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PubMed1995

The use of combined xylazine and lignocaine epidural injection in ewes with vaginal or uterine prolapses.

Two millilitres of solution calculated to contain 0.07 mg/kg xylazine and 0.5 mg/kg lignocaine injected at the sacrococcygeal epidural site provided caudal analgesia within 2 min in 61 sheep. This analgesic protocol eliminated forceful abdominal straining behavior following replacement of vaginal prolapse for at least 24 h in 48 of 52 ewes (92%) and in all 9 ewes with uterine prolapse. Moderate pelvic limb ataxia was observed in 25 sheep (41%) for up to 24 h after epidural injection. Sedation was noted in one ewe but no other systemic effects of xylazine injection, such as excessive salivation or ruminal distension, were observed. No long-term adverse reactions to xylazine injection were noted. The combined epidural injection regimen of xylazine and lignocaine is recommended as an adjunct for pain relief and control of abdominal straining following replacement of vaginal and uterine prolapse in ewes.

Journal Article↗
PubMedDate not supplied

Cardiovascular effects after epidural injection of xylazine in isoflurane-anesthetized dogs.

The cardiovascular effects following epidural injection of xylazine or isotonic saline during isoflurane anesthesia were assessed in six healthy dogs. Dogs were anesthetized with isoflurane in O2 and maintained at 2.0% end-tidal concentration. Ventilation was controlled to maintain PaCO2 at 35 to 45 mm Hg. The dorsal pedal artery was cannulated for measurement of arterial blood pressure (AP)(systolic AP, mean AP, diastolic AP) and for blood sample collection. Arterial pH and blood gas tensions (PaO2 and PaCO2) were determined. Cardiac output was measured by thermodilution. The electrocardiogram (ECG), heart rate (HR), core body temperature, central venous pressure (CVP), mean pulmonary AP, and end-tidal isoflurane concentration (ETISO) and CO2 tension (ETCO2) were monitored. Systemic vascular resistance (SVR), arterial HCO2 concentration, base balance, and cardiac index (CI) were calculated. After baseline measurements were taken, either xylazine (0.2 mg/kg) in 5 mL isotonic saline or 5 mL of isotonic saline was injected into the lumbosacral epidural space. Data were then recorded at 5, 15, 30, 45, 60, 75, 90, 105, and 120 minutes after epidural injection. Data were analyzed by two-way analysis of variance (ANOVA) for repeated measures. When significant differences were encountered, mean values were compared using Bonferroni's test. The level of significance was set at P < .05. Mean values for diastolic AP decreased at 90 and 120 minutes compared with the mean value at 15 minutes after epidural injection of xylazine. No differences were detected at any time or between treatments for HR, systolic AP, mean AP, CVP, CI, SVR, mean pulmonary AP, temperature, ETCO2, ETISO, arterial pH, PaCO2, PaO2, plasma bicarbonate concentration, or base balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗
PubMed1995

[Epidural injection for postoperative pain relief after thoracoscopic surgery].

For the pain relief after thoracoscopic surgery, the epidural injection of buprenorphine was performed in 46 cases. In 28 cases, intermittent injection was performed before awaking from anesthesia. The effect was excellent in 6 cases, who were free from pain without any more injection after returning to the ward, and good in 27 cases, who sometimes felt dull pain and had another analgetics (intermittent epidural injection in 16 cases, intermittent epidural injection and another medication in 5 cases). In 18 cases, continuous injection was performed. The effect was excellent in 9 cases and good in 9 cases. It was concluded that the epidural injection had effective analgesic effect after thoracoscopic surgery, both in intermittent injection group and continuous injection group. For limited medication, the intermittent epidural injection was considered the first choice after thoracoscopic surgery.

Analgesia, Epidural↗
PubMed1999

Accuracy of blind versus fluoroscopically guided caudal epidural injection.

