• The Korean Journal of Pain
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• v.11 no.1
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• pp.105-108
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• 1998

Backgrounds: Cervical epidural nerve block is useful in the management of a variety of acute, chronic and cancer related pain syndromes involving the head, face, neck and upper extrimity. To safely perfom the cervical epidural block, an appreciation of the expected distance from skin to epidural space is important. We studied the distance from skin to cervical epidural space of adults to determine if any relationship exists between patient height, weight and neck circumference and the distance from skin to epidural space. Methods: Patients 170, suffering from neck and upper extremity pain with cervical HIVD(herniated intervertebral dics) were selected. Cervical epidural block was performed at $C_{6\sim7}$ or $C_{7-}T_1$ intervertebral space. Then measured the distance from skin to epidural space and analysed the relationship between age, height, weight and neck circumference and the distance from skin to epidural space. Results: The cervical epidural depth of male $C_{6\sim7}$, male $C_{7-}T_1$, female $C_{6\sim7}$ and female $C_{7-}T_1$ groups were $5.17{\pm}0.63$, $5.47{\pm}0.59$, $4.84{\pm}0.56$ and $5.01{\pm}0.60$ cm respectively. Cervical epidural depth significantly correlated with body weight, ponderal index and neck circumference. Conclusions: The distance from skin to cervical epidural space has significant relationships with weight, ponderal index and neck circumference. Although experience is important, patient's weight and neck circumference are indicating factor, of the cervical epidural depth.

• The Korean Journal of Pain
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• v.9 no.2
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• pp.349-353
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• 1996

Background: Although the paramedian approach for epidural blockade is useful in some clinical situation, the parameters which are correlated with the distance from skin to the epidural space has not been established. Methods: We studied in 143 patients having elective continuous epidural blocks for relief of postoperative pain. All blocks were performed using paramedian approach with Tuohy needle in the lumbar (group 1, n=100) and thoracic (group 2, n=45) area. We measured the distance from skin to the epidural space, body weight, height, and the angle between the shaft of the needle and the skin. Data were analyzed by linear regression. The relationships between parameters identified by the F-test with a P value of less than 0.05 were considered statistically significant. Results: The mean distance from skin to the lumbar epidural space was $4.4{\pm}0.7$ cm. significant correlation between the body weight and the depth of lumbar epidural space ($\gamma$ value : 0.492) was noted with regression equation of depth(cm)=2.293+0.034${\times}$body weight (kg). Also the significant correlation between the ponderal index (PI) and the depth of lumbar epidural space ($\gamma$ value : 0.539) was noted with regression equation of depth(cm)=1.703+0.07${\times}$PI, The mean distance from skin to the thoracic epidural space was $5.2{\pm}0.7cm$ which did not correlated with other anatomic measurements. Conclusion: We found that PI and body weight are the suitable predictors of the depth of the lumbar epidural space, but not the thoracic epidural space.

• The Korean Journal of Pain
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• v.19 no.2
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• pp.168-174
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• 2006

Background: Several biochemical mediators, such as substance P, calcitonin gene-related peptide (CGRP) and prostaglandin $E_2$, have been demonstrated to be involved in herniated or degenerated disc-induced radiculopathy. The authors tested the hypothesis that these mediators would existed in the epidural space of humans. Methods: Thirty nine patients were divided into two groups; 27 patients, who were diagnosed with spinal stenosis (stenosis group), and 12 scheduled for epidural anesthesia, without a history of back pain (control group). Under fluoroscopic guidance, an epidural catheter was introduced through the caudal space and placed into the anterior and posterior spaces, up to and around the epidural adhesive area, in the stenosis group. In the control group, the catheter was placed into the posterior epidural space through the L3⁣-4 or L4⁣-5 intervertebral space. Epidural irrigation was performed with 10 ml of saline, via an epidural catheter. Aspirated lavage fluid was collected, and the concentrations of biochemical mediators (substance P, CGRP and prostaglandin $E_2$) measured using an enzyme immunoassay kit. Results: Substance P, CGRP and prostaglandin $E_2$ were detected in all the epidural lavage fluids from both groups. The concentrations of substance P and prostaglandin $E_2$ in the stenosis group were higher than those of the control (P < 0.05). However, there was no difference in the CGRP levels between the two groups. In the stenosis group, the concentrations of these three mediators in the anterior epidural space were no different to those in the posterior space. Conclusions: These results suggest that biochemical mediators, such as substance P and prostaglandin $E_2$, in the epidural space might be partly involved in pain mechanism associated with spinal stenosis.

