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Study Design.: Prospective, double-blind randomized controlled trial. Objective.: If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery. Summary of Background Data.: Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief. Materials and Methods.: In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery. Results.: Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred. Conclusion.: This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 48-year-old man presenting with left low back pain radiating to the left thigh after performing a heavyweighted exercise. Examination revealed positive straight leg raise and slump tests. MRI showed a fluid collection in the left lateral epidural space likely representing an epidural hematoma, causing severe spinal canal stenosis at L2-3.

The epidural space is commonly accessed via an interlaminar or transforaminal approach to administer corticosteroids for radicular pain. An alternative is a transarticular approach, which may be considered when conventional access to the epidural space is either not desired or contraindicated. This approach has been described in the cervical spine using computed tomography guidance but not fluoroscopic guidance. We describe a cervical transarticular approach to the epidural space under fluoroscopy and review the computed tomography–guided literature. The risks of transarticular epidural injections are likely low given that when performed prudently, they avoid direct contact with the vertebral artery, spinal medullary arteries, venous plexus, spinal cord, and nerve roots. [ABSTRACT FROM AUTHOR]

Study Design: Basic science study.Objective: The aim of this study was to examine whether epidural fat tissue (EFT) transplantation can prevent epidural adhesion after laminectomy more efficiently than subcutaneous fat tissue (SFT) transplantation.Summary Of Background Data: Epidural adhesion is almost inevitable after laminectomy. Although many materials have been used to prevent adhesion, none has been widely accepted. As EFT is an ectopic fat tissue located on the dura mater and there is no adhesion between EFT and the dura mater, we focused on the efficacy of EFT for adhesion prevention.Methods: We examined the differences in histology and gene expression between EFT and SFT of mice. We performed laminectomy at the 10th thoracic level and immediately transplanted EFT or SFT to the dura mater in mice. At 6 weeks after transplantation, we performed histological and gene expression analyses and evaluated the adhesion tenacity. In addition, we examined the characteristic differences between human EFT and SFT.Results: The adipocytes of EFT were significantly smaller than those of SFT in mice and humans. The gene expression of inflammatory cytokine and fibrosis-related factors was significantly higher in SFT than in EFT. At 6 weeks after transplantation, the percentage of the remaining fat area over the dura mater was significantly greater in the EFT group than in SFT group, and the adhesion tenacity score was significantly lower in the EFT group than that in the SFT group. An RNA sequencing analysis revealed 1921 differentially expressed genes (DEGs) between human EFT and SFT, and a Gene Ontology term associated with the inflammatory response was most highly enriched in SFT.Conclusion: EFT has different molecular and histological profiles from SFT and EFT grafting is more effective for epidural adhesion prevention than conventional SFT transplantation after laminectomy in a mouse model.Level of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Background: The traditional loss-of-resistance (LOR) technique for thoracic epidural catheter placement can be associated with a high primary failure rate. In this study, we compared the traditional LOR technique and dynamic pressure-sensing (DPS) technology for primary success rate and secondary outcomes pertinent to identifying the thoracic epidural space., Methods: This pragmatic, randomized, patient- and assessor-blinded superiority trial enrolled patients ages 18 to 75 years, scheduled for major thoracic or abdominal surgeries at a tertiary care teaching hospital. Anesthesiology trainees (residents and fellows) placed thoracic epidural catheters under faculty supervision and rescue. The primary outcome was the success rate of thoracic epidural catheter placement, evaluated by the loss of cold sensation in the thoracic dermatomes 20 minutes after injecting the epidural test dose. Secondary outcomes included procedural time, ease of catheter placement, the presence of a positive falling meniscus sign, early hemodynamic changes, and unintended dural punctures. Additionally, we explored outcomes that included number of attempts, needle depth to epidural space, need for faculty to rescue the procedure from the trainee, patient-rated procedural discomfort, pain at the epidural insertion site, postoperative pain scores, and opioid consumption over 48 hours., Results: Between March 2019 and June 2020, 133 patients were enrolled; 117 were included in the final analysis (n = 57 for the LOR group; n = 60 for the DPS group). The primary success rate of epidural catheter placement was 91.2% (52 of 57) in the LOR group and 96.7% (58 of 60) in the DPS group (95% confidence interval [CI] of difference in proportions: -0.054 [-0.14 to 0.03]; P = .264). No difference was observed in procedural time between the 2 groups (median interquartile range [IQR] in minutes: LOR 5.0 [7.0], DPS 5.5 [7.0]; P = .982). The number of patients with epidural analgesia onset at 10 minutes was 49.1% (28 of 57) in the LOR group compared to 31.7% (19 of 60) in the DPS group ( P = .062). There were 2 cases of unintended dural punctures in each group. Other secondary or exploratory outcomes were not significantly different between the groups., Conclusions: Our trial did not establish the superiority of the DPS technique over the traditional LOR method for identifying the thoracic epidural space ( Clinicaltrials.gov identifier: NCT03826186)., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Percutaneous epidural adhesiolysis (PEA) is an effective treatment for patients with lumbar radiculopathy unresponsive to single steroid injections. Various approaches and instruments have been developed to access these lesions. This study aimed to evaluate the utility of a retrodiscal approach for epidural adhesiolysis using a WHIP catheter®. This retrospective study was conducted at Bundang Seoul National University Hospital, reviewing cases from January to December 2022. Forty-seven patients diagnosed with lumbar radiculopathy, aged 20 to 80 years, who underwent PEA with the WHIP catheter® were included. Outcomes assessed Numeric Rating Scale (NRS) for pain, Patients' Global Impression of Change (PGIC) scores, and the incidence of procedure-related complications. Follow-up evaluations occurred at 1, 3, and 6 months post-procedure. Among 47 patients, 41 completed the study, showing significant pain reduction at all follow-up points: 1 month (N = 41, 1.32 ± 1.68, P < .001), 3 months (N = 31, 1.90 ± 2.14, P < .001), and 6 months (N = 30, 2.50 ± 2.30, P < .001). PGIC scores indicated that 40% of the patients reported substantial improvement at one-month post-procedure. The complications were minimal, with only one case of intradiscal injection and 2 cases of vascular uptake. The retrodiscal approach PEA using the WHIP catheter® demonstrated significant efficacy in pain reduction with minimal safety concerns for patients with lumbar radiculopathy. These findings suggest that this procedure is a viable option for patients who are unresponsive to conservative treatment. However, the retrospective nature of this study and its small sample size necessitate further prospective controlled studies to confirm our results and establish long-term outcomes., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 17-year-old boy with typical neurodevelopment presented with 3 months of lower-limb weakness without a history of trauma. Physical examination, plain radiography and a T2-weighted MRI revealed a port-wine stain over the lumbar region, significant scoliosis below the cervical segment, and a multifocal flow void sign (steal phenomenon) from epidural space to dorso-lumbar spine, respectively (Figure 1). CT angiography identified an enhancing dorsal vascular mass with involvement of the spinal canal including destruction of the vertebral body determined to be extensive arteriovenous shunts on digital subtraction angiography (DSA) (Figure 2).

