Back Pain Following Thoracic Epidural Placement-Now What?

Abstract

We describe a case of severe back pain following thoracic epidural placement. We discuss the differential for such a case, and the management as well.One of the most feared complications of epidural placement is epidural hematoma. Back pain following epidural catheter placement can have several causes, from those of a trivial nature to those that are a true medical emergency, and can range in degree from mildly sore to excruciating in nature. We present a case of severe back pain shortly following epidural catheter placement that mimicked epidural hematoma but was not. CaseA 66 year old 80 kilogram white male with non-small cell carcinoma of the lung was scheduled for a thoracotomy with excision of the mass. His past medical history was significant for a 100 pack-year cigarette smoking history, hypertension, and osteoarthritis. He took no antithrombotic or antiplatelet drugs, and had no history of bleeding diatheses or easy bruising. His coagulation studies were within normal limits, specifically a platelet count of 428, PT/INR 10.8/1.0, and PTT of 29. After sedation with 2 milligrams of midazolam administered intravenously, an epidural catheter was placed at the level of T6/T7 via a midline insertion for postoperative pain control preoperatively in the holding room. The placement itself was unremarkable, with loss of resistance (with air) at 7 centimeters, and the catheter was easily threaded to 12 centimeters at the skin. A 3 milliliter test dose of 1.5% lidocaine with epinephrine 1:200,000 was negative. The patient tolerated the procedure well.The patient's entrance into the operating room was delayed for a time. Three and a half hours later, the holding room staff advised us that the patient was complaining of severe back pain. The patient was found to be sitting on the side of the bed, asking for the epidural catheter to be removed. He said lying on the bed was too painful. He related that his pain was 10/10, sharp in nature, in the immediate area of the epidural catheter. He also related that dorsiflexion of his feet worsened the pain. There was slight radiation of the pain superiorly. His strength in all extremities was normal, and his patellar reflexes were intact. The epidural site was normal in appearance, and no blood or clear fluid was obtained upon aspiration of the catheter.A stat magnetic resonance imaging (MRI) was ordered, and neurosurgery was alerted to be on standby in case an epidural hematoma was discovered on imaging. The MRI showed no evidence of epidural hematoma, and the epidural catheter was visible in the epidural space; there was an incidental finding of a hemangioma in the body of the T4 vertebra. Furthermore, there was no significant disc disease or osteoarthritic changes.The catheter was removed following the MRI; over the next few hours, his pain gradually decreased. The patient was treated with opiate analgesics overnight, and the surgery was postponed. The patient underwent his planned thoracotomy the next day, and his postoperative pain was managed by intravenous, and t...

Dexamethasone added to Local Lidocaine for Infiltration along the Spinal-Epidural Needle Pathway Decreases Incidence and Severity of Backache after Gynecological Surgery

“…Muslu et al [ 3 ] in 2009 locally administered lornoxicam to lessen the incidence of back pain, but the authors could not evaluate its effect on chronic back pain because the half-life of lornoxicam is less than 4 hours. Other studies have also shown that dexamethasone could reduce postoperative pain and analgesic consumption [ 1 , 2 , 17 , 18 ].…”

“…Sample size was based on previous studies that indicate that the incidence of lumbar pain on the first day after epidural anesthesia in non-obstetric patients was approximately 20% [ 1 , 2 ]. To achieve a statistical power of more than 80%, with a significance criteria (α) of 0.05, Seventy-one patients were needed in each group to detect a difference of 15% in the incidence of back pain between the two groups (PASS, 2008, 2008, Kaysville, Utah) All the data were analyzed using the SPSS 13.0 (IBM, Armonk, NY, USA).…”

“…Spinal-epidural anesthesia is commonly used in gynecological surgery. The incidence of back pain after epidural anesthesia is over 20% [ 1 – 3 ]. It occurs rarely after spinal anesthesia [ 4 ].…”

“…In 2009 Muslu et al [ 3 ] found that local administration of nonsteroidal anti-inflammatory drugs significantly relieved post-epidural low back pain. Because of its anti-inflammatory effects, dexamethasone has been used to treat post-epidural lumbar pain and to reduce the consumption of postoperative analgesics [ 1 ]. Some studies have shown that epidural injection of dexamethasone could reduce back pain [ 7 – 9 ].…”