Edema caused by continuous epidural hydromorphone infusion: A case report and review of the literature

2018 ◽  
Vol 4 (4) ◽  
pp. 255 ◽  
Author(s):  
Xiulu Ruan, MD ◽  
Riaz Tadia, MD ◽  
Hainan Liu, MS ◽  
John Patrick Couch, MD ◽  
John Keun-Sang Lee, MD, PhD
Keyword(s):  
Case Report ◽  
Infusion Pump ◽  
Failed Back Surgery Syndrome ◽  
Outpatient Setting ◽  
Leg Pain ◽  
First Case ◽  
Epidural Opioid ◽  
Failed Back Surgery ◽  
Catheter Tip ◽  
Lockout Interval

Background: Intraspinal drug delivery (IDD) therapy has been increasingly employed in patients with intractable, nonmalignant pain. Before implantation of permanent intraspinal pump, an intraspinal opioid screening trial is conducted to demonstrate the efficacy. The patient-controlled continuous epidural opioid infusion trail, performed in an outpatient setting, is widely accepted by many interventional pain specialists.Objective: To report a case of severe edema observed during the continuous epidural hydromorphone infusion trial.Case Report: An otherwise healthy 68-year-old lady with a 5-year history of severe low back pain and bilateral leg pain because of failed back surgery syndrome was referred to our clinic for IDD therapy.A tunneled lumbar epidural catheter was placed at L2- L3 with catheter tip advanced to L1 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone (0.1 mg/ml) at basal rate of 0.3 ml/h. The bolus dose was 0.1 ml with a 60-minute lockout interval. The patient was instructed how to operate the infusion pump. During the following infusion trial, she reported satisfactory analgesia (>70 percent pain reduction) and was able to wean off her other systemic opioids. However, she developed diffuse edema and gained over 16 pounds during the 5-day infusion trial. Her edema finally resolved 3-4 days after termination of the epidural infusion.Conclusion: Edema may occur and persist during epidural hydromorphone infusion. This report represents the first case report, to the best of our knowledge, describing severe edema in a patient on continuous epidural hydromorphone administration during an outpatient epidural infusion trial.

Intractable pruritus during outpatient epidural hydromorphone infusion: A case report and a focused review of the literature

2015 ◽  
Vol 11 (2) ◽  
pp. 184 ◽  
Author(s):  
Xiulu Ruan, MD ◽  
Li Ma, MD, PhD ◽  
J. Patrick Couch, MD ◽  
Tao Chen, MD, PhD ◽  
Gary W. Bumgarner, PhD
Keyword(s):  
Drug Delivery ◽  
Opioid Analgesic ◽  
Infusion Pump ◽  
Failed Back Surgery Syndrome ◽  
Outpatient Setting ◽  
Leg Pain ◽  
Opioid Dose ◽  
Epidural Opioid ◽  
Failed Back Surgery ◽  
Catheter Tip

Background: Intraspinal drug delivery therapy has been increasingly used in patients with intractable, nonmalignant pain who have failed to respond to conventional treatment or cannot tolerate systemic opioid(s) due to adverse events. By infusing a small dose of an opioid analgesic directly into the cerebrospinal fluid, near opioid receptors, profound spinal analgesia can be obtained. Before the implantation of permanent intraspinal pump, a neuraxial opioid infusion trial is usually conducted to demonstrate the effectiveness of neuraxial opioid for analgesia. Patient-controlled epidural opioid infusion trial, performed in an outpatient setting, is one of the approaches used to conduct such a trial.Objective: To report a case of severe pruritus observed during the continuous epidural hydromorphone infusion trial and to conduct a focused review of the literature.Case report: An otherwise healthy 56-year-old lady, with a 4-year history of severe low back pain and bilateral leg pain due to failed back surgery syndrome, was referred to our clinic for intraspinal drug delivery therapy. Following a preimplantation psychological evaluation confirming her candidacy, she consented to an outpatient patient-controlled continuous epidural hydromorphone trial. A tunneled lumbar epidural catheter was placed at L3-L4 with catheter tip advanced to L2 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone 0.3 mL/h (0.06 mg, concentration 0.2 mg/mL) at basal rate of 0.3 mL/h, with bolus dose set at 0.2 mL (0.04 mg) and 30-minute lockout interval. The patient was instructed how to operate the infusion pump prior to discharging home. During the infusion trial, she reported satisfactory analgesia (>90 percent pain reduction) and was able to reduce her oral opioid dose by more than 80 percent. However, she developed severe, persistent itching, unresponsive to meticulous epidural infusion titration or various antipruritic treatments. Her pruritus remained severe and unabated until a few hours after the termination of the epidural hydromorphone infusion.Conclusion: Pruritus may occur and persist during epidural hydromorphone infusion. This report describes severe pruritus in a patient on epidural hydromorphone administration, in the setting of an outpatient infusion trial.

