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PubMed1983

Acute sacral epidural abscess following local anaesthetic injection.

Spinal epidural abscesses are uncommon infections of the central nervous system. Delay in making the diagnosis increases the morbidity and mortality because irreversible neurological damage occurs during this time. We report a 45-year-old male who developed an acute sacral epidural abscess following a local anaesthetic injection given for the relief of low back pain. We believe this is the first documented case of a local anaesthetic injection causing an acute sacral epidural abscess.

Abscess↗
PubMed1999

What height of block is needed for manual removal of placenta under spinal anaesthesia?

The technique of spinal anaesthesia for manual removal of placenta was examined prospectively in 101 women. Factors associated with maternal discomfort during surgery were the height of the block (P = 0.007) and the force applied by the surgeon in removing the placenta (P = 0.04). A sensory block to cold to T9 or T10 resulted in discomfort for six out of 27 women (22%). Only two women out of 38 experienced discomfort with a block to T6 or above. A block to cold to T6 or above is therefore recommended for manual removal of placenta under subarachnoid block. Factors not affecting maternal comfort were grade of the obstetrician, (P = 0.61), grade of the anaesthetist (P = 0.88), position of the mother during spinal injection (P = 0.32), volume of hyperbaric bupivacaine injected (P = 0.75), time from spinal injection to the start of surgery (P = 1.0), and duration of surgery (P = 0.77). Intraoperative hypotension was more common in those women with greater blood loss, (P = 0.002), but not with higher sensory levels (P = 0.31).

Journal Article↗
PubMed2001

Documented arterial gas embolism after spinal epidural injection.

We report the case of a 90-year-old man with syncope, arrhythmia, cardiac ischemia, and neurologic deficit after undergoing spinal epidural injection for control of pain related to post-herpetic neuralgia. The diagnosis of arterial gas embolus was made after air was identified in the left ventricle of the heart on an abdominal computed tomographic scan. Emergency physicians should consider and rapidly diagnose this rare but potentially fatal complication of spinal epidural puncture.

Aged↗
PubMed2005

Nitrous oxide anxiolysis for elective cesarean section.

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.

Adult↗
PubMed1995

Blood pressure changes during labour and whilst ambulating with combined spinal epidural analgesia.

OBJECTIVE: To determine the influence of combined spinal epidural analgesia with fentanyl and low dose bupivacaine on maternal blood pressure and pulse rate in labour. Also, to evaluate the maternal cardiovascular response to mobilising with this form of analgesia in labour. Finally, to define the changes that occur in blood pressure and pulse rate during the second stage of labour and immediately postpartum when using combined spinal epidural analgesia. DESIGN: A prospective observational study. SUBJECTS AND METHODS: Blood pressure and pulse measurements were made at least every 10 minutes, using the SpaceLabs 90207 ambulatory blood pressure monitor, on 62 women in labour with combined spinal epidural analgesia. RESULTS: A significant fall in systolic blood pressure (> 20%) occurred in eight women (12%), all within 30 minutes of the spinal injection. Fifty-two women subsequently received an epidural dose (mean interval 90 minutes after spinal) and none of these women had a fall in systolic blood pressure of greater than 20%. No women had symptoms related to hypotension. Thirty-five women ambulated for more than 10 minutes on 65 occasions. Average blood pressure remained unchanged while ambulating (126/79 versus 126/79), but pulse rate was significantly increased (85 to 90, P < or = 0.001). The mean blood pressure in the second stage of labour (n = 41) did not rise with pushing (134/83 versus 134/83), but the pulse rate increased significantly (94 to 108, P < or = 0.001). Blood pressure remained unchanged immediately postpartum (n = 33) (134/83 versus 134/81) following ergometrine administration. CONCLUSION: The combined spinal epidural analgesia will only result in significant falls in systolic blood pressure within 30 minutes of the spinal injection. No further important changes in blood pressure occur when mobilising or with epidural top-ups. The combined spinal epidural analgesia may modify the normal compensatory mechanisms of blood pressure control, but does not cause significant maternal hypotension once the spinal injection has been given.

