Anesth Analg 2006;102:1587
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215190.92116.2B
LETTER TO THE EDITOR
Comments on the Case Report of Paraplegia After Intracord Injection
Meda S. Raghavendra, MD,
Kenneth Candido, MD,
Mariadas Chinthagada, MD, and
Vikram Patel, MD
Department of Anesthesiology, Division of Pain Management, Loyola University Medical Center, Maywood, IL, mraghav{at}lumc.edu
To the Editor:
We read with concern the case report of paraplegia after a presumed intracord injection of corticosteroid and local anesthetics (1). We would like to address the following issues:
1. Proper patient selection for peridural injection of corticosteroid and adjuvant medications: The patient reported is an individual with a backache and pain in "the distribution of T12 to L3 nerve roots aggravated on bending." It was not specified whether pain occurred while bending forward, rearward, or laterally, all of which may signify non-radicular pain. The post-procedure magnetic resonance imaging does not demonstrate disk bulges, protrusions, herniations, extrusions, or fragments. Considering that internal disk disruption and degenerative disk disease are more common at the lower lumbar levels (e.g., L4-5, L5-S1), why choose an inherently dangerous level for the injection? The termination of conus medullaris could be easily identified and a lower level chosen for the injection (2,3).
2. Fluoroscopic guidance: How did the authors confirm the position of the needle tip? They do not mention the use of radiocontrast dye along with real-time fluoroscopic imaging, which could have identified the correct needle placement and ruled out intravascular, subdural, intrathecal, or intracord location.
3. Dose of local anesthetic: Why inject 10 mL of bupivacaine rather than confirm the location of the needle tip using radiocontrast spread under real-time fluoroscopy? If volume were important to achieve greater spread of the steroid and to dilute polyethylene glycol, then normal saline solution would have sufficed.
4. Was it an intracord injection? We are not certain that the injection was "intracord." The lateral fluoroscopy would have verified the needle tip location in reference to the dorsal epidural space even if the radiocontrast dye were not used. The late manifestations of motor weakness, sensory loss up to T10 and loss of bladder and bowel control could have been attributable to spinal cord edema, with subsequent acute vascular infarct (4).
5. Neurotoxicity related to polyethylene glycol vehicle: Polyethylene glycol in triamcinolone is not inherently neurotoxic to mammalian neural tissue (5).
This patient would have benefited from a thorough history, physical examination, and correlation with magnetic resonance imaging findings, as well as proper use of real-time fluoroscopy and radiocontrast dye, proper doses and volumes of steroids, avoidance of higher-risk levels such as the low thoracic and upper lumbar levels, and a thorough post-procedure evaluation.
Footnotes
Dr. Tripathi does not wish to respond.
References
- 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]
- Reimann A, Anson B. Vertebral level of termination of the spinal cord, with a report of a case of a sacral cord. Anat Record 1944;88:127.
- Saifuddin A, Burnett SJD, White J. The variation of position of the conus medullaris in an adult population: a magnetic resonance imaging study. Spine 1998;23:1452–6.[Web of Science][Medline]
- Huntoon MA, Martin DP. Paralysis after transforaminal epidural injection and previous spine surgery. Reg Anesth Pain Med 2004;29:494–5.[Medline]
- Benzon H, Gissen A, Strichartz G, et al. The effect of polyethylene glycol on mammalian nerve impulses. Anesth Analg 1987;66:553–9.[Abstract/Free Full Text]
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