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Cervical epidural anesthesia in tetraplegia
Hand Clin 18 (2002) 441–447
Cervical epidural anesthesia in tetraplegia Jacques Deschodt, MDa,*, Jean-Franc¸ois Lubrano, MDa, Miche`le Kassim, MDa, Yves Allieu, MDb a Department of Anesthesia, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France Orthopaedic and Upper Limb Surgery Department, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
b
Cervical epidural anesthesia (CEA) allows a patient to move his or her upper limb and provides optimal conditions for secondary tendon surgery. Nevertheless, this technique can have some adverse effects and requires good training in epidural anesthesia. The authors have used CEA in 10 operations in seven tetraplegic patients who underwent tendon transfer. The technique is time consuming, but all the patients in the series were able to participate in the tendon transfer adjustment. Because the incidence of inadvertent subarachnoid puncture is high, the greatest care must be taken. Under certain conditions, CEA can be used for tetraplegic patients who are undergoing upper limb surgery. The authors introduced CEA for hand and upper extremity surgery during the 1980s. The aim was to provide surgeons with the ability to check the accuracy of lesion correction in vivo during secondary tendon surgery. This could be done only if the patient (1) was awake enough to understand the surgeon’s commands and (2) was able to move his or her fingers actively to carry out these commands. To accomplish this, a locoregional anesthetic technique must be used to provide selective sensory block (ie, no or partial motor block) during the procedure. In the authors’ experience with tenolysis, tenoarthrolysis, tendon graft, and tendon transfer for the peripheral paralytic hand, only CEA possessed such selective action. In this chapter, the authors briefly describe their experience with CEA in more than 100 procedures and discuss the technique, repercussions, and indications pertaining to hand surgery. The
* Corresponding author. E-mail address: [email protected] (J. Deschodt).
results expressed (mean SD) are based on a series of 70 consecutive patients. Additionally, the authors relate their experience with hand surgery in the tetraplegic patient. Technical aspects Anatomic note The brachial plexus is the target for CEA during hand surgery. The epidural space is closed at its upper extremity at the level of the foramen magnum but is opened in the caudal way. Thus, if anesthesia of the cervical dermatomes C3–C5 and the upper thoracic dermatomes is constant, the spread of block may overreach into the lower thoracic segments. Puncture All epidural punctures are performed on the day of operation in the operating room. Patients are medicated 45 minutes before procedure, and this premedication must be sedative enough to block pain but not to prevent the patient’s cooperation. Currently, intramuscular midazolam, 5.0 to 7.5 mg, plus pethidine, 25 to 50 mg, are used. After the placement of routine monitors (eg, noninvasive oscillometric blood pressure measurement, continuous-lead II electrocardiography, pulse oximetry, end-tidal carbon dioxide via nasal line that also allows 2 L/min oxygen administration), the patient is moved into the lateral decubitus position on the operative side. This is more comfortable for the patient than the sitting position used by others [1–3]. The patient’s shoulders then are twisted forward to bear the cervical spine. The cervical spine is flexed on the thorax and its axis is positioned parallel to the side of the operating table. A 16-gauge
0749-0712/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 1 8 - 5
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J. Deschodt et al. / Hand Clin 18 (2002) 441–447
Tuohy needle is advanced with the bevel cephalad in the epidural space, which can be identified by the loss-of-resistance technique to air injection or by the hanging-drop technique. A 19-gauge endholed catheter with stylet is introduced 3 to 4 cm cephalad in the epidural space. If a rehabilitation under CEA is planned, the catheter should be tunneled subcutaneously. The tip of the catheter is always located radiologically (iopamidol 300:2 mL) to detect an abnormal position and to see precisely its relation to the brachial plexus. Anesthesia After a test dose (2 mL) of lidocaine 2% with adrenaline, CEA is induced. The volume induction of local anesthesia is approximately 0.50 to 0.75 mL for one segment to be blocked (ie, total volume 5–10 mL). The local anesthetic used for induction is bupivacaine 0.375% and, if needed, an additional volume can be injected at 30 minutes to obtain the desired anesthetic spread. Clonidine (1 lg/kg) and fentanyl (1.0–1.5 lg/kg) are added to the bupivacaine. The spread of block, sensory cephalad and caudal levels, are checked by the loss of cold sensation with an ether-soaked swab. The motor block is assessed on a scale from 0 to 5 using the Highet and Holmes scale. Anesthesia is maintained by continuous infusion of bupivacaine 0.25% in the epidural space. The surgical procedure is performed with the use of a pneumatic tourniquet, which causes an ischemic paralysis after approximately 30 minutes. When the surgeon wants to test the repair, the tourniquet must be deflated for a few (3 2) minutes until the patient can move his fingers (M3–M4) actively, allowing an adjustment of the tendon stretch. When the procedure is finished, the epidural catheter may be used for painless rehabilitation so long as the patient’s safety is ensured. In the authors’ hospital, the rehabilitation is performed in the recovery room two or three times daily for as long as necessary (1–10 days; mean 3.6 days). Clinical features of cervical epidural anesthesia Nerve block Sympathetic, sensory, and motor nerves are affected by CEA. The block is bilateral, as it is for any epidural anesthesia, but asymmetry is common [4]. Placing the catheter laterally in the epidural space to block only the affected side has
