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LETTER TO THE EDITOR

Epidural Steroid Injections After Epidurography May Prevent Otherwise Devastating Complications

Pain Management Department, Cleveland Clinic Foundation, Cleveland, OH, narouzs{at}ccf.org

To the Editor:

I read with interest the case report by Tripathi et al. (1) regarding the development of paraplegia after intracord injection during attempted epidural steroid injection in an awake patient. I have some concerns regarding their technique.

First, the report implies that the authors did not inject a contrast agent under real-time fluoroscopy to validate epidural placement of the needle. Epidurography is useful to indicate epidural position and can help to predict the dermatomal distribution of analgesic block. At the lower thoracic and lumbar segments, the pattern of spread is significantly wider in the cephalad than caudal direction (2).

Second, it is unclear why the authors chose the T11-12 level if the patient's pain was in the T12 to L3 distribution. After injection of 10 mL volume, the expected cephalad spread is 6–7 segments (up to T5), whereas the expected caudal spread is only 2 segments (down to L2) (2).

Tripathi et al. (1) concluded that patient safety can be improved by excluding typical epidural doses of local anesthetic and/or opioids from epidural steroid injections. In my view, epidurography under real-time fluoroscopy is the key to safety for epidural steroid injections. Performing the injection at a lower lumbar level with epidurography might have saved the patient from this devastating complication.

References

1. Tripathi M, Nath SS, Gupta RK. Paraplegia after intracord injection during attempted epidural steroid injection in an awake patient. Anesth Analg 2005;101:1209–11.[Abstract/Free Full Text]
2. Yokoyama M, Hanazaki M, Fujii H, et al. Correlation between the distribution of contrast medium and the extent of blockade during epidural anesthesia. Anesthesiology 2004;100:1504–10.[Web of Science][Medline]

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