STUDY DESIGN: A prospective observational study of a case series of patients with low back pain referred for epidural injection of corticosteroid. OBJECTIVES: To evaluate the accuracy of caudal epidural injections performed without the use of fluoroscopic guidance and to determine the value of specific clinical tests performed during the procedure in predicting successful epidural needle placement. SUMMARY OF BACKGROUND DATA: Epidural injection of corticosteroid is one of many treatments currently used in the nonsurgical management of low back pain. The face validity of many studies evaluating the efficacy of epidural corticosteroid injections has been criticized for use of a blind technique. Although there currently is no consensus in the spine literature as to whether epidural injection of corticosteroid (by any technique) is effective, it is imperative first to establish the accuracy of the technique being used. METHODS: A total of 54 consecutive patients underwent fluoroscopically guided caudal epidural injections. Needle insertion was performed blindly (without the use of fluoroscopic guidance), and the success of needle placement was predicted according to the presence of palpable landmarks, palpation of subcutaneous airflow, and the subjective impression that the needle was in a satisfactory position. These clinical criteria then were compared with the position of the needle as seen under fluoroscopy and the spread of radio-opaque contrast in the epidural space after the procedure. RESULTS: Successful injection placement on the first attempt occurred in 74.1% of the patients. Results were improved when anatomic landmarks were identified easily (87.5%) and no air was palpable subcutaneously over the sacrum when injected through the needle (82.9%). The combination of these two signs predicted a successful injection in 91.3% of attempts. CONCLUSIONS: Caudal epidural injection is performed ideally with fluoroscopic guidance as the gold standard for accurate drug placement. If fluoroscopic guidance is unavailable, impractical, or contraindicated, the presence of readily palpable anatomic landmarks at the sacral hiatus and the absence of palpable subcutaneous airflow over the sacrum significantly increase the operator's confidence in the likelihood of an accurate injection even before any products are administered into the epidural space.

Adult↗
PubMed1991

The effect of a priming epidural injection of adrenaline on epidural blockade with bupivacaine.

Twenty-four patients receiving epidural anaesthesia were studied to test the hypothesis that 1:200,000 adrenaline administered into the epidural space 5 minutes before 20 ml bupivacaine 0.5% would improve nerve block and delay systemic absorption of the local anaesthetic. Group A/B received 20 ml adrenaline 1:200,000 5 minutes before 20 ml bupivacaine 0.5%, group S/BA 20 ml saline followed by 20 ml bupivacaine 0.5% with 100 micrograms adrenaline, and group S/B saline 20 ml followed by 20 ml plain bupivacaine 0.5%. Mean maximum plasma concentrations of bupivacaine tended to be lower in the adrenaline groups. A delay in the time to peak plasma concentration of bupivacaine was noted in the A/B group; this indicated that priming with adrenaline may be effective at delaying early systemic uptake of the local anaesthetic. In both adrenaline groups a more prolonged epidural block and increased efficacy were noted, although this was only significant for the duration of block at T6 (p = 0.023) and duration of motor block at Bromage level 1 (p = 0.016) in group A/B. There seems little clinical advantage in administering adrenaline 5 minutes before bupivacaine.

Anesthesia, Epidural↗
PubMed1987

Relief of low back pain by epidural injection. A case report.

This report describes the use of epidural injection in the treatment of a patient with severe back pain whose medical history and physical examination suggest a diagnosis of a lumbar disk lesion. The patient's medical history included recurrent episodes of buttock and hip pain that previously responded well to lumbar manipulation. On this occasion, the pain had become so severe that the patient could not tolerate manipulation. The patient's pain was relieved by administering an epidural injection of 50 cc of 0.5% procaine through the sacral hiatus. This injection has two relevant implications for the physical therapy profession. First, it offers a nonsurgical treatment for a lumbar disk lesion when physical therapy has been ineffective or is impractical. Second, in an appropriate clinical setting, the epidural injection provides an opportunity to understand more clearly the causes of back pain.

Adult↗
PubMed2004

Evaluation of fluoroscopically guided caudal epidural injections.