• The Korean Journal of Pain
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• v.24 no.4
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• pp.216-220
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• 2011

Background: Transforaminal epidural steroid injection is one of the effective treatments in managing radicular pain. There have been some prospective studies on the depth to the epidural space with the transforaminal approach. However, there have been no studies about the depth in Asians, especially Koreans. This study was carried out in order to evaluate the depth to the epidural space and the oblique angle and factors that influence the depth to the epidural space during lumbar transforaminal epidural injection. Methods: A total of 248 patients undergoing fluoroscopically guided transforaminal epidural steroid injections were evaluated. At the L3-4, L4-5, L5-S1, and S1 levels, we measured the oblique angle and depth to the epidural space. Results: Needle depth was positively associated with body mass index (correlation coefficient 0.52, P = 0.004). The median depths (in centimeters) to the epidural space were 6.13 cm, 6.42 cm, and 7.13 cm for 50-60 kg, 60-70 kg, and 70-80 kg groups, respectively, at L5-S1. Age and height were not significantly associated with the needle depth. Conclusions: There is a positive association between the BMI (and weight) and transforaminal epidural depth but not with age, sex, and height.

• The Korean Journal of Pain
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• v.9 no.1
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• pp.130-134
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• 1996

Background: This study was designed to determine the distance from skin to lumbar epidural space in obstetric parturients and whether weight, height, or PI (ponderal index, $kg/m^2$) might influence the epidural depth. Methods: 71 obstetric patients undergoing elective cesarean section during epidural anesthesia in L2-3 level were partitioned into groups according to their prepregnant BMI(body mass index), and in each group weight, height, PI, epidural depth were measured. Results: All patients were classified as underweight(n=18), normal(n=49), overweight(n=4) and no one was partitioned into obese group. the distance from skin to lumbar epidural space was found to be 3.7 cm(underweight), 4.1 cm(normal), 4.7 cm(over weight) and total mean distance was found to be 4.0 cm. The epidural depth had correlation with weight and height in underweight, and weight and PI in normal, but had no correlation with any measurements in overweight group. Conclusion: These results suggest body weight may be a useful parameter for predicting the distance from skin to lumbar epidural space in underweight and normal weight obstetric parturients.

• The Korean Journal of Pain
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• v.8 no.1
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• pp.156-158
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• 1995

Total spinal anesthesia is a well documented serious life threatening complication which results from an attempted spinal or epidural analgesia. We had an accidental total spinal anesthesia associated with a cranial nerve paralysis and an eventual unconsciousness during epidural analgesia. A 45-year-old female with an uterine myoma was scheduled for a total abdominal hysterectomy under the epidural analgesia. A lumbar tapping for the epidural analgesia was performed in a sitting position at a level between $L_{3-4}$, using a 18 gauge Tuohy needle. Using the "Loss of Resistance" technique to identify the epidural space, the first attempt failed; however, the second attempt with the same level and the technique was successful. The epidural space was identified erroneously. However, fluid was dripping very slowly through the needle, which we thought was the fluid from the normal saline which was injected from the outside to identify the space. Then 20 ml of 2% lidocaine was administered into the epidural space. Shortly after the spinal injection of lidocaine, many signs of total spinal anesthesia could be clearly observed, accompanied by the following progressing signs of intracrainal nerve paralysis: phrenic nerve, vagus nerve, glossopharyngeal nerve and trigeminal nerve in that order. Then female was intubated and her respiration was controlled without delay. The scheduled operation was carried out uneventfully for 2 hours and 20 minutes. The patient recovered gradually in th4e reverse order four hours from that time.

