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LETTER TO THE EDITOR

Is It Time to Perform All Thoracic Epidural Placements Under Fluoroscopy?

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

To the Editor:

I agree with the alarming conclusion of Tsui and Armstrong (1) that an awake patient might not provide adequate feedback during placement of a thoracic epidural catheter to preclude spinal cord injury. Although it is impossible to confirm that the spinal cord injury was a direct result of needle trauma, the localized cord edema at the site of needle entry makes cord puncture the most likely etiology. This is consistent with previous reports of a lack of paresthesia in awake subjects during spinal cord puncture (2).

I recommend that all thoracic epidurals be placed under fluoroscopic guidance with cautious advancement of the epidural needle in the lateral view and that no local anesthetic injection or catheter placement be allowed until satisfactory epidural spread of a contrast agent is confirmed with real-time fluoroscopy, as is common practice in epidural placement for treatment of chronic pain.

Although this practice will increase surgical time and cost, patient safety must come first. Performing thoracic epidural placements under fluoroscopy may not prevent inadvertent spinal cord puncture, as described by another case report in the same issue of Anesthesia & Analgesia (3). However, the use of contrast to confirm a satisfactory epidurogram may prevent additional damage to the spinal cord.

References

1. Tsui BCH, Armstrong K. Can direct spinal cord injury occur without paresthesia? A report of delayed spinal cord injury after epidural placement in an awake patient. Anesth Analg 2005;101:1212–4.[Abstract/Free Full Text]
2. Pounder D, Elliott S. An awake patient may not detect spinal cord puncture. Anaesthesia 2000;55:194.[Web of Science][Medline]
3. 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]

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