scholarly journals Retinal Hemorrhage after Epiduroscopy in a Patient using Dexamethasone: A Case Report

2019 ◽  
pp. 33-36
Author(s):  
JanWillem Kallewaard
Keyword(s):  
Case Report ◽  
Epidural Space ◽  
Retinal Hemorrhage ◽  
Failed Back Surgery Syndrome ◽  
Epidural Fibrosis ◽  
Retinal Hemorrhages ◽  
First Case ◽  
Short Period ◽  
Failed Back Surgery ◽  
Back Surgery

Epiduroscopy is a minimally invasive procedure used to diagnose epidural fibrosis and to release this fibrosis; epiduroscopy is also used to precisely deposit medication into the epidural space. It is commonly used in patients who are diagnosed with failed back surgery syndrome (FBSS) after more conservative treatment has failed to provide sufficient relief of symptoms. A rare complication of epiduroscopy is retinal hemorrhaging, which is likely caused by overpressurization of the epidural space during the procedure. Patient-related risk factors for developing retinal hemorrhage after epiduroscopy remain largely unknown. This is the first case report of retinal hemorrhage in a patient using chronic dexamethasone. We describe a 73-year-old man diagnosed with FBSS who underwent epiduroscopy to diagnose and relieve epidural fibrosis. The procedure was uneventful and he was discharged from our clinic the same day, but upon routine check-up he mentioned blurry vision. Immediately he was referred to an ophthalmologist who diagnosed retinal hemorrhages in both eyes upon fundoscopic examination. Our patient was using dexamethasone for the treatment of allergies. Three months after the procedure, his vision was restored fully in the right eye and 95% in the left eye. Chronic corticosteroid use may weaken retinal veins, making them prone to rupture when there is increased pressure, even for a short period of time. Chronic use of corticosteroids must be considered a risk factor for developing retinal hemorrhages in patients undergoing epiduroscopy. Long-term use of corticosteroid can be considered as a relative contraindication for epiduroscopy. Key words: Epiduroscopy, complications, interventional pain, corticosteroids, retinal hemmorhage, failed back surgery syndrome

scholarly journals Severe Peripheral Edema During an Outpatient Continuous Epidural Morphine Infusion Trial in a Patient with Failed Back Surgery Syndrome

2008 ◽  
Vol 3;11 (5;3) ◽  
pp. 363-367
Author(s):  
Xiulu Ruan
Keyword(s):  
Case Report ◽  
Side Effects ◽  
Epidural Morphine ◽  
Failed Back Surgery Syndrome ◽  
Leg Pain ◽  
Peripheral Edema ◽  
Morphine Infusion ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
History Of

Background: Intraspinal drug delivery therapy has been increasingly used in patients with intractable, nonmalignant pain who fail to respond to conventional treatment or cannot tolerate systemic opioid therapy due to side effects. By infusing small amount of analgesics directly into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, one is able to achieve the spinally mediated analgesia, sparing side effects due to systemic opioids. Prior to permanent intraspinal pump implantation, an intraspinal opioid screening trial is required to document the efficacy of intraspinal opioid for analgesia. Although there are a few approaches in conducting such screening trials, a patient controlled continuous epidural morphine infusion trial, performed in an outpatient setting, is widely accepted by many interventional pain specialists. The major advantage of conducting an outpatient trial is that it mimics what patients do in their daily living, therefore minimizing the false positive rate. Objective: To report a case of severe peripheral edema observed during an outpatient continuous epidural morphine infusion trial. Case Report: A 64-year-old female, with a 7-year history of severe low back pain and bilateral leg pain due to failed back surgery syndrome, was referred to our clinic for intraspinal drug delivey therapy after failing to respond to conservative treatment, including a previous history of 3 lumbosacral surgeries. Following a pre-implantation psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine trial. A tunneled lumbar epidural catheter was placed at L2-L3 with catheter tip advanced to T12 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The proximal tip of the catheter was then tunneled, subcutaneously and connected to a MicrojectTM PCEA pump (Codman, Raynham, MA, USA) and reservoir bag containing preservative-free morphine 0.5 mg/mL. The pump was programmed to deliver a basal rate of 0.5 mL/hr. The bolus dose was 0.2 mL with 60 minute lock-out interval. The patient was instructed how to operate the infusion pump before discharging home. During the following 2 weeks, she reported more than 90% reduction of her low back and leg pain. She only had to use the on-demand bolus doses averaging 2 – 3 times a day. She was able to wean off her oral opioids completely. However, she developed bilateral leg edema and gained over 12 pounds during the 2-week infusion trial, despite wearing elastic stockings and keeping her legs elevated whenever possible. She did not experience any other significant side effects. Her edema finally resolved 2 days after termination of the epidural infusion. Conclusion: Peripheral edema may occur and persist during epidural morphine infusion. This report represents the first case report, to the best of our knowledge, describing severe peripheral edema in an otherwise healthy patient while on epidural morphine administration during an outpatient epidural morphine infusion trial. This case report shows that continuous epidural morphine infusion, even in small dose, may cause peripheral edema in some patients. Key words: Epidural morphine infusion trial, intraspinal drug delivery pump, failed back surgery syndrome, methadone, peripheral edema