• The Korean Journal of Pain
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• v.10 no.2
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• pp.285-290
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• 1997

Horner's syndrome is a well-recognized complication of regional analgesia of neck and shoulder region, and not often a complication of lumbar or low thoracic epidural block. Recently we experienced right Horner's syndrome accompanying paralysis of right upper extremity following lumbar epidural block in for an obstetric patient. Epidurography and MRI was performed to clarify the cause of unilateral high epidural block and cervical sympathetic block. Radiologic study demonstrated a loop formation of the epidural catheter and tip of catheter was located in right anterior epidural spaced(L1-2). The initial epidurogram revealed unilateral spreading of dye in the cervical region in right epidural space. A second epidurogram, 10 minutes following, showed dye filling in left epidural space, however spread of dye in left side was limited to lumbar and low thoracic region. We concluded the most probable cause of this unilateral high epidural block was due to misplacement of the catheter into the anterior epidural space.

• The Korean Journal of Pain
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• v.9 no.2
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• pp.344-348
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• 1996

Continuous epidural block can be useful in the management of acute and chronic pain. For the most effective analgesia, it is important to localize the tip of epidural catheter and the spread of radiopaque dye. Epidural catheterization was performed in 12 patients on the sitting position. Catheters were advanced by 10 cm cephalad in the cervical epidural space by median approach and radiopaque dye 3 ml was injected through the catheters. The position of cervical epidural catheters and the spread of dye was confirmed by radiography. The course of epidural catheter were: coiled 3/12 (25%), loop 2/12 (16.7%), straight 2/12 (16.7%). In 8 cases, the tip of epidural catheters were located within one vertebral segment from the level of insertion site. Radiopaque dye spreaded average 3.68 vertebral segment to cranially and 1.67 vertebral segment to caudally from the insertion site.

• The Korean Journal of Pain
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• v.8 no.1
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• pp.159-163
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• 1995

Accidental high epidural block is a rare but serious complication. It can result from many factors, which include the volume and concentration of drug, posture, puncture site, age, pregnancy or intra-abdominal mass, and patients' height and weight. We had a case of accidental high epidural block recently. This is a case report which was confirmed by an epiduragram. A healthy 50-year-old woman with a huge uterine myoma was scheduled for a total abdominal hysterectomy under continous epidural analgesia. Epidural catheterization was carried out smoothly. However, an unexpected hypotension was noticed after an epidural injection of 2% lidocaine 25 ml. Thereafter, the patient was intubated and her respiration was controlled during the operation. Using the 5mg of ephedrine, her blood pressure and pulse were well maintained. The scheduled operation was carried out for one hour uneventfully, but after the operation, she felt paresthesia on her hands in the recovery room. To differentiate between the high epidural and the subdural blocks. We injected 5 ml of a water soluble Niopam 300 through the catheter postoperatively. It was observed on the epiduragram that the catheter was placed in the epidural space. It was suggested that the high epidural block was induced from the widespread diffusion through the narrowed epidural space due to the engorgement of the epidural venous plexus by the patient's huge uterine myoma.

• The Korean Journal of Pain
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• v.5 no.1
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• pp.121-125
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• 1992

A 37-year-old male was admitted for left chest pain during a 6 months period and was given an epidural block for pain control. Vancomycin 500 mg/4 ml instead of 0.25% bupivacaine was accidentaly injected into the epidural space. The patient suddenly complained of an unexpected chest tightness and dyspnea after epidural injection. The patient was treated with steroids and local anesthetics via epidural space and recovered without any neurologic sequelae. The patient completely recovered on the 46th postadmission day and went home without any complaints. We report this case and review the accidental injection of substances into the epidural space.