Thoracic Epidural Injection

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Thoracic Epidural injectionDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist1Accessing the epidural space was first described in 1921

The initial reports mostly described epidural catheter placement for the management of failed chest, post- CABG pain, and post-thoracotomy painDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistEpidural steroid injections was introduced in 1953 and after that injected for millions patients with radicular and lumbur back painsDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistANATOMYDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistEpidural space:Superior boundary fusion of the periosteal and spinal layers of dura at the foramen magnumInferiory :sacrococcygeal membraneDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistAnteriorly :posterior longitudinal ligamentposteriorly vertebral laminae and the ligamentum flavum lateraly:vertebral pedicles and intervertebralforaminaDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistThe thoracic epidural space contains fat veins arteries lymphaticsconnective tissueDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistThoracic epidural space extends from the lower margin of the C7 vertebra to the upper margin of L I

The thoracic epidural space is 3 to 4 mm at the C7-Tl interspace with the cervical spine flexed and about 5 mm at the TII-TI2 interspace.Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistThoracic epidural block in the midline:Skin Subcutaneous tissuesSupraspinous ligamentInterspinous ligamentligamentum flavum


Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist"when the needle tip enters the space between the interspinous ligament and the ligamentum flavum false" loss of resistance may be perceived This phenomenon is more pronounced in the thoracic region than in the lumbar region as a result of the less well-defined ligamentsDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistDemifacet & transverse articular facetDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist




Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistThe thoracic vertebral interspaces between T3 and T9 are functionally unique(Acute downward angle of the spinous processes) This downward slope means that the spinousprocess of any given mid-thoracic vertebra is in fact inferior to the interlaminar space of its adjacent vertebraDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistApproachDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistInterlaminar (or translaminar) epidural block1- Midline in T1-T3 or T9-T12 ( C7 - T5 or T9-Ll )2-Paramedian in T3-T9

Transforaminal epidural block(selective epidural block)(selective nerve root block )

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistA selective nerve root block is a spinal procedure in which anesthetic is placed on a specific nerve root of the spine to help identify the exact source of leg or arm pain. The injection usually also contains steroid to decrease inflammation and pain. The injection is similar to a transforaminal epidural steroid injection, but in a selective nerve root block there is no attempt to have the medication enter the epidural space. Rather, the aim is strictly to cover the offending nerve root.

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Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistMidline Approach

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistINDICATIONSThoracic and upper abdominal surgical anesthesiaDiagnostic tool in the evaluation of chest wall and intraabdominal painIf destruction of the thoracic nerve roots is being consideredDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistpalliate acute pain emergencies while waiting for pharmacologic, surgical, or antiblastic methods to become effectivepostoperative painpain secondary to traumaacute herpes zosterpain of acute pancreatitiscancer-related painResistant angina

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistchronic benign pain syndromes:thoracic radiculopathy,Thoracic postlaminectomy syndrome vertebral compressionfractureschronic pancreatitis diabetic polyneuropathychemotherapy-related peripheral neuropathyPostherpetic neuralgiareflex sympathetic dystrophyabdominal pain syndromesDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistAbsolute ContraindicationsPatient refuses or uncooperativelocal infection sepsis ( relative)anticoagulation and coagulopathyUncorrected hypovolemia (relative)History of severe real anaphylaxisPreganancy

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistRelative ContraindicationsDistorted anatomySevere mitral or aortic stenosis (omit local anesthetic)Diabetes melitusCHFGlaucoma

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistTECHNIQUEDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistEQUIPMENTTuohy epidural needle or similarWhen applicable, special needles for epidural andelectrical stimulation catheter25-gauge, 3/4-inch infiltration needle3-cc syringe10-cc syringe Loss-of-resistance (LOR) syringeDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistepidural catheters and electrodesIV T-piece extensionDRUGS1% lidocaine0.25-0.5% bupivacaine and ropivacaineSteroidsPreservative-free normal saline (PFNS)Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistPOSITIONSDitting positionLateral positionProne positionDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

1-patient is placed in optimal sitting position with the thoracic spine flexed and forehead placed on a padded bedside table2- the skin is prepared with an antiseptic solution

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist3- Operator's middle and index fingers are placed on each side of the spinous processes. using a rocking motion in the superior and inferior planes4- One milliliter of local anesthetic is used to infiltrate the skin, subcutaneous tissues, and supraspinous and interspinous ligaments at the midlineDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist5 Epidural needle is inserted exactly in the midline through the supraspinous ligament into the interspinous ligament

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist6-syringe containing preservative-free saline with constant pressure being applied to the plunger of the syringe with the thumb of the right hand, the needle and syringe are continuously advanced in a slow and deliberate manner with the left handDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist7-As soon as the needle bevel passes through the ligamentum flavum and enters the epidural space, there will be a sudden loss of resistance to injection, and the plunger will effortlessly surge forwardThe syringe is removed gently from the needle.

