Cervical epidural analgesia via a thoracic approach using nerve‐stimulation guidance in adult patients undergoing total shoulder replacement surgery

Abstract

This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.

Electrophysiological stimulation (Tsui test) is feasible for epidural catheter positioning in adults with chronic back pain: a cohort study

“…It had a sample size comparable to those of other feasibility studies using the Tsui test. 11,12 Although the study was not powered to make comparisons between interventions, we found a substantial, but not statistically significant, correlation between the Tsui test and fluoroscopy for determining the appropriate position for the epidural catheter tip. We also used a compliant epidural catheter, which may have affected the accuracy of the positioning and consequently the procedure time.…”

“…Tsui et al had a high success rate using electrical stimulation to guide catheter placement to the desired position in the epidural space. 12 Their technique has also been used successfully to guide placement of thoracic epidural catheters via the caudal route in small infants and children. 28,30 In our study, the Tsui test elicited isolated sensory responses in only three patients (3/12), with no motor responses.…”

“…Consequently, no formal sample size was calculated, but using data from other feasibility studies with the Tsui test to attain a sample size of 12 was deemed appropriate. 11,12 Data are reported as means and standard deviations or as medians and interquartile ranges as appropriate. The kappa statistic was used to test for agreement between the interventions.…”

“…These investigators applied low-current electrical stimulation to nerves via an epidural catheter and assessed the patient's sensory and motor responses. [10][11][12] The Tsui test is considered positive (proper epidural catheter positioning) if there is a myotome response, either unilateral or bilateral, with a current of 1-10 mA and if the magnitude of the response is independent of the placement of the ground electrode. 10 The Tsui test is negative if a current of less than 1 mA elicits a motor response, which would imply either subarachnoid placement or placement against a nerve root.…”

Keys to minimizing the risk of spinal cord trauma during a lumbar approach to thoracic epidural

“…These observations also explain why an epidural catheter can be threaded successfully from the thoracic space to the cervical space in awake adults without any discomfort by using a paramedian thoracic approach with a styletted catheter with steep needle angulations ([ 30°). [6][7][8] In this situation, the angle of insertion of the catheter is already directed towards the cranially located target, easing advancement from the needle tip and threading through the epidural space.…”