Analgesia, Epidural↗
PubMed1983

[Pregnancy achieved by ambulatory treatment of an ejaculation in the paraplegic man. Apropos of a case].

The sub-cutaneous injection of physostigmine (Eserine), an indirect para-sympatheticomimetic by reversible anticholinesterase activity, is capable of provoking ejaculation. The result is therefore identical to that obtained with a spinal injection of neostigmine (Prostigmine), which is only effective by spinal injection. In 6 patients with lesions at T12, L1 and L2, the subcutaneous injection of physostigmine was always effective. When this injection does not provoke any adverse reactions, it can be repeated at home without medical supervision. When this injection results in ejaculation, the erection is improved in 80% of cases and the sexual act is made easier. The usual dose is 2 mg of Eserine. One woman is currently pregnant from such an ejaculation. This method can therefore be proposed in the outpatient treatment of sterility in couples in whom the man is paraplegic, until its oral administration has been perfected.

Ambulatory Care↗
PubMed2003

Antinociceptive potency of intrathecal morphine in the rat tail flick test: a comparative study using acute lumbar catheter in rats with or without a chronic atlanto-occipital catheter.

Chronic spinal catheterization via an atlanto-occipital puncture (CAO) has been widely used to study the effects of drugs on spinal nociceptive mechanisms, but this method is associated with spinal cord damage that may change the efficacy of spinally injected analgesics. Using a slight modification of the method of Storkson et al. (J. Neurosci. Methods 65 (1996) 167), the rat spinal cord was acutely catheterized via a lumbar puncture (AL) and the potency of morphine-induced antinociception in the tail flick test was comparatively studied in animals with or without a CAO catheter. The opiate potency via an AL catheter (AD50; 95% confidence limits) was significantly more intense in rats without (0.29 microg; 0.19-0.47) than in rats with a CAO catheter (1.1 microg; 0.87-1.47) and stronger than via a CAO catheter (8.2 microg; 4.6-14.4). The potency of morphine via a CAO catheter was significantly improved in indomethacin-pretreated rats (1 mg/kg, i.p., twice a day for 5 days), thus indicating that inflammatory changes produced by a CAO catheter are at least in part the reason for the lower efficacy of the opiate. The use of an AL catheter minimizes such spinal changes and permits acute experimental protocols in which more than one spinal injection is necessary.

Animals↗
PubMed1999

Effects of intrathecal clonidine injection on spinal reflexes and human locomotion in incomplete paraplegic subjects.

We studied the effect of the intrathecal (i.t.) injection of clonidine (30, 60 and 90 microg) on the polysynaptic spinal reflexes (PSR) elicited by electrical stimulation of flexor reflex afferents (FRA), monosynaptic reflex and gait of 11 subjects with spinal cord injuries. The effect of clonidine administration on gait velocity, stride amplitude and duration was measured in eight subjects who were able to walk. Five subjects were able to walk after intrathecal injection of clonidine and three were not able to stand up. Three subjects improved their gait velocity after clonidine administration; one (S6) increased his stride amplitude; the two others decreased their cycle durations. The tibialis anterior seemed to be more regularly activated during gait. Spasticity was reduced dramatically (P<0.0001) after i.t. clonidine injection, but there was no statistically significant difference in the soleus H reflex (no effect on Hmax/Mmax). Clonidine administration decreased the amplitude of the early PSR (90-120 ms, N=4) and the threshold and maximal integrated EMG corresponding to the late response (140-450 ms, N=7). This effect was dose dependent (30, 60 and 90 microg). Placebo injection (N=4) caused no change. The changes in spinal reflexes, with a large reduction in spasticity, no change in motoneurone excitability and a large decrease in PSR, suggest that clonidine acts at a premotoneuronal level, possibly by presynaptic inhibition of group II fibres. The increase in gait velocity in three subjects could have been due to reduced spasticity or activation of spinal circuitry.

Adrenergic alpha-Agonists↗
PubMed2002

Effect of delayed supine positioning after induction of spinal anaesthesia for caesarean section.