scholarly journals Long-Term Follow-Up of Inpatients with Failed Back Surgery Syndrome Who Received Integrative Korean Medicine Treatment: A Retrospective Analysis and Questionnaire Survey Study

2021 ◽  
Vol 10 (8) ◽  
pp. 1703
Author(s):  
Ju-Hun Park ◽  
Kang-Eah Choi ◽  
Sang-Gyun Kim ◽  
Hui-Yeong Chu ◽  
Sang-Woon Lee ◽  
...  
Keyword(s):  
Retrospective Analysis ◽  
Questionnaire Survey ◽  
Failed Back Surgery Syndrome ◽  
Post Treatment ◽  
Leg Pain ◽  
Korean Medicine ◽  
Failed Back Surgery ◽  
Back Surgery

Introduction: this study aimed to investigate the long-term clinical efficacy and satisfaction degree of integrative Korean medicine (KM) treatment for patients with failed back surgery syndrome (FBSS). Methods: we performed a follow-up questionnaire survey and retrospective analysis of medical records for patients with FBSS who underwent inpatient treatment for ≥ 1 week. The primary evaluation indices were numeric rating scale (NRS) scores for low back pain (LBP) and leg pain at admission and discharge. Sub-evaluation indices included the Oswestry Disability Index (ODI) and EuroQol 5-dimension (EQ-5D) score. The follow-up questionnaire survey obtained information regarding previous surgeries; reasons for satisfaction/dissatisfaction with surgical and KM treatment; and current status. Results: compared with at admission, there was a significant post-treatment decrease in the NRS scores for LBP and leg pain, as well as the ODI score. Further, there was a significant post-treatment increase in the EQ-5D score. Regarding the patients’ global impression of change for KM treatment administered during admission and at the follow-up questionnaire survey, 101 (95.3%) patients selected “minimally improved” or better. Conclusion: integrative KM treatment could effectively reduce pain, as well as improve function and health-related quality of life, in patients with FBSS.

Efficacy of Transverse Tripolar Spinal Cord Stimulator for the Relief of Chronic Low Back Pain from Failed Back Surgery

2008 ◽  
Vol 3;11 (5;3) ◽  
pp. 333-338
Author(s):  
Asokumar Buvanendran
Keyword(s):  
Spinal Cord ◽  
Low Back Pain ◽  
Back Pain ◽  
Case Report ◽  
Pain Relief ◽  
Failed Back Surgery Syndrome ◽  
Low Back ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Stimulation Of

Background: Failed back surgery syndrome is a common clinical entity for which spinal cord stimulation has been found to be an effective mode of analgesia, but with variable success rates. Objective: To determine if focal stimulation of the dorsal columns with a transverse tripolar lead might achieve deeper penetration of the electrical stimulus into the spinal cord and therefore provide greater analgesia to the back. Design: Case report. Methods: We describe a 42-year-old female with failed back surgery syndrome that had greater back pain than leg pain. The tripolar lead configuration was achieved by placing percutaneously an octapolar lead in the spinal midline followed by 2 adjacent quadripolar leads, advanced to the T7-T10 vertebral bodies. Results: Tripolar stimulation pattern resulted in more than 70% pain relief in this patient during the screening trial, while stimulation of one or 2 electrodes only provided 20% pain relief. After implantation of a permanent tripolar electrode system with a single rechargeable battery, the pain relief was maintained for one year. Conclusion: This is case report describing a case of a patient with chronic low back pain with a diagnosis of failed back surgery syndrome in which transverse tripolar stimulation using an octapolar and 2 quadripolar leads appeared to be beneficial. The transverse tripolar system consists of a central cathode surrounded by anodes, using 3 leads. This arrangement may contribute to maximum dorsal column stimulation with minimal dorsal root stimulation and provide analgesia to the lower back. Key words: Epidural, low back pain, spinal cord stimulation, failed back surgery syndrome, tripolar stimulation