Case: A 75-year-old man, who was a carpenter, experienced neck pain and numbness in the upper and lower extremities while hammering a nail and later developed a gait disturbance. Initial magnetic resonance imaging (MRI) revealed a tumorlike mass at the C5 epidural space compressing the spinal cord. The first diagnosis was cervical epidural hematoma. The following day, the patient’s symptom deteriorated. A second MRI revealed an increase in the size of the mass, and surgery was performed. Operative findings included a juxtafacet cyst. Conclusion: Repeated job-related load on the facet joint in this patient caused rapid progression of facet cysts, causing myelopathy similar to an epidural hematoma. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective study of 36 liver cirrhosis patients presenting with spondylodiscitis.Objectives: The aim of this study was to analyze the characteristics of spondylodiscitis in the presence of liver cirrhosis and furthermore, to evaluate the outcome of surgery in this specific group of patients.Summary Of Background Data: The incidence of haematogenous spondylodiscitis is increasing. The coexistence of liver cirrhosis makes the course of the disease more aggressive.Methods: A total of 36 liver cirrhosis patients presented with haematogenous spondylodiscitis. The onset of infection, clinical course and outcomes of management were reviewed retrospectively.Results: The associated comorbidities were cardiac in 17 patients, diabetes in 19, renal insufficiency in 16, and another focus for infection in nine cases. Neurological deficits were found in 24 patients (67%) and fever in 15 cases. Nine patients had septic manifestations. The lumbar spine was affected in 25 patients (69%). Noncontiguous spinal infection was found in nine patients (25%) and epidural abscess in 24 individuals. The preoperative C-reactive protein was elevated in all cases. The causative organism was most commonly Staphylococcus aureus (17 patients). A combined anteroposterior approach was necessary in 28 patients and a minimallly invasive surgery was performed in 30 cases. In-hospital mortality was 14% (5 patients). The neurological improvement rate was 82%. The postoperative antibiotic therapy was taken for more than 8 weeks in 22 patients. In 15 patients, a combination of antibiotics was necessary.Conclusion: Spinal infection in the presence of liver cirrhosis is challenging. The rate epidural abscess formation is relatively high. Early diagnosis remains the main cornerstone in the management and the indication for surgery should be carefully considered. Minimally invasive techniques should be used when possible to minimize complication rate, and higher amounts of intraoperative blood loss should be expected.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Case: This case report describes a 46-year-old woman undergoing right-sided L5 to S1 decompression who received liposomal bupivacaine (LB) for postoperative analgesia and developed unintentional epidural anesthesia with symptoms mimicking cauda equina syndrome. The patient's symptoms resolved 72 hours postoperatively, approximately the length that LB typically lasts. At the 16-month follow-up, the patient demonstrated complete neurological function with no lower extremity strength or sensation deficits. Conclusions: Tracking of LB into the epidural space after lumbar surgery may cause transient epidural anesthesia with symptoms that mimic cauda equina syndrome. [ABSTRACT FROM AUTHOR]

