Thoracic Epidural Injection

Thoracic Epidural
injection
Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist
Accessing the epidural space was

first described in 1921
The initial reports mostly described
epidural catheter placement for the
management of failed chest, postCABG pain, and postthoracotomy pain
Epidural steroid injections was

introduced in 1953 and after that
injected for millions patients with
radicular and lumbur back pains

ANATOMY

Epidural space:
Superior boundary
fusion of the periosteal and spinal
layers of dura at the foramen
magnum
Inferiory :
sacrococcygeal membrane
Anteriorly :
posterior longitudinal ligament
posteriorly
vertebral laminae and the ligamentum
flavum
lateraly:
vertebral pedicles and intervertebral
foramina
The thoracic epidural space contains

fat
veins
arteries
lymphatics
connective tissue



Thoracic 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.

Thoracic epidural block in the midline:

Skin
Subcutaneous tissues
Supraspinous ligament
Interspinous ligament
ligamentum flavum


"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 ligaments
Demifacet &
transverse
articular facet




The thoracic vertebral interspaces

between T3 and T9 are functionally unique
(Acute downward angle of the spinous
processes)
This downward slope means that the
spinous
process of any given mid-thoracic vertebra
is in fact inferior to the interlaminar space
of its adjacent vertebra

Approach
Interlaminar (or translaminar) epidural

block
1- 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 )

idline
Approach

INDICATIONS
Thoracic and upper abdominal
surgical anesthesia
Diagnostic tool in the evaluation of
chest wall and intraabdominal pain
If destruction of the thoracic nerve
roots is being considered

palliate acute pain emergencies

while waiting for pharmacologic,
surgical, or antiblastic methods to
become effective
postoperative pain
pain secondary to trauma
acute herpes zoster
pain of acute pancreatitis
cancer-related pain
Resistant angina
chronic benign pain syndromes:

thoracic radiculopathy,
Thoracic postlaminectomy syndrome
vertebral compressionfractures
chronic pancreatitis
diabetic polyneuropathy
chemotherapy-related peripheral
neuropathy
Postherpetic neuralgia
reflex sympathetic dystrophy
abdominal pain syndromes
Absolute Contraindications
Patient refuses or uncooperative
local infection
sepsis ( relative)
anticoagulation and coagulopathy
Uncorrected hypovolemia (relative)
History of severe real anaphylaxis
Preganancy
Relative Contraindications
Distorted anatomy
Severe mitral or aortic stenosis
(omit local anesthetic)
Diabetes melitus
CHF
Glaucoma

TECHNIQ
UE
EQUIPMENT
o Tuohy epidural needle or similar
o When applicable, special needles for
epidural andelectrical stimulation
catheter
o 25-gauge, 3/4-inch infiltration needle
o 3-cc syringe
o 10-cc syringe
o Loss-of-resistance (LOR) syringe
o epidural catheters and electrodes

o IV T-piece extension
DRUGS
1% lidocaine
0.25-0.5% bupivacaine and
ropivacaine
Steroids
Preservative-free normal saline
(PFNS)
POSITIONS
Ditting position
Lateral position
Prone position

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

3- Operator's middle and index

fingers are placed on each side of
the spinous processes. using a
rocking motion in the superior and
inferior planes
4- One milliliter of local anesthetic is
used to infiltrate the skin,
subcutaneous tissues, and
supraspinous and interspinous
ligaments at the midline
5 Epidural needle is inserted exactly

in the midline through the
supraspinous ligament into the
interspinous ligament

6-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 hand


7-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 forward
The syringe is removed gently from
the needle.
8-An air or saline acceptance test is

carried out by injecting 0.5 to I mL of
air or sterile preservative-free saline

Alternative:
Hanging drop
Fluoroscopy (especially in obesity)
Stimulation

9- aspiration
If CSF seen:
Change your epidural space and
adjust your doses
If blood seen
Slightly rotate the needleif the
blood disapear inject carefully