Degenerative Osteoarthritis of the Hip Misconceived as a Failed Back Surgery Syndrome - A case report -

2008 ◽  
Vol 54 (5) ◽  
pp. 589
Author(s):  
Sang Soo Kang ◽  
Keun Man Shin ◽  
Sung Keun Nam ◽  
Hyun Cheul Kim ◽  
Il Seok Kim ◽  
...  
Keyword(s):  
Case Report ◽  
Failed Back Surgery Syndrome ◽  
Osteoarthritis Of The Hip ◽  
Degenerative Osteoarthritis ◽  
Failed Back Surgery ◽  
Back Surgery

scholarly journals High-Frequency Spinal Cord Stimulation at T9/10 in Patients With Failed Back Surgery Syndrome

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Naoki Higashiyama ◽  
Takuro Endo ◽  
Taku Sugawara
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Stimulation ◽  
High Frequency ◽  
Low Frequency ◽  
The Elderly ◽  
Failed Back Surgery Syndrome ◽  
Leg Pain ◽  
Effective Treatment Option ◽  
Failed Back Surgery ◽  
Back Surgery

Abstract INTRODUCTION Spinal cord stimulation (SCS) is an effective treatment option for low back pain and radicular leg pain of failed back surgery syndrome (FBSS). In a recent study, high-frequency spinal cord stimulation (HFSCS) was found to be more effective in treating chronic pain than traditional paresthesia-based low-frequency SCS (paresthesia SCS). The purpose of this study is to evaluate the efficacy of paresthesia SCS and HFSCS in improving outcomes. METHODS We retrospectively reviewed the outcomes of patients who underwent paresthesia SCS or HFSCS between September 2016 and January 2019. Paresthesia SCS is generally characterized by programming stimulation parameters such that the patient experiences paresthesia, and the paresthesia topography overlaps the pain topography as much as possible. The patient in HFSCS had a placement of cylindrical lead at levels T9-10. Patients were programmed with the electrode overlying the inferior endplate of T9 (+) and the electrode overlying the superior endplate of T10 (–). RESULTS A total of 14 patients (4 males, 10 females) underwent paresthesia SCS implantation. Mean age was 77.2 ± 9.6 yr. A total of 5 patients (2 males, 3 females) underwent HFSCS implantation. Mean age was 78.2 ± 7.5 yr. Operative time was shorter for the HFSCS group compared to the paresthesia SCS group (53.4 ± 4.8 min vs 82.9 ± 20.3 min, respectively; P < .001). A total of 5 out of 5 patients in the HFSCS group (100%) and 10 out of 14 patients in the paresthesia SCS group (71.4%) achieved the outcome of 50% pain relief (P = .25) CONCLUSION To confirm paresthesia during the procedure in the elderly may be complicated by hearing/language difficulties or by sedative-related confusion. Compared to paresthesia SCS, HFSCS allows for lower operative times and a more efficient and accurate positioning of the electrodes.

scholarly journals Analysis of Subdural Injection During Lumbar Interlaminar Epidural Injection in Failed Back Surgery Syndrome

2020 ◽  
Vol 9 (10) ◽  
pp. 3132
Author(s):  
Jin Young Lee ◽  
Woo Seog Sim ◽  
Ji Yeong Kim ◽  
Yu Ri Ko ◽  
So Young Lee ◽  
...  
Keyword(s):  
Spinal Surgery ◽  
Epidural Injection ◽  
Failed Back Surgery Syndrome ◽  
Leg Pain ◽  
Daily Life Activities ◽  
Pain Scores ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Before And After ◽  
Interlaminar Epidural Injection

Persistent or recurrent back and leg pain following spinal surgery, known as failed back surgery syndrome (FBSS), significantly limits daily life activities. A lumbar epidural injection can reduce adhesions, inflammation, and nerve compression, although the epidural space can be distorted due to dura mater and epidural tissues changes after spinal surgery. This study analyzed subdural injection during lumbar epidural injection in FBSS patients. We retrospectively analyzed data from 155 patients who received a lumbar interlaminar epidural injection to manage FBSS. We grouped the patients based on the injected contrast medium appearance in the subdural (group S) or epidural spaces (group E) in fluoroscopic contrast images. Demographic, clinical, surgical and fluoroscopic data were recorded and evaluated, as were the pain scores before and after injection. There were 59 patients (38.1%) in the subdural group. Injection distance from the surgery level differed between the groups. Risk of subdural injection at level 1 distance from the surgery level had an odds ratio of 0.374, and at level ≥2, it was 0.172, when compared to level 0. Subdural incidence differed with the distance from surgical site. Physicians should strive to reduce subdural incidence when the injection is planned at surgery site in FBSS.

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