been proposed for analgesia [5], but the low doses of local anesthetic used might not be enough for a surgical procedure and may explain the complete asymmetry of the block. The authors also try to obtain a lateral, cervical epidural catheter placement; moreover, they move the operating table in the horizontal plane in relation to the catheter tip position to spread the local anesthetic further to the operated side. Lower and upper thoracic sympathetic chain block is constant, followed by an increase in blood flow in the upper limbs. This could be of interest for replantation [2]. Horner’s syndrome can occur with miosis, scleral and face hyperemia, and sometimes ptosis and nasal congestion. Because keeping the lower level of CEA off the upper thoracic segments (T1–T5) is impossible, the sympathetic tone of the heart is decreased. Sensory block always involves the cervical and the brachial plexus at the upper level. The lower level is usually around T5 (T2–T10; mean T4.88 1.92). Motor block of the upper leg is always present, and hand-grip power is decreased by approximately 40% (93 27 kg before CEA, 56 43 kg after CEA; P < 0.05; n ¼ 12). Motion against gravity (M3), however, is always preserved, which explains why CEA is the only way to obtain a differential sensory block. Cardiovascular effects Cardiovascular effects are related closely to sympathetic block intensity and are all the more important because pre-CEA sympathetic tone is high. Clinically, the fall in systolic and diastolic blood pressures 30 minutes after the induction of anesthesia is approximately 5% to 10% (114 26 mm Hg vs. 123 15 mm Hg for systolic blood pressure and 63 13 mm Hg vs. 67 10 mm Hg for diastolic; P < 0.01 and P < 0.05, respectively). Bradycardia (15% to 25%) allowed by vagal dominance is even more important (66 12 bpm vs. 79 17 bpm; P < 0.001). Only one patient in the authors’ first series had shown a highly important fall in blood pressure that was caused by a large anesthetic spread. Lower level T10 [6] and, generally, CEA are well tolerated in American Society of Anesthesiology (ASA) 1-2 patients. The slight reduction of the cardiac index is the primary consequence of the decrease in heart rate [7]. Respiratory effects Taking into account motor blockade, one can expect a phrenic and upper intercostal nerve paresis or paralysis. Clinically, no shortness of breath is
J. Deschodt et al. / Hand Clin 18 (2002) 441–447
observed; neither paradoxical abdominal breathing nor arterial blood gasometry shows any significant change. Recently, the effects of CEA on pulmonary function have been studied by two authors. Capdevila et al. [8] showed a decrease ( 20%–25% of the diaphragmatic course) in tidal and other volumes during CEA C2–T5 with bupivacaine 0.25%. Stevens et al. [3] observed similar results with lidocaine 2% but he described a shortness of breath that resolved spontaneously in one patient. A pulmonary function impairment, therefore, is clearly a possibility during CEA. If this occurs, an anesthesiologist would be the most optimal person to perform the appropriate method for assuming the patient’s ventilation. Indications The indications for a particular treatment arise from the surgeon’s experience, the patient’s informed desires, and the anesthesiologist’s determination of whether the technique is feasible and appropriate. Presently, the authors recommend CEA for hand surgery when the surgeon considers intraoperative active motion essential for a good surgical outcome. Tenolysis, tendon grafts, and tendon transfers for the paralytic hand all satisfy this criterion. In some special instances, CEA can be used for tetraplegic hand surgery. Aside from surgery, there is sometimes an indication for the treatment of a complex regional pain syndrome that affects the whole upper extremity.
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a position as possible. Lowering the patient’s blood pressure further, however, is dangerous. Respiratory system problems A few patients exhibit a lesion level that spares diaphragmatic function; however, their vital capacity and ventilation are reduced because of the intercostal paralysis. Anesthesia, therefore, must not lessen the diaphragm’s activity or must do so as little as possible. Consequently, the concentration of local anesthetic should be low; bupivacaine 0.25% is used as the base local anesthetic (the authors have not yet tested ropivacaine). Nevertheless, an acute respiratory failure can occur, and the patient must be warned that general anesthesia might become necessary in such an event. Technical point of view Because osteosynthesis sometimes prevents flexion of the cervical spine on the thorax, the space between the spinous process is often too narrow to admit access to the epidural space.
