BACKGROUND: No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects. METHODS: Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported. RESULTS: A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001). CONCLUSIONS The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.
Pregnancy ; Female ; Humans ; Post-Dural Puncture Headache/epidemiology* ; Anesthesia, Obstetrical/adverse effects* ; Retrospective Studies ; Punctures ; Starch ; Blood Patch, Epidural

OBJECTIVE: To evaluate the efficacy of lumbar transforaminal epidural block (LTEB) for treatment of low back pain with radicular pain. METHODS: We retrospectively analyzed the clinical data of 78 patients with low back pain and radicular pain admitted to the Department of Orthopedics of Beijing Chuiyangliu Hospital from March, 2017 to April, 2019. Thirty-three of the patients received treatment with LTEB (LTEB group), and 45 received comprehensive conservative treatment including traction, massage, acupuncture and physiotherapy (control group). The demographic and clinical data of the two groups were compared. The patients were followed up for 3 to 24 months, and numerical rating scale (NRS) and Oswestry disability index (ODI) scores of the patients were evaluated before the treatment and at 2 weeks, 1 month and 3 months after discharge to assess the efficacy of the treatment. RESULTS: The mean operation time of LTEB was 25.7 7.5 min (15-45 min). After the operation, 5 patients developed weakness of the lower limbs but all recovered within 24-72 h. The patients receiving LTEB all showed significantly decreased NRS scores for low back and radicular pain and ODI scores after the operation ( CONCLUSIONS As a minimally invasive approach, LTEB is effective for treatment of low back pain with radicular pain and can produce good short-term effects of pain relief and functional improvement.
Humans ; Injections, Epidural ; Low Back Pain/drug therapy* ; Lumbar Vertebrae ; Radiculopathy/drug therapy* ; Retrospective Studies ; Treatment Outcome

INTRODUCTION: Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS: 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS: Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.
Adrenocorticotropic Hormone ; blood ; Adult ; Aged ; Blood Glucose ; analysis ; Body Mass Index ; Dexamethasone ; administration & dosage ; therapeutic use ; Diabetes Mellitus ; therapy ; Endocrine System ; drug effects ; Female ; Glucocorticoids ; administration & dosage ; Humans ; Hydrocortisone ; blood ; Hypothalamo-Hypophyseal System ; drug effects ; Injections, Epidural ; methods ; Male ; Middle Aged ; Pituitary-Adrenal System ; drug effects ; Postprandial Period ; Singapore ; Young Adult

BACKGROUND: Lumbosacral transforaminal epidural injection (TFEI) is an effective treatment for spinal disease. However, TFEI may have several types of complications, some of which can be attributed to intravascular injection. We reviewed studies to compare the intravascular injection rate among different needle types. METHODS: We searched the literature for articles on the intravascular injection rate among different needle types used in TFEI. The search was performed using PubMed, MEDLINE, the Cochrane Library, EMBASE, and Web of Science. RESULTS: A total of six studies comprising 2359 patients were identified. Compared with the Quincke needle, the Whitacre needle reduced the intravascular injection rate (OR = 0.57, 95% CI = [0.44–0.73], P < 0.001). However, compared with the Quincke needle, the Chiba needle did not reduce the intravascular injection rate (OR = 0.80, 95% CI = [0.44–1.45], P = 0.46). In one study, the intravascular injection rate using a blunt-tip needle was lower than that using a sharp needle. In another study, the Whitacre and the blunt-tip needle have similar intravascular injection rates, while, the catheter-extension needle showed a reduced intravascular injection rate. CONCLUSIONS: This meta-analysis showed that the Whitacre needle reduced the intravascular injection rate as compared with the Quincke needle, but failed to establish that the Chiba needle can decrease the intravascular injection rate in TFEI. Moreover, the blunt-tip needle can reduce the intravascular injection rate compared with the Quincke needle, and the catheter-extension needle can reduce the intravascular injection rate compared with the Whitacre and the blunt-tip needle.
Anesthesia, Epidural ; Humans ; Injections, Epidural ; Needles ; Spinal Diseases

BACKGROUND: Hypertonic saline (HS) injections for decompressive neuroplasty (DN) can cause pain. We assessed whether a continuous infusion of HS through an infusion pump would reduce injection-related pain compared with repeated bolus administrations. METHODS: Fifty patients scheduled for DN were randomized to either the bolus injection or the continuous infusion group. After appropriately placing the epidural catheter, 4 mL of 5% NaCl was injected as four boluses of 1 mL each at 15-minute intervals or infused over 1 hour using an infusion pump. The severity of pain induced by HS injection, as measured by the 11-point numerical rating scale (NRS), was the primary outcome. The severity of low back or lower extremity pain, as measured by the 11-point NRS and Oswestry Disability Index (ODI), 3 months following the procedure, was the secondary outcome. RESULTS: Data from 21 patients in the bolus group and 23 in the continuous infusion group were analyzed. No statistically significant difference in injection-related pain was identified between the two groups during the initial HS administration (P = 0.846). However, there was a statistically significant reduction in injection-related pain in the continuous infusion group compared to the bolus injection group from the second assessment onwards (P = 0.001, < 0.001, and < 0.001, respectively). No significant between-group differences in the NRS and ODI scores 3 months post-procedure were noted (P = 0.614 and 0.949, respectively). CONCLUSIONS: Our study suggests that administering HS through a continuous infusion is a useful modality for reducing HS injection-related pain during DN.
Catheters ; Chronic Pain ; Humans ; Infusion Pumps ; Injections, Epidural ; Low Back Pain ; Lower Extremity ; Radiculopathy ; Saline Solution, Hypertonic ; Spinal Stenosis