OBJECTIVE: To evaluate accuracy of needle placement and flow patterns of fluoroscopically guided caudal epidural injections. DESIGN: A prospective observational study of patients with low back pain undergoing caudal epidural injections under fluoroscopy. BACKGROUND: Epidural administration of corticosteroids is one of the commonly used interventions in managing chronic low back pain. Sacral or caudal epidural placement of the needle is one of the commonly used means to access the lumbar epidural space for administration of various drugs. METHODS: A total of 100 consecutive patients underwent fluoroscopically guided caudal epidural injections. Needle insertion was performed blindly (without the use of fluoroscopic guidance) based on palpable landmarks, palpation of subcutaneous airflow, subjective impression that the needle was in a satisfactory position, and ease of injection of contrast. These clinical criteria were compared with the position of the needle as seen under fluoroscopy and the spread of radiopaque contrast in the epidural space. The contrast flow patterns, ventral or dorsal epidural filling, nerve root filling, and correlation of filling to the side of pain were evaluated. RESULTS: Successful injection placement without fluoroscopic visualization was confirmed on subsequent fluoroscopic visualization in 77% of the patients. Various filling and flow patterns showed that with injection of 10 mL of contrast, filling was noted up to S1 in 70% of the patients, followed by L5 nerve root filling in 12% of the patients. Ventral epidural filling was seen in 69% of the patients, in contrast to dorsal filling in 92% of the patients. Nerve root filling correlated with leg pain in only 43% of the patients. Intravenous placement of the needle was noted in 14% of the patients with positive flashback and aspiration in 50% of the patients. CONCLUSION: Caudal epidural injections are ideally performed with fluoroscopic guidance as the gold standard for accurate needle placement. However, this does not assure either targeted delivery or accurate placement of the drug.

Journal Article↗
PubMed1998

The effect of epidural injection of betamethasone or bupivacaine in a rat model of lumbar radiculopathy.

STUDY DESIGN: The effect of epidural injection of betamethasone or bupivacaine was investigated in an animal model of lumbar radiculopathy. OBJECTIVE: To investigate the effects of an epidural steroid (betamethasone) or a local anesthetic (bupivacaine) in an animal model of radiculopathy produced by nerve root irritation. SUMMARY OF BACKGROUND DATA: Epidural injections are commonly used for the treatment of low back pain and sciatica. However, efficacy remains controversial, and there is a paucity of basic information to support clinical use or the injections. METHODS: Fifty-one rats were used. The left L4 and L5 nerve roots were loosely ligated with chromic gut, and either betamethasone, bupivacaine, betamethasone in combination with bupivacaine, or saline was injected using an epidurally placed catheter. The effects of epidural injection were evaluated using response to noxious stimuli and immunohistochemical methods. RESULTS: In betamethasone-treated rats (either alone or in combination with bupivacaine), thermal hyperalgesia was significantly less (P < 0.010 after surgery than that in saline- or bupivacaine-treated groups, in which the hyperalgesia was maximum at 2-3 postoperative weeks before resolving 5 weeks after surgery. Immunohistochemical analysis did not correlate with these results. CONCLUSIONS: Epidural steroid injection has a significant effect on the thermal hyperalgesia produced in a model of radiculopathy, which may provide clinical support for advocates of epidural steroids.

Anesthetics, Local↗
PubMed2000

[Analysis of inadvertent epidural injection of drugs].

We asked 31 anesthesiologists, who were on the Japanese Board of Anesthesiology, about inadvertent injection of drugs into the epidural space, and received answers from 28 (90%). Fifteen (54%) had an experience of inadvertent epidural injection, and five of them had two experiences. Injected drugs were ephedrine (6 times), a mixture of neostigmine and atropine (3), thiopental (2), etilefrine (2), vecuronium (1), suxamethonium (1), bicarbonate (1), midazolam (1), lactated Ringer's solution (1), nicardipine (1), and pentazocine (1). The inadvertent injection of thiopental or bicarbonate was noticed by back pain during injection. No treatment was added after the inadvertent injections, except a patient with an epidural steroid injection following thiopental. No neurological complications were found in any patients.

Anesthesia, Epidural↗
PubMed2003

An audit of the use of epidural injections for back pain and sciatica.

An audit was conducted to determine if epidural injections for back pain and sciatica were practised in accordance with guidelines prescribed by the National Health and Medical Research Council (NHMRC). More than 80% of injections were used for conditions for which they were not indicated, and which the NHMRC considers experimental. Most commonly, epidural injections afforded no benefit to the patients, yet were often repeated. In no instance was informed consent recorded as recommended by the NHMRC. The practice of epidural injections is dissonant both with the evidence-based literature and with recommended guidelines, and squanders both financial and professional resources.