10 When satisfactory needle position

is confirmed
5 to 7 mL of solution in upper
thoracic region
8 to 10 mL of solution in lower
thoracic region
6 to 7 ml in midthoracic
(paramedian)
Drugs
Diagnostic and prognostic blocks
1.0% preservative-free lidocaine
Therapeutic blocks
0.25% preservative-free
bupivacaine,
+ with 80 mg of depot
methylprednisolone
(Subsequent nerve blocks 40mg
steroid)
Opioids
upper thoracic
1 mg morphine
Lower thoracic
4 to 5 mg of
morphine
Midthoracic (paramedian)
3 mg
morphine
Fentanyl
infusion
Fluoroscopy
1- prone position
2- A-P fluoroscopy:
Interlaminar space visualized
3-epidural needle advanced until
contact to lamina
4- needle walked off the lamina ,
ligamentum flavum contacted and
needle advanced with loss of
resistance
5-Lateral view
6- 1ml dye injected to confirm
7- medicatin injected
8- needle restyletted and removed






SIDE EFFECTS AND

COMPLICATIONS
Infection
epidural hematoma
injury to the nerve roots
intravascular injection
respiratory depression

subdural
subarachnoid injection
spinal cord damage
Epidural abscess
Interaplural injection
Bradycardia & hypotension
Respiratory muscle weakness in
COPD and..

Paramedian
approach



Indications
Epidural block in midthoracic
This technique has been especially
successful in the relief of pain
secondary to metastatic disease
of the spine

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

2- 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

Transforamina
l Approach

Indications
Diagnostic tool or treatment modality
when
performing differential neural
blockade
If destruction of the thoracic nerve
roots is being considered

Common painful conditions

Thoracic radicular pain and
radiculopathy secondary to thoracic
disk displacement
Acute herpes zoster
Vertebral compression fracture
Metastases to the thoracic spine
Neural foraminal stenosis
Perineural fibrosis
specialists 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 complications

TECHNIQUE
Position
prone
1- 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
3-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
visualized
The magic box represents the target
for needle placement.


4-skin is then prepared with an

antiseptic solution
5-skin wheal of local anesthetic is
placed at a point overlying the magic
box that corresponds to the inferior
aspect of the foramen
6-spinal needle is then Placed in area
and advanced until the tip is near the
level of the posterior elements

Care 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 foramen
8-An anteroposterior view is then
obtained, and the needle tip is seen to
lie just medial to the lateral laminar
border

8-After satisfactory needle position is

confirmed, 0.2 to 0.4 mL of
contrast medium suitable for
subarachnoid use is gently injected
under active fluoroscopy


9-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.

SIDE EFFECTS AND

COMPLICATIONS
1-All the potential side effects and
complications associated with the
interlaminar approach
Higher incidence:
Persistent paresthesias and trauma to neural
structures (quadriplegy)
Unintentional dural puncture
Damage or injection to the segmental artery
can by transforaminal approach to the T7-L4
neural foramen on the left

Thoracic Epidural Injection

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Thoracic Epidural

Dr Mehran Rezvani pain fellowship

Accessing the epidural space was

Epidural steroid injections was

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

The thoracic epidural space contains

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Thoracic epidural space extends from

Dr Mehran Rezvani pain fellowship

Thoracic epidural block in the midline:

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

"when the needle tip enters the space

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

The thoracic vertebral interspaces

Dr Mehran Rezvani pain fellowship

Interlaminar (or translaminar) epidural

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

palliate acute pain emergencies

chronic benign pain syndromes:

Dr Mehran Rezvani pain fellowship

o epidural catheters and electrodes

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

3- Operator's middle and index

5 Epidural needle is inserted exactly

Dr Mehran Rezvani pain fellowship

6-syringe containing preservative-free

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

7-As soon as the needle bevel passes

8-An air or saline acceptance test is

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

10 When satisfactory needle position

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

SIDE EFFECTS AND

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

2- Epidural needle is inserted

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Common painful conditions

specialists believe the