WAHAL, VENUGOPAL : EVALUATION OF THORACIC EPIDURAL ANALGESIA BY MRI.

189
Introduction
Many studies have shown that complications related
to thoracic epidural block (TEA) are far less as compared
to lumbar epidurals
1.2
. TEA is employed for upper
abdominal surgeries and postoperative pain relief. In great
majority of cases, catheter inserted in the midthoracic
region traverses in the epidural space according to the
wishes of the anaesthesiologist
3
. Midline approach is often
unsuccessful because of the overhanging vertebral spines.
Paramedian approach is more suitable
4
. The fear of total
sympathetic block and accidental spinal cord injury has
been exaggerated
5
. The present study is aimed at studying
1) The spread of limited volume of analgesic solution,
when injected in the epidural space in the midthoracic
region between T
6
to T
9
. 2) Technical feasibility of the
procedure as to cause minimal tissue trauma and safety of
the spinal cord against injury with review of anatomical
highlights and MRI study of paraspinous region and of
spinal lumen.
Patients and Methods
Institutional ethical committee approval was
obtained. From the consecutive operation list, fifty-one
patients (fifty female and one male) of ASA I and II
scheduled for open cholecystectomy were included in the
study. No attempt was made to exclude any case except
for known coagulopathy, infection at the site, gross obesity,
spinal and neural anomalies. Two patients were controlled
hypertensives and one reported with history of bronchial
asthma. The mean SD (range) age of the patients were
33.57. 4 (20-51) years. Their weight was 49.16
7.56 (40-65) kg and height 154.8 6.6 (146-172) cm.
All patients received thorough preanaesthetic evaluation.
Preoperative heart rate was 87.812.8 (60-115) min
-1
and systolic BP was 1189.67 (100-140) mmHg. They
were briefed and counselled in outpatient department and
in the surgical wards a day prior to surgery. Written
informed consent was obtained. Pre-medication: all patients
received orally 150 mg of ranitidine and 10mg of
metoclopramide at 10 pm on previous night and 6 am on
day of surgery. All patients received preloading with
1000 ml of ringer lactate, light sedation with IV pethidine
1 mg kg
-1
body weight, 15 minutes prior to initiation of
TEA.
Patients were positioned in left decubitus position
with 10 degree trendelenberg tilt. With all aseptic
precautions the procedure was conducted. Right
paramedian approach in the left lateral position was adopted
(since both the investigators were right handed). The tip
of the spine of T
7
(vertebra prominence) is opposite the
inferior angle of the scapula with the arms to the sides,
can be easily palpable and identified. Most accessible
intervertebral space was chosen by gentle palpation of the
spine and paraspinous region between T
6
to T
9
. A skin
THE SPREAD OF THORACIC EPIDURAL ANALGESIA:
EVALUATION OF SAFETY AND TECHNICAL FEASIBILITY
WITH ANATOMICAL HIGHLIGHTS AND MRI STUDIES.
Dr. A. K. Wahal
1
Dr. M. Venugopal
2
SUMMARY
The technical feasibility, safety and spread of Thoracic Epidural Analgesia (TEA) was evaluated injecting 10 ml of 2% lignocaine
with adrenaline 1:200,000 between T
6
to T
9
intervertebral spaces in 51 ASA I and II patients. Anatomical highlights were reviewed
with MRI studies of paraspinous region and of spinal lumen. The extent of analgesia was 9.8 1.72 (mean SD) segments. The
caudal and cephalic spread of analgesic solution from the site of institution of epidural block was found to be in a ratio of 2:1 (caudal:
cephalic). There was not any major alteration in pulse or blood pressure. T
6-7
is found to be the most accessible intervertebral space.
This is consistent with MRI studies and anatomical fact that only two layers of muscles (Trapezius and Spinalis thoracic) overlap T
6-7
interlaminar space. In midthoracic region epidural and subarachnoid spaces are 3.36 0.13 and 4.24 0.28 mm respectively.
Paramedian approach with 45
0
angulation effectively increases the skin to cord distance by 40%. This simple law of geometry ensures
that cord injury is remote in expert hands.
Keywords : Thoracic Epidural Analgesia (TEA), Magnetic Resonance Imaging (MRI).