BACKGROUND: The study tested the hypothesis that the incidence of hypotension during spinal anaesthesia for caesarean section is less in parturients who remain in the sitting position for 3 min compared with parturients who are placed in the modified supine position immediately after induction of spinal anesthesia. METHODS: Spinal anaesthesia was induced with the woman in the sitting position using 2.8 ml hyperbaric bupivacaine 0.5% at the L(3-4) or L(2-3) interspace. Ninety-eight patients scheduled for elective caesarean section under spinal anaesthesia were randomised to assume the supine position on an operating table tilted 10 degrees to the left (modified supine position) immediately after spinal injection (group 0, n=52) or to remain in the sitting position for 3 min before they also assumed the modified supine position (group 3, n=46). Isotonic saline 2-300 ml was given intravenously over 15 min before spinal injection followed by 15 ml/kg over 15-20 min after induction of spinal anaesthesia. If the systolic blood pressure decreased to less than 70% of baseline or to less than 100 mmHg or if there was any complaint of nausea, ephedrine was given in 5 mg boluses intravenously every 2 min. RESULTS: The blood pressure decreased significantly in both groups following spinal injection (P<0.001). Blood pressure variations over time differed significantly between the two groups (P<0.05). However, the incidence of maternal hypotension before delivery was similar in the two groups. The difference was caused by the time to the blood pressure nadir being significantly shorter in group 0 compared with group 3 (9.1+/-4.5 min vs. 11.7+/-3.7 min, P<0.01). Similar numbers of patients received rescue with ephedrine before delivery: 35 (67%) in group 0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9 mg in group 0 vs. 9.2 mg in group 3 (NS). There were no differences in neonatal outcome between the two groups. CONCLUSION: At elective caesarean section, a 3-min delay before supine positioning does not influence the incidence of maternal hypotension after induction of spinal anaesthesia in the sitting position with 2.8 ml of bupivacaine 0.5% with 8% dextrose.

Adult↗
PubMed2002

Therapeutic spinal corticosteroid injections for the management of radiculopathies.

Current literature and a recent meta-analysis suggest a favorable role for corticosteroid injections in the nonoperative treatment of radiculopathy [70]. The superior results reported in recent literature may be attributable to precise fluoroscopically guided transforaminal placement of injectate close to the disc-nerve root interface and near the dorsal root ganglia, maximizing the therapeutic effect. The favorable results of corticosteroid injections in the treatment of radiculopathy caused by a focal disc herniation are consistent with the biochemical construct of radicular pain. The preliminary unfavorable results of therapeutic SNRB for radicular pain caused by epidural or intraneural fibrosis or occurring after trauma may relate to a biomechanical rather than a biochemical etiology. Outcomes for acquired cervical or lumbar spinal stenosis are intermediate compared with those observed for herniated discs and scarring or trauma. Such results may stem from the multifactorial origin of stenosis symptoms; they may develop from impaired venous flow, restricted neural glide, inflammation, or structural root injury. Better-designed studies that use strict inclusion criteria that stratify patients into categories according to the mechanism of injury (atraumatic versus traumatic), the presence or absence of neurologic deficits or imaging abnormalities, and prior treatment will provide the basis for evidence-based treatment decisions. Such an emphasis is just beginning and inevitably will occur. Until then, decisions have to be predicated on the limited and flawed work conducted to date [71]. Nevertheless, the information gleaned from these published reports provides valuable insight not available just a decade ago.

Animals↗
PubMed2003

N-methyl-D-aspartate receptor subunit expression and phosphorylation following excitotoxic spinal cord injury in rats.

The role of NMDA receptor expression and post-translational modification in the pathological and behavioral consequences of injury were examined in rats receiving spinal injections of quisqualate. Spinal cords were removed 3 days following the development of excessive grooming behavior or, if the spontaneous pain-like behavior was not observed, 13 days following injections. Western blots from the spinal tissue demonstrated that non-grooming animals had elevated protein levels of the NR1 subunit of the NMDA receptor. These subunits did not demonstrate an enhanced level of phosphorylation. NR1 protein in grooming rats was not elevated, but there was a significant increase in NR1 serine phosphorylation. These findings suggest that excitotoxic lesions of the spinal cord induce both NR1 expression and NR1 serine phosphorylation. However, the injury-induced excessive grooming behavior is only associated with phosphorylation of the NR1 subunit.