Background: Vertebral hemangioma (VH) is one of the most common benign spinal tumors and can be aggressive in some cases. While most aggressive VHs have typical radiographic features, including vertical striations, a honeycomb appearance, and/or a "polka-dot sign" in computed tomography (CT) scans, cases with atypical features might complicate diagnosis. This study aimed to determine the range and frequency of these atypical features.Methods: In this retrospective study, to identify the typical and atypical features of aggressive VH, pretreatment CT and magnetic resonance imaging (MRI) were reviewed retrospectively by 1 radiologist and 1 orthopaedic surgeon. Percutaneous biopsies were performed to confirm the VH in atypical cases.Results: A total of 95 patients with aggressive VHs were treated in our hospital from January 2005 to December 2017. Thirty-four (36%) of the lesions showed at least 1 atypical radiographic feature: 16 patients (17%) had a vertebral compression fracture, 11 patients (12%) had expansive and/or osteolytic bone destruction without a honeycomb appearance and/or "polka-dot sign", 11 patients (12%) had obvious epidural osseous compression of the spinal cord, 12 patients (13%) had involvement of >1 segment, 9 patients (10%) had a VH centered in the pedicle and/or lamina, and 8 patients (8%) had atypical MRI signals. Forty-three patients underwent percutaneous biopsies, which had an accuracy of 86%.Conclusions: Based on radiographic analysis, aggressive VH can be classified as typical or atypical. More than one-third of aggressive VH lesions may have at least 1 atypical feature. CT-guided biopsies are indicated for these atypical cases. [ABSTRACT FROM AUTHOR]

Study Design: The effect of cetuximab on the development of epidural fibrosis (EF) was assessed using immunohistochemical methods as well as antibodies for CD105 and osteopontin (OPN).Objective: The goal of this study was to assess of EGFR inhibition for the postoperative treatment of fibrosis.Summary Of Background Data: EF is one of most common causes of failed back surgery syndrome, which occurs after laminectomy. Numerous causes and mechanisms have been proposed to explain its development after laminectomy. Many agents have been tested to prevent the development of EF. EGFR, a multi-functional transmembrane glycoprotein, causes cell growth, proliferation, and EF by interacting with epidermal growth factor and TGF-β1. The inhibition of postoperative fibrosis using cetuximab, an epidermal growth factor receptor blocker, is theoretically possible. However, this has not been tested to date.Methods: Sixteen Wistar-Albino rats were divided into two groups, namely, control and cetuximab groups. L1-2 laminectomy alone was performed in both groups, and topical cetuximab was applied to the treatment group. After 6 weeks, rats were sacrificed and examined histopathologically and immunohistochemically; EF tissue was also graded. Statistical significance was accepted at P < 0.05.Results: Fibroblast counts and fibrosis density, determined by histopathologic examination, and EF, according to immunohistochemical assessment based on CD105, were found to be higher in the treatment group than in the control group, and this was statistically significant (P < 0.001). Based on OPN staining, the results were consistent with classical methods, and no significant difference was detected among the groups (P = 0.358).Conclusion: Our study revealed that cetuximab inhibits the development of EF and that CD105, and not OPN, is a reliable marker for grading EF. In addition, cetuximab did not result in toxic, systemic side effects in surrounding tissues.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Background: Detecting loss of resistance (LOR) can either be taught with dedicated simulators, with a cost ranging from &OV0556;1500 to 3000, or with the 'Greengrocer's Model', requiring simply a banana.Objectives: The purpose of this study was to compare three dedicated epidural puncture training simulators and a banana in their ability to simulate LOR. Our hypothesis was that there was a difference between the four simulators when comparing the detection of LOR.Design: Single-blinded, randomised, controlled study.Setting: Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Switzerland.Participants: Fifty-five consultant anaesthesiologists.Interventions: The participants were asked to insert an epidural catheter in four different epidural puncture training simulators: Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan), Lumbar Epidural Injection Trainer (Erler-Zimmer, Lauf, Germany), Normal Adult Lumbar Puncture/Epidural Tissue (Simulab Corp., Seattle, Washington, USA) and a banana. The simulators were placed in identical boxes to blind the participants.Main Outcome Measures: The primary outcome was the detection of LOR rated on a 100-mm visual analogue scale, in which 0 mm represented 'completely unrealistic' and 100 mm represented 'indistinguishable from a real patient'.Results: The mean visual analogue scale scores for LOR in the four simulators were significantly different: 60 ± 25 mm [95% confidence interval (CI), 55 to 65 mm], 50 ± 29 mm (95% CI, 44 to 55 mm), 64 ± 24 mm (95% CI, 58 to 69 mm) and 49 ± 32 mm (95% CI, 44 to 54 mm); P less than 0.001, Friedman test.Conclusion: Two of the three dedicated epidural simulators were rated more realistic in detecting LOR than the banana, but some participants preferred the banana to the other three simulators. Given the relative cost of a banana compared with a dedicated simulator, we suggest that a banana be used to teach the technique of LOR for epidural puncture.Trial Registration: KEK Nr: Req-2015-z087. [ABSTRACT FROM AUTHOR]