Use of cervical epidural anesthesia in tetraplegia Patients Because tetraplegic patients generally do not exhibit much anxiety about their upcoming surgery, premedication is not necessary. A good explanation of the anesthetic technique, its benefit, and its risks allows patients to give informed consent. Cardiovascular problems Before anesthesia, resting blood pressure is commonly low and sinus bradycardia usually occurs. Despite these conditions of low sympathetic tone, one must bear in mind that autonomic hyperreflexia is possible. This sympathetic discharge can be produced by any cutaneous stimulus (ie, a distention of either the bladder or the rectum). Before anesthesia, therefore, the bladder must be catheterized and a rectal injection administered, while placing the patient in as comfortable
Fig. 1. Photoradiograph showing cervical spine osteosynthesis and catheter tip position.
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The usual puncture level (C7–D1) cannot always be used, particularly if there is osteosynthesis of the posterior column (Fig. 1), and the puncture must be performed either at a higher level (ie, C4–C5, where the epidural space is narrow) or at a lower level (ie, T1–T2, where the lower the puncture is, the more difficult anesthesia administration becomes, because the tip of the catheter moves off the brachial plexus). The epidural space often is altered in front of the spinal cord injury and the osteosynthesis. Because synechial adherences stand in the way of the epidural catheter, if the dura mater adheres to the ligamentum flavum, then introducing the catheter is impossible and can cause unintentional punctures of the subarachnoid to occur more frequently than usual. These adherences also can reduce the speed of local anesthetic diffusion. Radiographs can be difficult to read because of the superposition of the osteosynthesis material; hence, shifting the angle of incidence is sometimes necessary to see the catheter tip. Local anesthetic solutions The bupivacaine concentration used is 0.25% and boluses must be injected progressively because the lower level of anesthesia cannot be well defined. Induction of anesthesia, therefore, may last a particularly long time.
As for other indications for CEA, fentanyl (1 lg/kg) can be used. Oral clonidine not only reduces the hypertensive effect of autonomic hyperreflexia but also increases the bradycardia. Through the epidural route, this drug exhibits a strongly sedative effect that may not be desirable. Results Patients and procedures Seven tetraplegic patients (four female, three male) underwent surgery on the upper limb using CEA. Patient age, weight, and height ranged from 19 to 30 years (22.6 3.6), 45 to 66 kg (56 9), and 155 to 175 cm (167 9), respectively. Overall, 10 procedures (Table 1) were performed (two patients underwent surgery for both upper limbs, and one patient underwent a revision of a key grip procedure). Osteosynthesis appeared three times on the posterior column, three times on the anterior column, and once on both columns in a single case. In nine cases, the operations were a key grip procedure, with brachioradialis tendon transfer being performed on the flexor pollicis longus in two of the nine cases. A boutonniere deformity repair was performed in the remaining case. The operating time from the induction of anesthesia to the end of the procedure ranged from 80
Table 1 Surgical data Level of tetraplegia
Cervical spine osteosynthesis
1 2 3 4
C5 C6 C6 C7
Anterior Posterior Posterior Posterior
5
C6
Anterior
6
Same patient as case 4
Same patient as case 4
7 8
C6 C5
9
Same patient as case 7 Same patient as case 7
Anterior Anterior and posterior Same patient as case 7 Same patient as case 7
Case no.
10
Tourniquet time (minutes)
Operating time (minutes)
Key grip Key grip Key grip Active key grip (BR to FPL), left side Boutonniere deformity repair Active key grip (BR to FPL), right side Key grip, left side Key grip
50 120 20 120 55 65 30
90 150 380 240
Key grip revision, left side Key grip, right side
Procedure
60
80
105
110
60 70 130
180 220
125 30
240
130
Abbreviations: BR to FPL, brachioradialis tenclon transfer to the flexor pollicis longus.
00
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to 380 minutes (192 89). Total tourniquet time ranged from 60 to 175 minutes, and half the procedures required twice the tourniquet time. Within 5 minutes after tourniquet deflation, all patients recovered active motion of their hands (Fig. 2). In one case, stretching the tendon transfer again was necessary. Anesthesia The epidural space was reached five times via the T1–T2 interspace, three times via the C7–D1 interspace, one time via the T2–T3 interspace, and one time via the C6–C7 interspace. In one case, the administration was particularly difficult and time consuming to achieve. In two cases, an inadvertent subarachnoid puncture required a second attempt for epidural space identification. No postdural puncture headache was observed in these cases.
