Cervical epidural hematoma with Brown-Sequard syndrome caused by an epidural injection: a case report

Epidural hematoma with Brown-Sequard syndrome caused by an epidural injection is a rarely found condition in the emergency department (ED). We report an unusual case of Brown-Sequard syndrome in a 55-year-old man who presented at the ED with right-sided weakness and contralateral loss of pain and temperature sensation after a cervical epidural injection for shoulder pain. Cervicla spine magnetic resonance imaging showed an epidural hematoma from C4 to C6. After admission, his right hemiparesis and contralateral sensory loss improved within eight days, and surgical decompression was not required. Diagnosing spinal lesions in the ED is challenging, especially in patients with acute neurological signs requiring immediate evaluation for stroke. In this case, definite hemiparesis and some contralateral sensory loss were noted. Therefore, a potential spinal lesion was suspected rather than a stroke. This case emphasized the importance of conducting a focused neurological examination after history taking.

Comparative study of ropivacaine with tramadol and ropivacaine with midazolam for post-operative epidural analgesia

Epidural analgesia is the most commonly used method for surgical anesthesia, obstetric analgesia, post-operative pain control, and chronic pain management. These epidurals are used either as a single-shot technique or with the catheter that allows intermittent boluses or continuous infusion, or both. All of these variables are controlled by choice of drug concentration, dosage, and level of injections. To compare the onset and duration of sensory block, motor block, and post-operative analgesia duration using Ropivacaine with Tramadol and Ropivacaine with Midazolam in the Epidural technique. In this prospective, non-randomized, comparative study, the total of 160 patients who underwent surgeries below the umbilicus did under epidural technique at Govt. Kilpauk Medical college hospital a Govt. Royapettah hospital, Chennai, was screened. Patients were divided into two groups. Patients in Group R received an epidural injection of 0.5% Ropivacaine (30ml) with Tramadol 2 mg/kg, whereas patients in Group L received an epidural injection of 0.5% ropivacaine (30ml) with Midazolam (50mg/kg). On studying the comparison of the onset of sensory, motor blockade, and duration of the sensory-motor blockade in the two groups, the onset of sensory blockade, motor blockade, and duration of motor blockade was more among ropivacaine with midazolam group. In comparison, the duration of sensory blockade was more among ropivacaine with tramadol group. A statistically significant difference in onset of sensory, motor blockade, and duration of sensory blockade across the group was found (p<0.005). Tramadol or Midazolam's addition to caudal epidural block with ropivacaine showed significant prolongation of post-operative analgesia compared to ropivacaine alone. The mean duration of analgesia was more among ropivacaine with the Tramadol group.

Platelet-Rich Plasma for the Treatment of Degenerative Lumbosacral Stenosis: A Study with Retired Working Dogs

Traditionally, canine degenerative lumbosacral stenosis (DLS) has been defined as a multifactorial syndrome characterized by lumbosacral pain triggered by the compression of the nerve rootlets of the cauda equina. There is still no consensus on the treatment of this condition, probably because there are a plethora of possible causes. In addition to compression, inflammation is a very important factor in the physiopathology of the disorder. Platelet-rich plasma (PRP) consists of an increased concentration of autologous platelets suspended in a small amount of plasma. Platelets are a source of several growth factors. Growth factors were shown to help in wound healing and biological processes, such as chemotaxis, neovascularization and synthesis of extracellular matrix, and growth factors were used to improve soft tissue healing and bone regeneration. PRP also facilitates the restoration of the structural integrity of the affected anatomy. Fourteen dogs diagnosed with DLS were treated with three epidural injections of PRP on days 0, 15 and 45. All dogs showed clinical improvement 3 months after the initial treatment. Gait was also objectively assessed by means of the use of force platform analysis before and after treatment, showing significant improvement. The results show that PRP may provide a good alternative to other nonsurgical treatments, such as prednisolone epidural injection.