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Study Design: Multicenter case-control study.Objective: To characterize the pathogenesis of idiopathic spinal epidural lipomatosis (SEL).Summary Of Background Data: SEL is often associated with the history of steroid use or endocrine disorders; however, the pathogenesis of idiopathic SEL remains poorly understood.Methods: Sixteen patients who underwent lumbar decompression surgery due to severe idiopathic SEL were included in the study (L group, 15 men and 1 woman; mean age, 71.5 yrs). Fifteen patients without SEL, who underwent decompression surgery for lumbar canal stenosis, were selected as controls (C group, 14 men and 1 woman; mean age, 70.3 yrs). The following parameters were analyzed in these two groups: body mass index (BMI), medical history, histology, the size of adipocytes in the epidural fat (EF) tissues, and the expression level of the transcripts for adiponectin, leptin, tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, and IL-8.Results: The mean BMI of the L group was significantly higher than that of the C group (29.1 vs. 25.2 kg/m, P = 0.006), and there was a significant correlation between BMI and the width of EF in both groups. The average adipocyte size in the EF was significantly larger in the L group than in the C group (2846.8 vs. 1699.0 μm, P = 0.017). Furthermore, the expression levels of the transcripts for TNF-α and IL-1β in the L group were significantly higher than those in the C group [2.59-fold increase (P = 0.023) and 2.60-fold increase (P = 0.015), respectively].Conclusion: Our data suggest that the pathogenesis of idiopathic SEL is associated with obesity. In addition, the increased expression of two major inflammatory cytokines in the EF in the L group may indicate that SEL is causally related to chronic inflammation.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Short-term epidural analgesia is effective for postoperative pain, procedural pain, trauma pain, and labor pain. This article describes the skills, procedures, and nursing care required for removing a short-term, temporary epidural catheter. [ABSTRACT FROM AUTHOR]

The laboratory risk indicator for necrotizing fasciitis (LRINEC) score was 9, indicating high suspicion for necrotizing fasciitis. B Introduction: b Monomicrobial Klebsiella pneumoniae necrotizing fasciitis is rare in North America. The strain that causes necrotizing fasciitis is thought to be hypermucoviscous or hypervirulent K. pneumoniae (hvKP). hvKP is responsible for increasing numbers of cases within the US due to the prevalence of travel and immigration. [Extracted from the article]

Study Design: Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with neurologic deficits secondary to metastatic epidural spinal cord compression (MESCC). Clear understanding of these factors will guide surgical decision-making by helping to elucidate which patients are more likely to benefit from surgery and how surgeons can increase the probability of neurologic and functional restoration.Summary Of Background Data: Surgical spinal cord decompression has been shown to improve neurologic function in patients with symptomatic MESCC. However, prognostication of neurologic improvement after surgery remains challenging, owing to sparse data and complexity of these patients.Methods: PubMed and Embase databases were searched for relevant publications. PRISMA Statement guided publication selection and data reporting. GRADE guidelines were used for evidence quality evaluation and recommendation formulation.Results: Low-quality evidence supports the use of the duration and severity of neurologic deficit as predictors of neurological recovery in patients with MESCC. Low-quality evidence supports the use of thoracic level of compression and previous irradiation as adverse predictors of neurological recovery. Nearly all of the AOSpine Knowledge Forum Tumor members who responded to the survey agreed that ambulation with assistance represented a successful surgical result and that duration of ambulation loss and the severity of weakness should be considered when trying to predict whether surgery would result in restoration of ambulation.Conclusions: Review of literature and expert opinion support the importance of duration of ambulation loss and the severity of neurologic deficit (muscle strength, bladder function) in prediction of neurologic recovery among patients with symptomatic MESCC. Efforts to reduce the duration of ambulation loss and to prevent progression of neurologic deficits should be made to improve the probability of neurologic recovery.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Background: Ultrasound imaging of the spine is thought to reduce failed and traumatic neuraxial procedures. Most of the evidence supporting this assumption has been produced in the context of an expert sonographer performing the ultrasound assessment, and it remains unknown whether this technique is useful when used by multiple individual operators.Objective: To invesstigate the impact of preprocedural spinal ultrasound on the ease of insertion of labour epidurals by a group of trainees. We hypothesised that the ultrasound-assisted technique would improve the ease of insertion when compared with the conventional palpation technique.Design: A randomised controlled trial.Setting: Academic hospital in Toronto, Canada.Participants and Intervention: A group of 17 second-year anaesthesia residents and five anaesthesia fellows underwent a training programme in ultrasound assessment of the spine. Parturients with easily palpable lumbar spines were randomised to either ultrasound or palpation group. Residents and fellows performed both the assessment (ultrasound or palpation) and the epidural procedure.Main Outcome Measures: Primary Outcome: ease of insertion of epidural catheter composed of the time taken to insert the epidural catheter, number of interspace levels attempted and number of needle passes.Secondary Outcomes: total procedural time (assessment and insertion); first pass success rate; number of attempts required to thread the epidural catheter; failure of epidural analgesia; and patient satisfaction.Results: We analysed 128 epidural catheter insertions (residents 84, fellows 44). There was no difference in median (interquartile range, IQR) epidural insertion time between the ultrasound and palpation groups [174 (120 to 241) versus 180 (130 to 322.5) s, respectively; P = 0.14]. The number of interspace levels attempted and needle passes were also similar in both groups. The total procedural time was longer in the ultrasound group.Conclusion: The use of preprocedural spinal ultrasound by a cohort of anaesthesia trainees did not improve the ease of insertion of labour epidural catheters in patients with easily palpable lumbar spines, as compared with the traditional palpation technique based on anatomical landmarks.Trial Registration: ClinicalTrials.gov identifier: NCT00996905. [ABSTRACT FROM AUTHOR]

