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BackgroundEpidural lipomatosis (EL) is an increase of adipose tissue, normally occurring in the epidural space, sufficient to distort the thecal sac and compress neural elements. There is a lack of knowledge of risk factors, impact on patient’s symptoms, and its possible association with epidural steroid injections.MethodsHistory, physical examination, patient chart, and MRI were analyzed from 856 outpatients referred for epidural steroid injections. Seventy patients with signs of EL on MRI comprised the study group. Thirty-four randomly selected patients comprised the control group. The severity of EL was determined by the MRI assessment. The impact of EL was determined by the patient’s history and physical examination. Logistic regression was used to correlate the probability of developing EL with BMI and epidural steroid injections.ResultsEL was centered at L5 and S1 segments. The average BMI for patients with EL was significantly greater than that of control group (36.0 ± 0.9 vs. 29.2 ± 0.9, p <0.01). The probability of developing EL with increasing BMI was linear up to the BMI of 35 after which it plateaued. Triglycerides were significantly higher for the EL group as compared to controls (250 ± 30 vs. 186 ± 21 mg/dL p < 0.01). The odds of having EL were 60% after two epidural steroid injections, 90% after three epidural steroid injections and approached 100% with further injections, independent of BMI. Other risk factors considered included alcohol abuse, use of protease inhibitors, levels of stress, hypothyroidism and genetic predisposition. However there were insufficient quantities to determine statistical significance with a degree of confidence. The impact of EL on patient’s symptoms correlated with EL severity with Spearman correlation coefficient of 0.73 at p < 0.01 significance level.ConclusionsThe BMI and triglycerides levels were found to be significantly elevated for the EL group, pointing to an increased risk of EL occurrence in progressively more obese US population. The data also revealed a strong correlation between the number of subsequent epidural steroid injections and EL occurrence calling for caution with the use of corticosteroids.

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We examined the effects of the following variables on interpleural analgesia after thoracotomy: addition of epinephrine to local anesthetic, thoracostomy drainage, two-catheter placement, and location of catheter tips. Twenty patients were randomized to have one catheter (paravertebral tip location) or two catheters (paravertebral and lateral thoracic wall tip locations). Interpleural catheters were sutured to the parietal pleura by the surgeon at time of wound closure. Patients were then randomly assigned to receive 20 mL of 0.5% bupivacaine with 1:200,000 epinephrine through the single catheter or 10 mL of 0.5% bupivacaine with or without 1:200,000 epinephrine through each of the two catheters while supine. Bupivacaine concentrations in whole blood and in thoracostomy drainage fluid were assayed by gas chromatography. Actual content of bupivacaine in the drainage fluid was calculated. Degree of analgesia was assessed by verbal numerical pain scores over the first 4 h and opioid demand thereafter. Addition of epinephrine to bupivacaine did not influence the degree of analgesia. Approximately 30%-40% of any administered dose of bupivacaine was lost via the thoracostomy tube over a 4-h period. There was no correlation between the true initial dose (100 mg minus thoracostomy drainage) and Cmax. Use of two catheters resulted in significantly less opioid requirements after an initial 8-h period. Failure to achieve adequate interpleural analgesia in postthoracotomy patients may be related to loss of anesthetic via thoracostomy drainage, presence of extravasated blood and tissue fluid in the pleural space, and possibly sequestration and channeling of flow of local anesthetic by restricted motion of an operated lung.(ABSTRACT TRUNCATED AT 250 WORDS)

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Epidural morphine injection followed by a steroid has been reported to be effective for the post-laminectomy pain ('failed back') syndrome. This double-blind, parallel study was undertaken to evaluate that mode of therapy. Twenty-two patients who had undergone at least one prior laminectomy, who were still symptomatic, were randomized to receive 50 mg of lidocaine epidurally with: (a) 75 mg triamcinolone diacetate (TR); or (b) 8 mg of preservative-free morphine (MP); or (c) both (TR and MP), at 1 month intervals for 3 consecutive months. The spinal interspace identified with the patients' pain complaint was the site of injection. For each treatment, patients were admitted to the Clinical Research Center for 24 h and their condition continuously monitored with a pulse oximeter and apnea monitor. Five to 7 patients in each group had pain relief for less than 1 month. No patient given morphine had pain relief for more than 1 month. Life-threatening ventilatory depression occurred in the group given triamcinolone and morphine. The use of morphine alone or combined with slow release triamcinolone does not appear to be appropriate for the treatment of the post-laminectomy pain syndrome.