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist8-An air or saline acceptance test is carried out by injecting 0.5 to I mL of air or sterile preservative-free salineDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistAlternative:Hanging dropFluoroscopy (especially in obesity)Stimulation

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist9- aspirationIf CSF seen:Change your epidural space and adjust your dosesIf blood seen Slightly rotate the needleif the blood disapear inject carefully

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist10 When satisfactory needle position is confirmed5 to 7 mL of solution in upper thoracic region8 to 10 mL of solution in lower thoracic region

6 to 7 ml in midthoracic (paramedian)

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistDrugs Diagnostic and prognostic blocks 1.0% preservative-free lidocaineTherapeutic blocks 0.25% preservative-free bupivacaine, + with 80 mg of depot methylprednisolone(Subsequent nerve blocks 40mg steroid)Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistOpioidsupper thoracic 1 mg morphineLower thoracic 4 to 5 mg of morphineMidthoracic (paramedian) 3 mg morphine

Fentanyl infusion

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistFluoroscopy1- prone position2- A-P fluoroscopy:Interlaminar space visualized3-epidural needle advanced until contact to lamina4- needle walked off the lamina , ligamentum flavum contacted and needle advanced with loss of resistanceDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist5-Lateral view6- 1ml dye injected to confirm7- medicatin injected8- needle restyletted and removedDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist




Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistCATHATER52

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistCATHATER

53SIDE EFFECTS AND COMPLICATIONSInfectionepidural hematomainjury to the nerve roots intravascular injectionrespiratory depression Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist54subdural subarachnoid injectionspinal cord damageEpidural abscessInteraplural injectionBradycardia & hypotension Respiratory muscle weakness in COPD and..


Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistParamedian approach



Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistIndications Epidural block in midthoracic

This technique has been especially successful in the relief of pain secondary to metastatic disease of the spineDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

TECHNIQUE

Only differences :After finding epidural space by fingers:1-At a point about 0.5 inch lateral to the midline at the level of the inferior border of the spinous process, I mL of local anesthetic is used to infiltrate

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist2- Epidural needle is inserted perpendicular to the skin into the subcutaneous tissues The needle is then redirected slightly medial and craniad and advanced about 0.5 inch

3- With loss of resistance technique advanced the needle and syrange Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistTransforaminal ApproachDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistIndicationsDiagnostic tool or treatment modality when performing differential neural blockade

If destruction of the thoracic nerve roots is being considered

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistCommon painful conditionsThoracic radicular pain and radiculopathy secondary to thoracic disk displacementAcute herpes zosterVertebral compression fractureMetastases to the thoracic spine Neural foraminal stenosisPerineural fibrosisDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistspecialists believe the transforaminal approach to the thoracic epidural space is more efficacious in the treatment of painful conditions involving a single nerve root albeit with a higher incidence of potential complicationsDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistTECHNIQUE

Position prone1- End plates of the affected vertebra are aligned or squared up on fluoroscopy

2-Fluoroscopy beam is rotated to a more ipsilateral oblique position to bring the images of the spinous process and head of the ribs medially Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist3-A "magic box" consisting of the superior end plate, the inferior end plate, the lamina or lateral pedicle lines, and the rib head is then visualizedThe magic box represents the target for needle placement.


Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist4-skin is then prepared with an antiseptic solution5-skin wheal of local anesthetic is placed at a point overlying the magic box that corresponds to the inferior aspect of the foramen6-spinal needle is then Placed in area and advanced until the tip is near the level of the posterior elements


Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistCare must be taken to ensure the needle tip does not stray laterally (pleura) or medially (spinal cord)7-A lateral view is then used to advance the needle tip into the foramen8-An anteroposterior view is then obtained, and the needle tip is seen to lie just medial to the lateral laminar borderDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist8-After satisfactory needle position is confirmed, 0.2 to 0.4 mL of contrast medium suitable for subarachnoid use is gently injected under active fluoroscopyDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist9-After a satisfactory pattern is observed 3 to 6 mg of betamethasone solution, 20 to 40 mg of methylprednisolone, or triamcinolone 20 to 40 mg suspension with 0.5 to 1.5 mL of 2.0% to 4.0% preservative-free lidocaine is slowly injected.Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturistSIDE EFFECTS AND COMPLICATIONS1-All the potential side effects and complications associated with the interlaminar approachHigher incidence:Persistent paresthesias and trauma to neural structures (quadriplegy)Unintentional dural punctureDamage or injection to the segmental artery can by transforaminal approach to the T7-L4 neural foramen on the left


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Thoracic Epidural Injection