Adrenal Cortex Hormones↗
PubMed2003

Complications of fluoroscopically guided interlaminar cervical epidural injections.

OBJECTIVES: To assess the incidence of complications of fluoroscopically guided interlaminar cervical epidural injections. DESIGN: A retrospective cohort design study. SETTING: A multidisciplinary spine care center. PARTICIPANTS: One hundred fifty-seven consecutive patients with cervical radicular pain caused by cervical spondylosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning. INTERVENTIONS: Fluoroscopically guided interlaminar cervical epidural injections were performed at the C7-T1 or C6-7 level using an 18-gauge, 9-mm Tuohy needle with 2mL of 1% lidocaine (Xylocaine) and 80-mg of triamcinolone acetonide (Kenalog). All injections were performed consecutively over a 12-month period by 1 of 5 physicians. MAIN OUTCOME MEASURES: An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who asked a standardized questionnaire about complications after the injections. Also reviewed were physician notes regarding office follow-up consultations 3 weeks or less after the injections and epidurograms. RESULTS: The charts of 157 patients, who received 345 injections, were reviewed. Complications per injection included 23 increased neck pain (6.7%), 16 transient nonpositional headaches that resolved within 24 hours (4.6%), 6 episodes of insomnia the night of the injection (1.7%), 6 vasovagal reactions (1.7%), 5 facial flushing (1.5%), 1 fever the night of the procedure (0.3%), and 1 dural puncture (0.3%). The incidence of all complications per injection was 16.8%. CONCLUSIONS: Because all complications resolved without morbidity and no patient required hospitalization, fluoroscopically guided interlaminar cervical epidural injections may be a safe procedure for use in patients with cervical radicular pain.

Adult↗
PubMed2001

Development and evaluation of an epidural injection simulator with force feedback for medical training.

Performing epidural injections is a complex task that demands a high level of skill and precision from the physician, since an improperly performed procedure can result in serious complications for the patient. The objective of our project is to create an epidural injection simulator for medical training and education that provides the user with realistic feel encountered during an actual procedure. We have used a Phantom haptic interface by SensAble Technologies, which is capable of three-dimensional force feedback, to simulate interactions between the needle and bones or tissues. An additional degree-of-freedom through an actual syringe was incorporated to simulate the "loss of resistance" effect, commonly considered to be the most reliable method for identifying the epidural space during an injection procedure. The simulator also includes a new training feature called "Haptic Guidance" that allows the user to follow a previously recorded expert procedure and feel the encountered forces. Evaluations of the simulator by experienced professionals indicate that the simulation system has considerable potential to become a useful aid in medical training.

Computer Simulation↗
PubMed1988

Epidural injection of xylazine for perineal analgesia in horses.

Local anesthetics given in the epidural space of a horse may cause hind limb weakness in addition to analgesia. Because alpha 2 agonists given by epidural injection cause sensory blockade without motor effects in human beings and other species, their use in veterinary anesthesia is appealing. This study was designed to examine the effectiveness of xylazine HCl, an alpha 2 agonist commonly used in horses. Xylazine, 0.9% NaCl, and lidocaine were given by epidural injection to horses subjected to perineal electrical stimulation. Administration of xylazine (0.17 mg/kg of body weight, diluted to a 10-ml volume, using 0.9% NaCl) induced approximately 2.5 hours of local analgesia without apparent side effects. Higher doses of xylazine caused mild hind limb ataxia. Administration of lidocaine induced a similar duration of analgesia, with severe hind limb ataxia (100% incidence). We concluded that xylazine given by epidural injection results in safe, effective perineal analgesia in horses.

Analgesia, Epidural↗
PubMed1999

Computed tomographic epidurography: an aid to understanding deformation of the lumbar dural sac by epidural injections.