1. MBBS, Supertime Grade II Medical Officer
2. MBBS, MD, MNAMS, Sr. Specialist, Anaesthesiology and
Medical Superintendent Dept. of Anaesthesiology,
Swami Dayanand Hospital, Delhi-110095.
Correspond to :
Dr. M. Venugopal
E-138-A, Dilshad Garden, Delhi-110095
Indian J. Anaesth. 2002; 46 (3) : 189-192
ASHOK\D:\JOBWORK\KOTUR\ANAESTH\ANAESTH3.P65190
INDIAN JOURNAL OF ANAESTHESIA, JUNE 2002 190
wheel was raised 1 cm lateral to the tip of the spine of the
superior vertebra. After infiltration of the space with 3 to
5 ml of 1 % lignocaine, epidural space was identified
employing loss of resistance to air technique using
18 SWG Tuohy needle and 10 ml glass syringe filled with
3 ml air attached to it. The needle is inserted at 90
0
to
skin surface and lamina is touched. The skin to lamina
distance is noted. Epidural needle is withdrawn up to
muscle sheath and reinserted to detect the epidural space
at 45
0
and 10
0
to sagittal and vertical planes respectively.
After inserting the needle to a distance of approximately
40% more than the skin to lamina distance, epidural needle
is further advanced mm by mm and simultaneously testing
for loss of resistance to air. If lamina is touched again, the
needle is withdrawn one cm and the angle of needle to
sagittal plane is corrected to 40
0
. The process is repeated
again. If lamina is still encountered the needle is withdrawn
one centimeter and reintroduced at an angle of 35
0
to
sagittal plane. This process is well known as to walk on
lamina. This process is continued till we get through the
interlaminar space and reach the ligamentum flavum and
the epidural space. After negative aspiration test for CSF
and blood, the epidural block was induced by injecting
10 ml of 2% lignocaine with adrenaline 1: 200,000 at a
steady rate. An epidural catheter was inserted to a distance
of 2-3 cm from the tip of the needle. Epidural catheter
was secured safely and patients were made to lie down in
supine position. The onset and extent of analgesia was
assessed by bilateral loss of sensation to pinprick. Upper
and lower limits of the sensory block were demarked.
Standard monitoring was applied to all (NIBP, Pulse rate,
ECG and SpO
2
). Oxygen was administered via face mask
throughout surgical procedure. Respiratory status was
closely observed. Verbal communication was maintained
all through the institution of TEA and surgical operation.
Patients were carefully observed for any inadvertent subdural
spread. Level of block was monitored at regular intervals.
Observations and Results
At T
6-7
, 28 (54.9%); at T
7-8
, 12 (23.53%); and at
T
8-9
, 11 (21.57%) epidural blocks was well established in
47 cases. No significant block was achieved in one. Patchy
analgesia, unilateral block and dural puncture were observed
in one patient each. The observations of successful blocks
were recorded and analyzed.
The onset of analgesia was found to be 6.421.7(4-
15) min the upper and lower limits of sensory block were
identified. The maximal limits of rostral analgesia spread
was found to be C
8
, T
2
, T
3
, for the blocks induced at T
6
,
T
7
, and T
8-9
respectively. The maximal caudal analgesia
was up to L
1
for the blocks given at T
6-7
and L
2
for the
blocks those given at T
7-8
and T
8-9
. Limits of sensory
block in individual patients are as shown in Figure 1.
Number of spinal segments blocked was 9.81.72(7-13)
caudal 6.41.37(3-8) and rostral 3.41.1(1-6) segments.
Average dose of analgesic solution was 1 ml. segment
-1
.
The spread of analgesic solution found to be in a ratio of
2:1 (66% caudal and 34% rostral).
The extent of block was 7 to 13 dermatomes as
shown in Table 1. Massive epidural block was not observed
in any of the patients in this series. With limited analgesia
of 7 to 8 dermatomes open cholecystectomy was feasible
without supplementation of balanced general anaesthesia.
Table 1: Frequency for appropriate extent of analgesia
N = 47.