Study Design. A retrospective case-control study. Objective. To evaluate the safety and efficacy of the ventral epidural filling technique in lumbar interlaminar epidural steroid injection (ESI). Summary of Background Data. The ventral epidural space can be a preferred target in ESI because it contains many spinal pain generators. However, there have been few studies regarding the ventral epidural space filling technique in interlaminar ESI. Methods. This study involved a retrospective analysis of 150 consecutive patients treated with the ventral epidural filling technique in interlaminar ESI (ventral ESI) and a control cohort of 150 consecutive patients treated with the dorsal epidural filling technique in interlaminar ESI (conventional ESI). The visual analogue scale for leg pain, the visual analogue scale for back pain, and the Oswestry Disability Index were compared at preinjection and 2 weeks, 6 weeks, 6 months, and 1 year postinjection. The groups were compared with regard to repeated injection or surgery within 1 year after the initial procedure. The fluoroscopic time and the procedure-related complications including severe pain (visual analogue scale score > 7) during injection, dural puncture (subdural contrast spread), headache, neurological symptoms, and infection were also compared. Results. There were no significant differences in leg pain, back pain, or Oswestry Disability Index improvement at each visit between the ventral ESI group and the conventional ESI group (all P > 0.05). The numbers of repeat injections and surgical procedures were not significantly different between 2 groups ( P = 0.262 and 0.385, respectively). There were no significant differences in severe pain at injection ( P = 0.326), dural puncture ( P = 0.428), headache ( P = 0.393), neurological symptom ( P = 0.419), or infection ( P = 0.500) between the 2 groups. The fluoroscopic time was significantly shorter in ventral than in conventional ESI ( P < 0.000). Conclusion. The ventral epidural filling technique can be performed safely and more easily during lumbar interlaminar ESI. The clinical results and procedure-related complications with this technique were comparable with those seen with conventional interlaminar ESI. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective case report.Objective: The objective of this article is to report a spinal epidural hematoma (SEH) due to shock wave.Summary Of Background Data: SEH is an infrequent condition. Most of SEH's are spontaneous. We have reported an SEH traumatic case without bone lesions due to exploding truck tire. A different category of blast injuries is the one related with exploding tyres. Shock waves are the main mechanism that is responsible for blast injuries. We are presenting the first report of acute SEH due to shock wave.Methods: A 33-year-old man was brought to the emergency department with complaints of weakness and numbness of the upper extremities. There was an epidural high-signal density without osseous lesion in computerized tomography from the level of C2 to C5, and there was a T2-weighted hyperintense lesion in magnetic resonance imaging from the level of C2 to C5 with compression of the spinal cord the anterior and posterior which proved to be an SEH.Results: The patient was discharged from the hospital with complete neurologic recovery.Conclusion: SEH should be considered possible in the blast injury. SEH condition carries a significant risk of morbidity and mortality without early recognition and rapid management.Level Of Evidence: 5. [ABSTRACT FROM AUTHOR]

Background: Epidural steroids are more effective if administered in the anterolateral epidural space. It follows that the ability to administer local anesthetics in the ipsilateral anterolateral epidural space should likewise improve their efficacy for postoperative epidural analgesia. Questions/purposes: We determined whether epidural catheters can be reliably placed in the ipsilateral anterolateral epidural space using the paramedian approach. Motor responses elicited by electrical stimulation were used to identify lateralization. We further assessed what angle of needle insertion resulted in successful catheter placement. Methods: Epidural anesthesia was performed in 68 patients undergoing total joint arthroplasty using the paramedian approach. FDA-approved electrical stimulating catheters were utilized, and the muscle response elicited was recorded with each centimeter of advancement of the catheter. Digital photographs were taken to determine the angle of needle entry. Results: Using the paramedian approach, an ipsilateral twitch was noted in 66 of the 68 patients (two had no response). With advancement of the catheter (2-5 cm), the twitch remained ipsilateral in 56 but disappeared in 12. The mean angle of the epidural needle was 40° to the midline. All patients had successful epidural anesthesia as evidenced by no response to surgical incision. Conclusions: Epidural catheters can be reliably placed onto the side of surgery using the paramedian approach. This provides the opportunity to more selectively administer epidural local anesthetics. Level of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Rationale: Subcutaneous and epidural abscesses following epidural injection are a serious but rare complication. Epidural abscesses are typically caused by Staphylococcus aureus bacterial infection. In this case presented here, the causative bacterium was Enterococcus faecalis., Patient Concerns: A 67-year-old woman having chronic lower back and right leg pain with past history of 20 years of rheumatoid arthritis, diabetes mellitus, and osteoporosis (T-score: -2.7) visited the outpatient pain clinic. Magnetic resonance imaging (MRI) revealed L4-5 right central disc extrusion with inferior migration. We performed a continuous epidural block for 7 days without complications. After 10 days, she presented with worsened low back pain, erythematous skin change on the lower back, chilling, and elevated serum acute phase reactants., Diagnosis: The diagnosis was subsequently confirmed by MRI suggesting subcutaneous and epidural abscess. Blood and pus cultures showed the growth of E. faecalis., Interventions: Pigtail catheter drainage was performed and intravenous antibiotics (ampicillin-sulbactam) targeting E. faecalis were applied for 3 weeks. Oral antibiotics (amoxicillin/potassium clavulanate) were applied for 6 weeks after discharge., Outcomes: At the 2-month follow-up, improvement in both the clinical condition and serum acute phase reactants levels were noted., Lessons: Epidural injection can lead to a subcutaneous abscess that is further extended into the epidural space. One of the key factors is the presence of comorbid conditions, including diabetes mellitus and prolonged steroid usage due to rheumatoid arthritis., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: There is a long history of neuromodulation of the spinal cord after injury in humans with recent momentum of studies showing evidence for therapeutic potential. Nonrandomized, mechanistic, hypothesis-driven, small cohort, epidural stimulation proof of principle studies provide insight into the human spinal circuitry functionality and support the pathway toward clinical treatments., Recent Findings: Individuals living with spinal cord injury can recover motor, cardiovascular, and bladder function even years after injury using neuromodulation. Integration of continuous feedback from sensory information, task-specific training, and optimized excitability state of human spinal circuitry are critical spinal mechanisms. Neuromodulation activates previously undetectable residual supraspinal pathways to allow intentional (voluntary) control of motor movements. Further discovery unveiled the human spinal circuitry integrated regulatory control of motor and autonomic systems indicating the realistic potential of neuromodulation to improve the capacity incrementally, but significantly for recovery after severe spinal cord injury., Summary: The discovery that both motor and autonomic function recovers with lumbosacral spinal cord placement of the electrode reveals exciting avenues for a synergistic overall improvement in function, health, and quality of life for those who have been living with the consequences of spinal cord injury even for decades., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The article presents information on the study related to the development of an animal model of rats for the study of biochemical changes in the epidural space after intervertebral disc herniation. It mentions that epidural lavage and analysis of cytokines was performed by using autologous nucleus pulposus (NP). It concludes that this model may prove to be beneficial for the study of biochemical processes by which NP induces inflammation-induced nerve root irritation and radiculopathy pain.

