripolar electrode (53 patients), or a Resume quadripolar electrode via laminotomy (2 patients). RESULTS: Of the 74 patients, 60.7% underwent implantation of a permanent device and were followed for an average of 3.9 years (range, 0.3-9 yr). Early failure (within 1 yr) occurred in 20.3% of patients, and late failure (after 1 yr) occurred in 33.8% of patients. Overall, 45.9% of patients were still receiving SCS at latest follow-up. Successful SCS (>50% reduction in pain for 1 yr) occurred in 83.3% of patients with nonspecific leg pain, 89.5% of patients with limb pain associated with root injury, and 73.9% of patients with nerve neuropathic pain. SCS was less effective for the control of allodynia or hyperpathia than for spontaneous pain associated with neuropathic pain syndromes. Third-party involvement did not influence outcome. There was a lesser incidence of surgical revisions when quadripolar leads were used than with monopolar electrodes. CONCLUSION: SCS is as effective for treating nonspecific limb pain as it is for treating neuropathic pain, including limb pain associated with root damage.