* Extent of +T
6- 7
+T
7- 8
+T
8- 9
+T
6- 9
Analgesia (collective)
7 3 Nil 2 5
8 5 2 1 8
9 4 2 3 9
10 Nil Nil 3 3
11 8 3 1 12
12 7 2 Nil 9
13 Nil 1 Nil 1
* Number of dermatomes blocked
+ Number of occasions when the block induced at.
WAHAL, VENUGOPAL : EVALUATION OF THORACIC EPIDURAL ANALGESIA BY MRI. 191
All patients were haemodynamically stable on
establishment of block. There was no catastrophic
hypotension or significant changes in heart rate. 30% fall
in systolic BP occurred in two patients. This was easily
managed with 6 mg of ephedrine hydrochloride and
intravenous fluids. The extent of blocks was T
1
to T
11
in
these two patients. However such changes were not
observed in three other patients with similar extensive
blocks, C
8
to T
11
in one and T
1
to T
12
in two patients.
None of the patients had any kind of sequelae.
MRI of thoracic paraspinous region revealed that
only two layers of muscles overlap T
6-7
interlaminar space
(Figure 2).
Table 2: MRI Of The Spinal Lumen At (T
6-7
) Level N=10
Number Age Sex Epidural Sub Cord Dural Sac
of (Years) M/F space mm arachnoid Thickness mm
Patients space mm mm
1 22 M 3.5 4.5 4.7 11.7
2 25 M 3.5 4.3 4.6 11.9
3 26 M 3.3 4.3 4.6 10.8
4 41 M 3.4 4.0 4.8 10.4
5 55 M 3.2 3.9 5.2 10.9
6 22 F 3.4 4.4 4.7 11.8
7 29 F 3.4 4.5 4.8 11.2
8 30 F 3.5 4.5 4.6 11.8
9 32 F 3.2 4.0 4.5 11.1
10 55 F 3.2 3.8 5.0 11.0
Discussion
Our study shows that TEA is a safe method for
upper abdominal surgeries and post operative pain relief
without undue risk of catheter related or drug induced
complications
4
. An interesting characteristic of the epidural
block in this study is the variability in the analgesia onset
time and extent of block (7 to 13 dermatomes), but no
massive epidural block
7
. The fastest onset time was 4
min; in others analgesia could not be appreciated until 15
min after the injection of the drug. The variability in the
extent of block may be due to relative overdose of the
analgesic solution in relation to physical characteristics of
the individuals. The difference in the limits of sensory
block may be due to that in an attempt to locate the
epidural space through an interlaminar space while keeping
the Tuohys needle at <40-45 angle to sagittal plane, we
may enter a space superior to the one actually attempted.
It is observed that the spread of bolus dose of 10 ml of
analgesic solution is more caudal than rostral, i.e. in a
ratio of 2:1 (66% caudal and 34% rostral).
The fear of total sympathetic blockade with attended
potential for cardiovascular compromise seems unjustified.
It is reported that there is incomplete sympathetic blockade
even with complete thoracolumbar analgesia
8
. It is also
well documented that in normovolemic persons, near total
centro-neuraxis block induced sympathectomy produces
only 15% to 18% fall in peripheral resistance
5
.
The arrangement of muscles of back in the thoracic
region is that there is a triangular bare area in the
midthoracic paramedian region corresponding to T
6-7
interlaminar space. The boundaries of the bare area are
medially, the spine of the T
6
vertebra; inferiorly the upper
margin of latismus dorsi; superio-laterally, inferio-medial
border of rhomboideus major. We name this triangle as
W V epidural triangle after the name of the authors.
MRI assessment of the spinal lumen was done in
ten adults, five male and five female, ages varied 22 to
55 years. The anterioposterior measurements of epidural
and subarachnoid space; cord thickness and dural sac are
shown in Table 2. The epidural and subarachnoid space
were 3.360.13(3.2-3.5) and 4.240.28 (3.8-4.5) mm
respectively. Cord thickness and dural sac were
4.750.21(4.5-5.2) and 11.260.51(10.4-11.9) mm.
These findings are consistent with the cadaveric studies
6
.