Background: Intraoperative nausea and vomiting (IONV) is a common symptom during cesarean section (CS) delivery causing significant discomfort to patients. Combined spinal and epidural anesthesia (CSEA) can provide both intraoperative anesthesia and postoperative analgesia. During CSEA, it is reasonable to administer local anesthetics to the epidural space before patient complaints to compensate for the diminished effect of spinal anesthesia. Therefore, we hypothesized that intraoperative epidural administration of 2% mepivacaine would reduce the incidence of IONV., Methods: Patients who were scheduled for elective CS were randomly allocated to 2 groups. Patients and all clinical staff except for an attending anesthesiologist were blinded to the allocation. After the epidural catheter was inserted at the T11-12 or T12-L1 interspace, spinal anesthesia was performed at the L2-3 or L3-4 interspace to intrathecally administer 10 mg of 0.5% hyperbaric bupivacaine. Twenty min after spinal anesthesia, either 5 mL of 2% mepivacaine (group M) or saline (group S) was administered through an epidural catheter. Vasopressors were administered prophylactically to keep both the systolic blood pressure ≥ 80 % of the baseline value with the absolute value ≥ 90 mm Hg and the mean blood pressure ≥ 60 mm Hg. The primary endpoint was the incidence of IONV. The secondary endpoints were degree of nausea, the degree and incidence of pain, and Bromage score., Results: Ninety patients were randomized, and 3 patients were excluded from the final analysis. There was no significant difference in the incidence of IONV between the groups (58% in group M and 61% in group S, respectively, P = .82). In contrast, the incidence and degree of intraoperative pain in group M were significantly lower compared to group S. In addition, the incidence of rescue epidural administration of fentanyl (18% vs 47%) or mepivacaine (2.3% vs 25%) for intraoperative pain was lower in group M compared to group S., Conclusions: Our results indicate that epidural administration of 2% mepivacaine 20 minutes after spinal anesthesia does not reduce the incidence of IONV in CS under CSEA. However, intraoperative epidural administration of 2% mepivacaine was found to improve intraoperative pain., Competing Interests: All authors declare that they have no conflict of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Epidural needle insertion is usually a blind technique where the rate of adverse events depends on the experience of the operator. A novel ultrasound method to guide epidural catheter insertion is described.Methods: An ultrasound transducer (40 MHz, a -6 dB fractional bandwidth of 50%) was placed into the hollow chamber of an 18-gauge Tuohy needle. The single crystal was polished to a thickness of 50 μm, with a width of 0.5 mm. Tissue planes were identified from the reflected signals in an A-mode display. The device was inserted three times into both the lumbar and thoracic regions of five pigs (average weight, 20 kg) using a paramedian approach at an angle of 35-40°. The epidural space was identified using signals from the ligamentum flavum and dura mater. Epidural catheters were placed with each attempt and placement confirmed by contrast injection.Results: The ligamentum flavum was identified in 83.3% of insertions and the dura mater in all insertions. The dura mater signal was stronger than that of the ligamentum flavum and served as a landmark in all epidural catheter insertions. Contrast studies confirmed correct placement of the catheter in the epidural space of all study animals.Conclusions: This is the first study to introduce a new ultrasound probe embedded in a standard epidural needle. It is anticipated that this technique could reduce failed epidural blocks and complications caused by dural puncture. [ABSTRACT FROM AUTHOR]

