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Department of Anesthesiology; University of Alabama at Birmingham; Aldrete Pain Care Center, Inc.; Arachnoiditis Foundation, Inc.; Birmingham, Alabama; aldrete{at}arachnoiditis.com
To the Editor:
Tsui and Armstrong (1) reported a spinal cord injury without paraesthesia when the midthoracic spine was entered laterally. The axial view of the magnetic resonance image shows that the puncture was made nearly 70° from the posterior midline. At the T8 level, if the spinal cord is touched or punctured laterally it does not produce paraesthesia, as when cervical chordotomy is performed (2).
The posterior epidural space is located at the intervertebral disk level, where the space is wider (Fig. 1) and narrower at the midpoint of the vertebra. In the axial view of Tsui et al.'s magnetic resonance image, there was no posterior epidural space at that point implying that the puncture occurred where the right-sided edema of the cord is shown; precisely where the vascular pedicle enters the vertebral body anterior to the dural sac, at midvertebral point, coming from the lateral and the posterolateral aspect of the spinal cord, where the vessels run.
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Puncture of the epidural veins and of the spinal artery is more likely when a near-lateral or paramedian translaminar entry is used. It is therefore not surprising that a right-sided extradural hematoma was also found. These minor anatomical points are relevant to avoid complications.
Other reported cases (3–6) have shown that thoracic epidural anesthesia is hazardous. If in doubt anesthesiologists may consider a high lumbar insertion of the epidural catheter; as Horlocker et al. (7) used in more than 4000 cases of upper abdominal and thoracic surgery, with "only six patients having neurological complications."
REFERENCES
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