ASHOK\D:\JOBWORK\KOTUR\ANAESTH\ANAESTH3.P65192
INDIAN JOURNAL OF ANAESTHESIA, JUNE 2002 192
The T
6-7
interlaminar space is covered by two layers
of muscles viz. trapezius and spinalis thoracic. In addition
to these two layers of muscles, spaces superior to T
6-7
are
covered by rhomboideus and spaces inferior by latismus
dorsi muscles
9
. These findings are also evident in the
paramedian sections of MRI of thorax (Figure 2).
Rhomboidus major and latismus dorsi are muscle
bellies at the attachment to vertebral spines and paraspinous
region of approximately half a centimeter thickness
(Dr. J Khanna, Reader in the department of anatomy;
University college of Medical Sciences and associated Guru
Teg Bahadur Hospital, Dilshad Garden, Delhi 95. INDIA:
personal communication). Piercing this mass of muscle is
avoided if T
6-7
intervertebral space is selected for employing
TEA. On follow up three of our patients in this series
reported with complaints of backache at the site of epidural
puncture, none was of the group with block at T
6-7
. The
dura-arachnoid to cord distance is 4.2 mm. with 40
0
angulation of the needle in the midthoracic region, the
distance available to touch the spinal cord is >6.7 mm
after piercing through the dura-arachnoid. Thus in expert
hands, with the technique described to locate epidural
space; accidental injury to the spinal cord is rare.
Conclusion
The authors conclude that employing TEA as
discussed is absolutely safe. On sound anatomical and
technical reasons, T
6-7
interlaminar space is recommended
for the procedure. Cord injury is remote in expert hands.
The spread of bolus dose of analgesic solution is 66%
caudal and 34% cephalic.
Acknowledgements : We thank Dr. P Gulati, Organ
Imaging research centre (I) Pvt. Ltd., Green park, New
Delhi; India; for providing data of MRI reproduced in this
paper.
References
1. Dawkins, CJM An analysis of complications of extradural and
caudal block. Anaesthesia 1969, 24:554-63.
2. Tanaka, K; Watanbe, R; Narda, T., Extensive application of
epidural anaesthesia, incidence of complications related to
technique. Reg. Anaesthesia 1993; 18: 34-35 Summ. In Engl.
3. Dawkins, CJM; Steel, GC. Thoracic extradural block for upper
abdominal surgery. Anaesthesia 1971; 26:41-2-48
4. Scherer, R; Schmutzler, M; Giebler, J; Erhard, L: stocker;
Kox; W.J. Complications related to thoracic epidural analgesia.
a prospective study in 1071 surgical patients. Acta Anaesthesiol
Scandinavia 1993; 37 (4) 370-374.
5. Brown, DL. Spinal epidural and caudal anaesthesia In:Miller
RD, ed. Anaesthesia 4
th
edition, London Chuchill Livingston,
1994, 1511.
6. Collins, VI Epidural anaesthesia In Collins VJ Ed Principles
of Anaesthesiology 2
nd
edition, Philadelphia: Lea & Febiger,
1976,700.
7. Lubenow, T : Wong, EK, Kristof K; et al: Inadvertent subdural
injections: A complication of an epidural block. Anesthesia &
Analgesia 1988; 67: 175-9.
8. Rom, A; Stenens, MD; Beardsley, D; White, JE; Kas JC; Gantt,
R: Holman, S. Does spinal anaesthesia result in a more
complete sympathetic block than that from epidural
Anaesthesia. Anaesthesiology 1995; 82:877-883.
9. Salmons, S. Muscle In; Williams PI, Ed. Grays anatomy 38
th
edition, Churchill Livingstone, 1995; 811; 835-37.
DIRECTORY OF ISA MEMBERS - 2002
A comprehensive directory of ISA members containing personalised information such as blood group, telephone nos, e-mail ID,
mailing address is being brought out. Manuscript will be ready in July 2002 and publication will be done in August 2002. If any
members, who would like to update their address details including personal data, are requested to provide the same to Secretary
ISA (National) before 31
st
July 2002 in the format below:
ISA Number ________________________ Name ______________________________________________________
City branch _____________________________________________________________________________________
Address ________________________________________________________________________________________
______________________________________________________________________________________________
Post office ______________________________________________________________________________________
Pine code__________________________ District _____________________ State ____________________________
Tele. No. (R) _______________________ (O) ________________________ email ID _________________________
Blood group ____________________________________________________