Animals↗
PubMedDate not supplied

Hindlimb paralytic effects of arginine vasopressin and related peptides following spinal subarachnoid injection in the rat.

Intrathecal (IT) injection of arginine vasopressin (AVP) in rats caused a transient (less than 30 min), dose-related paralysis of the hindlimbs, loss of hindlimb and tail nociceptive responsiveness, and increased mean arterial pressure. Motor dysfunction was produced with comparable potency by lysine vasopressin (LVP) and arginine vasotocin (AVT); oxytocin (OXY) was approximately 1000 times less potent. Paralysis induced by these peptides was selectively blocked following IT pretreatment with 0.5 nmoles of the vasopressin V1 receptor antagonist [1-(beta-mercapto-beta,beta-cyclopentamethylene propionic acid), 2-(O-methyl)tyrosine] Arg8-vasopressin (d(CH2)5[Tyr(Me2)]AVP). Pressor and antinociceptive responses to AVP were also blocked by this compound. However, at higher doses (2-5 nmoles, IT), d(CH2)5[Tyr(Me2)]AVP produced hindlimb paralysis, antinociception, and pressor responses by itself. In contrast to the fiber degeneration, cell loss, and necrosis found in lumbosacral cords of rats persistently paralyzed by other peptides (dynorphin A, somatostatin, and ICI 174864), neuropathological changes were not evident in spinal cords of rats transiently paralyzed by IT AVP. These results indicate that AVP-related peptides affected diverse spinal cord functions through interactions with a V1-like receptor. The similar pattern of cardiovascular and antinociceptive responses to other peptides (dynorphin A, somatostatin, and ICI 174864), which also caused hindlimb paralysis, suggests that the former responses may actually reflect the nonselective consequences of a peptide-induced disruption of spinal cord function, rather than specific shared pharmacological effects.

Animals↗
PubMed2000

Pyogenic arthritis of a lumbar facet joint.

We herein report the case of a 68-year-old man with diabetes who developed pyogenic arthritis of a lumbar facet joint after spinal injection. We performed magnetic resonance imaging (MRI), computed tomography (CT), technetium 99 methylene diphosphonate scintigraphy, and single photon emission computed tomography (SPECT) for this patient. MRI showed a lesion in the facet joint and no evidence of spondylodiscitis. CT showed a swelling of periarticular soft tissue around the facet joint. Bone scintigraphy showed a characteristic vertical uptake. In particular, SPECT was able to clearly confirm the location of the infection. An infection of the facet joint has only been rarely reported, but we recommended that this area should be carefully evaluated whenever a patient develops an infection of the lumbar spine after a spinal injection.

Aged↗
PubMed1990

Enflurane reduces the excitation and inhibition of dorsal horn WDR neuronal activity induced by BK injection in spinal cats.

The effects of enflurane (0.5%, 1.5% and 2.5%) on the excitation and inhibition of dorsal horn wide dynamic range (WDR) neuronal activity induced by bradykinin (BK) injection was studied in spinal cats. Extracellular activity was recorded in the dorsal horn from single WDR neurons responding to noxious and non-noxious stimuli applied to the cutaneous receptive fields on the left hind paw foot pads of decerebrate, spinal cord transected (L(1-2)) cats. When 10 microg of BK was injected into the femoral artery ipsilateral to the recording site as the noxious test stimulus, 24 of 26 WDR neurons (92%) gave excitatory responses and 2 (8%) gave inhibitory responses. On the other hand, when the injection of 10 microg of BK into the femoral artery contralateral to the recording site was used as the noxious test stimulus, 7 of 12 WDR neurons (58%) gave inhibitory responses, 3 (25%) gave excitatory responses, and 2 (17%) showed no response. The excitatory neuronal activity in WDR neurons was not depressed by 0.5% or 1.5% enflurane but was depressed significantly by 2.5%. However, the inhibitory neuronal activity in WDR neurons was significantly depressed by 0.5%, 1.5% and 2.5% enflurane. We have found that enflurane reduces the excitation as well as the inhibition of dorsal horn WDR neuronal activity induced by BK injection. These results suggest that the reduction of excitatory and inhibitory responses produced by noxious stimulation is likely to be the fundamental basis of the enflurane-induced anesthetic state in terms of WDR neurons.