Comparison of Caudal Epidural Steroid Injection with Interlaminar Lumbar Epidural Injection in treating Spinal Stenosis

Background: Lumbar spinal stenosis is a condition caused by narrowing of spinal canal. Steroid injection either lumbar or caudal can improve the functional outcome and low back pain. Aim: To compare the outcome of caudal epidural steroid injection with lumbar epidural steroid injection in treating spinal stenosis in patients suffering from sciatica. Methods: In this prospective study 338 patients having low backache due to spinal stenosis with sciatica were included from June 2013 to December 2014. Patients were randomly divided into two groups. Group I and II. Patients in Group I (160 patients) received caudal epidural steroid injections while the patients in Group II (178 patients) received lumbar epidural steroid injections. Visual analog scale (VAS) and Oswestry Disability Index (ODI) was used to assess outcome of the Caudal and Lumbar steroid injections and was measured at 2 weeks, at 3months, and improvement was declared if VAS decrease ≥50% of baseline and Oswestry disability index decrease ≥40% at 3 months. Results: In group I, there were 70(43.75%) males and 90(56.25%) females, while in group II there were 98(55.1%) males and 80(44.9%) females. The mean age of the patients in group I was 46.46±10.37 (18-75 years) years and was 43.77±15.27 years (18-75 years) in group II (P=0.0619). The change in pain score (>50%) was observed in 159 (89.33%) in group II compared with 121 (75%) in group I (P=0.0008). Conclusion: Lumbar epidural of steroids injections are more effective then caudal epidural injection of steroids in treating spinal stenosis. MeSH words: Caudal epidural, Lumbar epidural, Sciatica

Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

BACKGROUND: There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections. OBJECTIVE: To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition. STUDY DESIGN: Retrospective study. SETTING: Primary pain clinic and spine hospital. METHODS: Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection. RESULTS: The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group. LIMITATIONS: A retrospective analysis based on the relatively short-term follow-up period clinical results. CONCLUSIONS: The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems. KEY WORDS: Cervical disease, epidural injection, interlaminar, paramedian, midline, ventral epidural spread, Numeric Rating Scale, McNab criteria

ANALGESIC EFFICACY AND HAEMODYNAMIC PROFILE OF DEXMEDETOMIDINE VERSUS FENTANYL AS EPIDURAL ADJUVANTS – A PROSPECTIVE STUDY

BACKGROUND: Combined spinal epidural anaesthesia is the most popular anaesthetic technique for major gynaecological surgeries. Epidural adjuvants enhance the quality and duration of surgical anaesthesia. Adjuvants like opioids or alpha 2 agonists provide a dose sparing effects on local anaesthetics and accelerate the onset of sensory blockade of epidural anaesthesia. Our study was aimed to compare the hemodynamic, sedative and analgesia potentiating effects of Dexmedetomidine and Fentanyl when added to epidural Bupivacaine for gynaecological surgeries. METHODOLOGY: Patients of ASA Grade I and II, aged between 30 and 65 years who were scheduled for major gynaecological surgeries were included in the study. Patients were randomly divided into two groups, Group D (N = 51) and Group F (N = 51). Group D received epidural injection of 0.5 mcg/kg of Dexmedetomidine diluted to 5ml with Normal Saline (NS) and Group F received 0.5mcg/ kg of Fentanyl diluted to 5 ml with NS, in addition to a spinal dose of 3ml of 0.5 % Bupivacaine. When two segment regression of sensory level was noted, epidural block was supplemented with 0.5 mcg /kg of the study drug in combination with 1.5 ml/segment of 0.5% Bupivacaine. Duration of sensory block, motor block, and incidence of bradycardia, hypotension, nausea and pruritus were assessed. RESULTS: The duration of analgesia and motor block were signicantly longer in the Dexmedetomidine group. The incidence of bradycardia was more in the Dexmedetomidine group, but the incidence of hypotension was nearly the same. CONCLUSION: Dexmedetomidine seems to be a better alternative to Fentanyl as an epidural adjuvant due to early onset of sensory anaesthesia and prolonged postoperative analgesia.