Background and objective: Epidural volume extension via a combined spinal-epidural is the enhancement of a small-dose intrathecal block by an epidural injection of physiological saline solution. We evaluated the effect of epidural volume extension on the combined spinal-epidural technique of providing spinal anaesthesia for Caesarean section with hyperbaric or plain 0.5% bupivacaine. Methods: Patients (n = 240) with height >163cm received 9mg and patients <163cm received 8mg of bupivacaine. Each study drug was combined with 20 μg fentanyl. Using the combined spinal-epidural technique, Group A (n = 60) received hyperbaric bupivacaine, and Group B (n = 60) received hyperbaric bupivacaine and 10 mL saline epidurally 5 mm after subarachnoid injection. Group C (n = 60) received plain bupivacaine and Group D (n = 60) received plain bupivacaine and 10 mL saline epidurally 5 mm after subarachnoid injection. An anaesthetist blinded to the anaesthetic solution injected examined the level of analgesia by the pinprick method and motor block with the modified Bromage scale for 30 mm after subarachnoid injection, during the intraoperative period and subsequently every 15 mm for 135 mm during the recovery period. Results: Time to reach a sensory block at T4 was significantly shorter in Groups C and D than in Groups A (P = 0.003 and 0.017) and B (P = 0.006 and 0.048), respectively. During the intraoperative period, sensory block levels were significantly higher in Group C than in Group A. Recovery was similar in all groups; only onset was faster in Groups C and D. Conclusion: There was no effect of epidural volume extension on the profile of spinal anaesthesia with the combined spinal-epidural technique for Caesarean section using hyperbaric or plain bupivacaine. [ABSTRACT FROM AUTHOR]

Study Design: A laboratory investigation using a feline model of graded ventral spinal canal compromise was performed.Objective: To quantify the effects of graded ventral spinal canal compromise, both in the static condition and in combination with passive spinal motion, on cervical ventral epidural pressure (CVEP). The CVEP effects of laminectomy are also investigated.Summary Of Background Data: Spinal canal compromise, both in the static condition and in combination with passive spinal motion, has been implicated as a cause of spinal cord dysfunction.Methods: Seventeen cats underwent anterior corpectomy of C3 and placement of a flexible ventral graded compression device incorporating a pressure transducer. Ten animals also underwent laminectomy of C3. The implant was advanced stepwise into the spinal canal. CVEP was measured, at each degree of canal compromise, in the flexed, extended, and neutral positions, as well as during neck movement.Results: CVEP rose as a function of spinal canal compromise. In animals without laminectomy, mean CVEP was higher in the extended position and lower in the flexed position than in the neutral position. Mean CVEP during continuous passive neck movement was found to be higher than mean CVEP in the neutral position. Laminectomy was found to lower CVEP during all conditions examined, although substantial rises in CVEP were still observed in the presence of a residual ventral mass. All reported differences were statistically significant (P < 0.05).Conclusions: CVEP is elevated by both spinal canal compromise and spinal motion. [ABSTRACT FROM AUTHOR]

Background and objective: The quality of combined spinal-epidural anaesthesia mainly depends on accurate identification of the epidural space, The real-time ultrasound control of the procedure for puncture was therefore evaluated. Methods: Thirty parturients scheduled for Caesarean section were randomized to three equal groups. Ten control patients received conventional combined spinal-epidural anaesthesia. Ten of the remaining patients received ultrasonic scans by an offline scan technique, and 10 received online imaging of the lumbar region during epidural puncture. The epidural space was identified and needle advancement was surveyed through the interspinal and flaval ligaments. The number of attempts to advance the needle to achieve a successful puncture was measured and compared, as well as the number of vertebral interspaces punctured before successful entry into the epidural space. Results: There was no difference between patient characteristics in the three groups. The visualization of the epidural structures and of the needle manipulations was very effective. In the ultrasound group, the reduction in the number of attempts at puncture was significant (P < 0.036). The number of interspaces necessary for puncture was reduced (P < 0.036)] in the ultrasound online group compared with controls. The number of spinal needle manipulations was significantly reduced (P < 0.036). Conclusions: Real-time ultrasonic scanning of the lumbar spine is an easy procedure, It provides an accurate reading of the location of the needle tip and facilitates the performance of combined spinal-epidural anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Several studies have provided data on the vertebral morphology of normal spines, but there is a paucity of data on the vertebral morphology in patients with idiopathic scoliosis.Methods: The morphology of the pedicles and bodies of 307 vertebrae as well as the distance between the pedicles and the dural sac (the epidural space) in twenty-six patients with right-sided thoracic idiopathic scoliosis were analyzed with use of magnetic resonance imaging and multiplanar reconstruction.Results: A distinct vertebral asymmetry was found at the apical region of the thoracic curves, with significantly thinner pedicles on the concave side than on the convex side (p < 0.05). The degree of intravertebral deformity diminished farther away from the apex, with vertebral symmetry restored at the neutral level. In the thoracic spine, the transverse endosteal width of the apical pedicles measured between 2.3 mm and 3.2 mm on the concave side and between 3.9 mm and 4.4 mm on the convex side (p < 0.05). In the lumbar spine, the pedicle width measured between 4.6 mm at the cephalad part of the curve and 7.9 mm at the caudad part of the curve. The chord length and the pedicle length gradually increased from 34 mm and 18 mm, respectively, at the fourth thoracic vertebra to 51 mm and 25 mm, respectively, at the third lumbar vertebra. The transverse pedicle angle measured 15 in the cephalad aspect of the thoracic spine, decreased to 7 at the twelfth thoracic vertebra, and increased again to 16 at the fourth lumbar vertebra. The width of the epidural space was <1 mm at the thoracic apical vertebral levels and averaged 1 mm at the lumbar apical vertebral levels on the concave side, whereas it was between 3 mm and 5 mm on the convex side (p < 0.05).Conclusion: Idiopathic scoliosis is associated with distinctive intravertebral deformity, with smaller pedicles on the concave side and a shift of the dural sac toward the concavity. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The authors report the case of a 69-year old female with a persistent history of low back pain. Plain lumbar radiographs, performed at symptom initiation, revealed lumbar spondylolisthesis. Low back pain was attributed to this, and the patient received conservative treatment with partial relief of symptoms. Four years later, and as a result of acute onset of radicular symptoms, a lumbar spine magnetic resonance imaging scan was performed, revealing an epidural cystic lesion. The cyst was removed, and histopathology revealed a synovial cyst. [ABSTRACT FROM AUTHOR]