Local anaesthetics injected into the epidural space may deform the dural sac to a variable degree, thereby contributing to variability in the extent of the block. We investigated deformation of the lumbar dural sac after injection into the lumbar epidural space. The subjects were 26 patients with low-back pain who underwent lumbar epidurography and computed tomographic (CT) epidurography, of whom seven also underwent myelography and computed tomographic myelography. The epidural space was entered via the sacral hiatus in 24 patients and through the L5/S1 interspace in two patients. Ten millilitres of local anaesthetic was then injected into the epidural space followed by 20 mL of contrast medium. Computed tomographic epidurography was undertaken approximately 30-min after the epidural injection at the mid-vertebral and mid-discal levels from the first lumbar through to the first sacral vertebrae. The dural sac usually showed an oval or hexagonal shape on the transverse views at the first and second lumbar vertebral levels, and the shape of an inverted triangle below the level of the third lumbar vertebra. A median line of translucency was also observed on the posteroanterior epidurographic view in 25 of the 26 patients. This line was though to be a manifestation of the dural deformation to the inverted triangle. Dural sac deformation usually shows a specific pattern, although there are individual variations. Dural deformability is an important consideration in any analysis of the spread of epidural block or of the changes of epidural pressure after epidural injection of local anaesthetics.

Adult↗
PubMed2006

[Treatment of patients with herpes zoster by epidural injection of steroids and local anaesthetics: less pain after 1 month, but no effect on long-term postherpetic neuralgia--a randomised trial].

OBJECTIVE: To assess the effectiveness of a single epidural injection of steroids and local anaesthetics, as a supplement to the standard treatment, for the prevention ofpostherpetic neuralgia in older patients with herpes zoster. DESIGN: Open randomised trial. METHOD: In the period September 2001-February 2004, 598 patients, aged > 50 years, with acute herpes zoster (rash for < 7 days) below dermatome C6, were randomly assigned to receive either standard therapy (oral antiviral agents and analgesics) alone or standard therapy plus an additional single epidural injection of 80 mg methylprednisolone and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain one month after inclusion. The presence and severity of zoster-associated pain at other time points were secondary endpoints. RESULTS: At one month, pain was reported by 137 (48%) patients in the injection group versus 164 (58%) in the control group (relative risk; RR: 0.83; 95% CI: 0.71-0.97; p = 0.02). After three months, these values were 58 (21%) and 63 (24%), respectively (RR: 0.89; 95% CI: 0.65-1-21; p = 0.47), and at 6 months: 39 (15%) and 44 (17%) (RR: 0.85; 95% CI: 0.57-1-13; p = 0.43). No subgroups were detectable in which the relative risk for pain at one month after inclusion substantially differed from the overall estimate. At one month, the median severity of pain in the injection group was 2 (on a 100-points scale) versus 6 in the control group (p = 0.02). At later follow-up, there was no longer any statistically significant difference in the severity of pain between the two groups. No patient had major adverse events related to the epidural injection. CONCLUSION: A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster resulted in a modest decrease in zoster-associated pain in the first month. This treatment did not, however, prevent long-term postherpetic neuralgia.

Aged↗
PubMed1987

Spread of epidural analgesia following a constant pressure injection--an investigation of relationships between locus of injection, epidural pressure and spread of analgesia.

(1) The spread of epidural analgesia following injection of 15 ml of 2% mepivacaine was 17.3 +/- 0.6, 14.3 +/- 0.4, and 13.3 +/- 0.7 spinal segments in cervical, thoracic, and lumbar epidural analgesia, respectively. The patient's age showed significant correlation with the spread of epidural analgesia in cervical (r = 0.5776, p < 0.001), thoracic (r = 0.3758, p < 0.01), and lumbar area (r = 0.8195, p < 0.001). The spread of cervical epidural analgesia was more caudad than cephalad (p < 0.05), but in lumbar epidural analgesia it was more cephalad than caudad (p < 0.05). There was no difference between the cephalad and caudad spread in thoracic epidural analgesia. (2) The epidural pressure immediately after injection of 15 ml of 2% mepivacaine into the lumbar epidural space at a constant pressure (80 mmHg) correlated to the patient's age (r = -0.5714, p < 0.001) and the spread of analgesia (r = -0.3904, p < 0.05). The lower epidural pressure associated with higher age, the wider spread of analgesia. There was no significant correlation between the residual pressure at 60 seconds and the age or the spread of analgesia.

Journal Article↗