BACKGROUND: To develop a rabbit epidural steroid injection (ESI) model for analyzing steroid retention in the tissue, and to assess the difference in steroid retention in the model according to the location and time elapsed after ESI. METHODS: Fluoroscopy-guided ESI was performed using the interlaminar approach between the lowest two lumbar segments in 13 female New Zealand white rabbits. Four rabbits were allocated to each of three different groups according to the time of sacrifice: 3, 7, and 15 days post-ESI; the remaining rabbit was sacrificed immediately post-ESI to obtain baseline data. After sacrifice, two segments were harvested: the lowest two lumbar vertebrae and another two lumbar vertebrae immediately above these. The residual steroid amount (RSA) and residual steroid concentration (RSC) in the collected spinal columns were analyzed. A linear mixed model was used to compare RSAs and RSCs between the injected and adjacent segments, and among the number of days until sacrifice; P < 0.05 was considered statistically significant. RESULTS: Both RSA and RSC of the injected segment were significantly higher than those of the adjacent segment (P < 0.001, both). The RSA and RSC significantly decreased over time (P = 0.009 and P = 0.016, respectively). CONCLUSIONS: The developed rabbit ESI model verified that significantly more steroid was retained at the injected segment than at the adjacent segment and the residual steroid decreased over time. This model could be useful not only for comparing current steroid medications, but also for developing new, better steroid formulations.
Female ; Fluoroscopy ; Humans ; Injections, Epidural ; Lumbar Vertebrae ; Models, Animal ; Rabbits ; Spine ; Steroids

A 55-year-old man with an implantable intrathecal drug delivery system (IDDS) implant removal surgery was performed to control a suspected implant infection. Clear discharge from a lumbar wound was detected after IDDS removal, but transcutaneous cerebral spinal fluid (CSF) leakage was not suspected because the patient did not suffer from a postural headache. Finally, a suspected CSF leakage was resolved with a single epidural blood patch.
Blood Patch, Epidural ; Drug Delivery Systems ; Headache ; Humans ; Middle Aged ; Neuralgia, Postherpetic ; Wounds and Injuries

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous leakage of cerebrospinal fluid, with postural headache as the primary symptom. Orthostatic headache caused by SIH is often not resolved by conservative management. CASE: We performed 15 epidural blood patch treatments in a 43-year-old female patient; however, they were only transiently effective. To improve the patient's SIH and orthostatic headache, epidural fibrin glue patch treatment was attempted. Fibrin glue is a substance that can act as a bio-friendly adhesive by facilitating the coagulation cascade. In our case, 3 epidural fibrin glue patch treatments were performed and the symptoms completely resolved. CONCLUSIONS: The epidural fibrin glue patch may be beneficial for the treatment of refractory postural headaches caused by SIH.
Adhesives ; Adult ; Blood Patch, Epidural ; Cerebrospinal Fluid ; Female ; Fibrin Tissue Adhesive ; Fibrin ; Headache ; Humans ; Intracranial Hypotension

We encountered a very rare case of spontaneous spinal cerebrospinal fluid (CSF) leakage and a spinal intradural arachnoid cyst (AC) that were diagnosed at different sites in the same patient. These two lesions were thought to have interfered with the disease onset and deterioration. A 30-year-old man presented with sudden neck pain and orthostatic headache. Diplopia, ophthalmic pain, and headache deteriorated. CSF leakage was confirmed in C2 by radioisotope cisternography, and an epidural blood patch was performed. While his symptoms improved gradually, paraparesis suddenly progressed. Thoracolumbar magnetic resonance imaging (MRI) revealed an upper thoracic spinal intradural AC, which was compressing the spinal cord. We removed the outer membrane of the AC and performed fenestration of the inner membrane after T3-4 laminectomy. Postoperative MRI showed complete removal of the AC and normalized lumbar subarachnoid space. All neurological deficits including motor weakness, sensory impairment, and voiding function improved to normal. We present a case of spontaneous spinal CSF leakage and consecutive intracranial hypotension in a patient with a spinal AC. Our report suggests that if spinal CSF leakage and a spinal AC are diagnosed in one patient, even if they are located at different sites, they may affect disease progression and aggravation.
Adult ; Arachnoid ; Blood Patch, Epidural ; Cerebrospinal Fluid Leak ; Cerebrospinal Fluid ; Diplopia ; Disease Progression ; Headache ; Humans ; Intracranial Hypotension ; Laminectomy ; Magnetic Resonance Imaging ; Membranes ; Neck Pain ; Paraparesis ; Spinal Cord ; Subarachnoid Space

The approach we suggest was developed for cases in which the fourth and fifth lumbar and first sacral spinal nerves were affected in lumbar degenerative disc disease. Retrodiscal transforaminal epidural injection is known to be very effective for lumbar radiculopathy because of excellent access to primary pathology; however, access below L5 is often restricted by the anatomic characteristics of the L5–S1. In the translateral recess approach (TLR), proper final needle placement (i.e., in the axillary portion between the exiting and traversing nerve roots) can be achieved by setting the direction of the needle laterally and superiorly from the distal tip of the infra-adjacent spinous process toward the medial wall of the pedicle and neural foramen of the given level without neural injury. This approach is possible because of the wide interlaminar space in the L5–S1. Preganglionic epidural injection through TLR is an effective and safe spinal intervention for lumbosacral radiculopathy.
Injections, Epidural ; Needles ; Pathology ; Radiculopathy ; Spinal Nerves