Journal Article↗
PubMedDate not supplied

Effect of He-O2, O2, and N2O-O2 breathing on injected bubbles in spinal white matter.

Injected air bubbles in spinal white matter in the rat were studied at 1 bar after decompression from an exposure to air at 3.1 bar (absolute) for 4 h. During air breathing all injected bubbles grew for the first 2 h of the observation period. Thereafter three of nine bubbles began to shrink and one of them disappeared. During breathing of heliox (80:20) bubbles consistently shrank and disappeared from view. If the breathing gas was changed from heliox to N2O-O2 (80:20), while bubbles still had an appreciable size, they started growing again. If the change to N2O-O2 was done after a bubble disappeared from view, it did not reappear. During breathing of 100% oxygen, all bubbles initially grew. Subsequently they all shrank and disappeared at about the same time after gas shift, as during heliox breathing. The effect of heliox treatment on CNS decompression sickness after air dives is discussed.

Adipose Tissue↗
PubMed1994

Influence of duration of lateral decubitus on the spread of hyperbaric tetracaine during spinal anesthesia: a prospective time-response study.

Searching for a differential spinal block between dependent and nondependent sides, we evaluated a prospective randomized time-response study of the influence of the duration of lateral decubitus on the spread of hyperbaric local anesthetic solution during spinal anesthesia in 60 patients undergoing lower limb surgery. In a lateral position with the operated side dependent, all patients received 12 mg of lyophilized tetracaine with 0.2 mg epinephrine in 2.5 mL 10% dextrose and were randomized into four groups according to the duration of lateral decubitus after spinal injection: Group 0, patients immediately turned supine after spinal injection; Group 6, 6 min in lateral decubitus then supine; Group 12, 12 min in lateral decubitus then supine; Group 18, 18 min in lateral decubitus then supine. There was no difference in maximum sensory level between both sides in the same group nor between the four groups. In all four groups a comparable number of patients had a Grade 4 motor block on the dependent as well as on the nondependent side. A positive correlation found between duration of lateral decubitus and duration of sensory block on the dependent side suggested a preferential spread of hyperbaric local anesthetics. This differential spread was confirmed by the positive correlation between the duration of lateral decubitus and the difference in duration between dependent and nondependent sides of both sensory and motor blocks. However, because of the minimal differences between groups, we believe there is no reason to routinely maintain patients in the lateral position after performing spinal anesthesia.

Adult↗
PubMed2001

Neostigmine combined with bupivacaine, clonidine, and sufentanil for spinal labor analgesia.

UNLABELLED: We previously found that spinal clonidine prolongs labor analgesia when combined with spinal bupivacaine and sufentanil. We sought to determine whether the addition of spinal neostigmine to these drugs would further enhance labor analgesia. By use of a combined spinal/epidural technique, 36 patients were randomized to receive a hyperbaric spinal injection of bupivacaine 2.5 mg plus clonidine 50 microg and sufentanil 10 microg with or without neostigmine 10 microg. Pain, maternal hemodynamics, fetal heart rate, nausea, pruritus, sedation, motor block, sensory levels to pinprick, and maternal oxygen saturation were assessed at regularly specified intervals after spinal injection until additional analgesia was requested. The duration of spinal analgesia was similar between groups (215 +/- 60 min in the Control group versus 205 +/- 62 min in the Neostigmine group). Likewise, pain scores, the duration of labor, Apgar scores, and side effects were similar between groups except that patients administered neostigmine experienced significantly more nausea and vomiting (53% vs 7%, P = 0.01). We conclude that spinal neostigmine 10 microg produces severe nausea and does not potentiate the duration of spinal analgesia in laboring women from spinal bupivacaine, clonidine, and sufentanil. IMPLICATIONS: Spinal neostigmine 10 microg as an adjunct to spinal bupivacaine, clonidine, and sufentanil produces severe nausea and fails to potentiate analgesia in laboring women.

Adjuvants, Anesthesia↗