Purpose of Review: Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics., Recent Findings: During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed., Summary: For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.

Background: Performance of epidural anesthesia and analgesia depends on successful identification of the epidural space (ES). While multiple investigations have described objective and alternative methodologies to identify the ES, traditional loss of resistance (LOR) and fluoroscopy (FC) are currently standard of care in labor and delivery (L&D) and chronic pain (CP) management, respectively. While FC is associated with high success, it exposes patients to radiation and requires appropriate radiological equipment. LOR is simple but subjective and consequently associated with higher failure rates. The purpose of this investigation was to compare continuous, quantitative, real-time, needle-tip pressure sensing using a novel computer-controlled ES identification technology to FC and LOR for lumbar ES identification., Methods: A total of 400 patients were enrolled in this prospective randomized controlled noninferiority trial. In the CP management arm, 240 patients scheduled to receive a lumbar epidural steroid injection had their ES identified either with FC or with needle-tip pressure measurement. In the L&D arm, 160 female patients undergoing lumbar epidural catheter placements were randomized to either LOR or needle-tip pressure measurement. Blinded observers determined successful ES identification in both arms. A modified intention-to-treat protocol was implemented, with patients not having the procedure for reasons preceding the intervention excluded. Noninferiority of needle-tip pressure measurement regarding the incidence of successful ES identification was claimed when the lower limit of the 97.27% confidence interval (CI) for the odds ratio (OR) was above 0.50 (50% less likely to identify the ES) and P value for noninferioirty <.023., Results: Demographics were similar between procedure groups, with a mild imbalance in relation to gender when evaluated through a standardized difference. Noninferiority of needle-tip pressure measurement was demonstrated in relation to FC where pain management patients presented a 100% success rate of ES identification with both methodologies (OR, 1.1; 97.27% CI, 0.52-8.74; P = .021 for noninferiority), and L&D patients experienced a noninferior success rate with the novel technology (97.1% vs 91%; OR, 3.3; 97.27% CI, 0.62-21.54; P = .019) using a a priori noninferiority delta of 0.50., Conclusions: Objective lumbar ES identification using continuous, quantitative, real-time, needle-tip pressure measurement with the CompuFlo Epidural Computer Controlled Anesthesia System resulted in noninferior success rates when compared to FC and LOR for CP management and L&D, respectively. Benefits of this novel technology may include nonexposure of patients to radiation and contrast medium and consequently reduced health care costs.

Purpose of Review: As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue., Recent Findings: Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine., Summary: Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.

Cranioplasty is a common procedure in neurosurgical practice. However, some complications may occur after the operation. We here presented a case of bilateral skull defect and underwent cranioplasty with polyetheretherketone (PEEK) prosthesis. The patient developed epidural effusion on both sides 7 days after surgery. The effusion was light yellow and transparent, and laboratory examinations revealed normal glucose level, negative bacteriological results, and increased IgG protein concentration. The effusion disappeared after treatment with dexamethasone and drainage. We speculated that the epidural effusion was because of delayed type allergic reactions after PEEK cranioplasty. However, further studies are needed to investigate its related mechanisms.

Rationale: Psoas compartment block (PCB) is typically performed using surface anatomical landmarks and neurostimulation for guidance. However, anatomical anomalies, such as scoliosis, make this technique unreliable, posing a challenge for the anesthesiologist when inducing regional anesthesia., Patient Concerns: A 69-year-old woman with lumbar scoliosis scheduled for total hip arthroplasty underwent PCB with catheterization., Diagnoses: Inadvertent epidural anesthesia with catheterization following PCB was diagnosed using a lumbar radiograph., Interventions: Due to hypotension induced by local anesthetic (LA) epidural diffusion, the patient received intravenous hydration and vasopressor. Since bilateral sensory block was noted at the T3 level, with an incomplete motor blockade in both legs, the surgery was performed under epidural anesthesia., Outcomes: The patient remained hemodynamically stable throughout the duration of the surgical procedure. The surgery was uneventful and without further complications., Lessons: Patients with lumbar scoliosis are highly at risk of LA epidural diffusion, following PCB using traditional landmark-based approach. Other nerve-localizing technique can minimize the risk of this complication.

A response from the author of the article "Ventral epidural filling technique in interlaminar epidural steroid injection" in the 2015 issue is presented.

A letter to the editor is presented in response to the article "Ventral epidural filling technique in interlaminar epidural steroid injection," by C. H. Jeon and colleagues in the 2015 issue.