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The volume of bupivacaine 0.25% that was used for the induction ranged from 3 to 13 mL (7.0–32.5 mg). The total bupivacaine dosage injected during the procedure was approximately 20 mg/h. Fentanyl, 50 to 75 lg, was used in seven cases. Clonidine was not tested. In half the cases, no intravenous sedative drug was needed. In the other half, midazolam (1–2 mg) achieved mild sedation. In six cases, the anesthesia was not adequate, and until an epidural bolus of local anesthetic could be effective, an intravenous bolus of fentanyl was necessary to provide sufficient anesthesia (total dose 25–100 lg). Eight of the anesthetic procedures were uneventful. One patient suffered painful paresthesia in the upper arm during the epidural injection. Another patient experienced apnea immediately after the induction-dose injection (bupivacaine,
Fig. 2. (A, B) Illustration of active motion and adjustment of the key grip during the procedure.
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15 mg, plus fentanyl, 50 lg). This patient was ventilated for approximately 30 minutes with a facial mask and afterward recovered adequate pulmonary function. During this time, the patient’s pupils were in an intermediate mydriasis state. No cardiovascular distress was observed, however, and the patient had no recollection of the incident. The other patients never complained of shortness of breath. The cardiovascular effects were similar with those observed among nontetraplegic patients (ie, mild decrease in blood pressure and bradycardia). At some point during the anesthesia, five patients experienced a heart rate of less than 45 bpm, with a minimum of 40 bpm for one patient. As is commonly seen during CEA, attracting the patient’s attention caused the heart rate to increase immediately. In one case, intravenous atropine (0.25 mg) was injected. Discussion Cervical epidural anesthesia for tetraplegic upper leg surgery is not actually restful. Identification and catheterization of the epidural space is difficult, as is the management of local anesthetic injections. This is because the lower anesthetic threshold is unknown, and the patient can become suddenly aware of pain, particularly after the tourniquet deflation, which usually is followed by a decrease in both sensory and motor block. The anesthetist, therefore, must be especially attentive to the patient’s respiratory system, keeping him or her focused during what can be a long procedure. Additionally, urging the patient to participate actively during the surgical adjustments is essential to obtain active motion, because tetraplegic patients already find this motion difficult to achieve without anesthesia. Although there is usually some sensitivity left in the upper limbs of tetraplegic patients, it becomes tremendously difficult for those who have lost all sensation. Only a patient’s strong will, boosted by a conscientious anesthetist, can achieve this motion. In the end, patients were satisfied with their anesthesia, and two patients agreed to undergo the same technique several times. Comparing the authors’ experience with that of others is difficult because there have been no published reports. The recent study of CEA in reconstructive hand surgery [2] concerns nontetraplegic patients and concludes that CEA is safe and reliable while emphasizing the difficulty of comparing it with other techniques. The authors’ experience
in secondary tendon surgery brings them to the same conclusion, despite being convinced of the benefits of CEA. In the authors’ series of tetraplegic patients, one proved to be problematic. The rapid diffusion of the local anesthetic solution (bupivacaine, 6 mL, plus fentanyl, 50 lg) into the brain (via the cerebrospinal fluid) likely caused his apnea. The unintentional subarachnoid puncture that occurred in a previous epidural-space catheterization might have furthered that diffusion. The simultaneous appearance of a relative mydriasis is characteristic of a block of the parasympathetic system. No alarm sign was observed after the test dose (bupivacaine 1 mL) had been injected 5 minutes earlier, but fentanyl was not present in that test dose. A drug interaction may have occurred in this patient and she had undergone another procedure a few months earlier and a few months later without any incident. Furthermore, another patient whose earlier procedure was uneventful was given a total dose of bupivacaine 12 ml, and fentanyl, 75 lg, to induce anesthesia. At the time of the second procedure, an inadvertent. Other patients, however, had undergone another procedure a few months earlier and a few months later without any incident. Furthermore, two more patients whose earlier procedures were uneventful were given a total dose of bupivacaine, 12 mL, and fentanyl, 75 lg, to induce anesthesia. At the time of the second procedure, an inadvertent subarachnoid puncture occurred and a second attempt was necessary to reach the epidural space. The total dose for induction of anesthesia was 3 mL of bupivacaine, emphasizing that, when subarachnoid punctures occur, one must either give up the technique, or proceed carefully because the diffusion speed and the power of local anesthetic solutions clearly increase.
Summary The primary result of this series is that each patient participated actively during his or her procedures. The concept of selective sensory block, therefore, which was the authors’ overriding reason for using CEA in secondary tendon surgery, also may be beneficial to tetraplegic patients. Nystrom and Nystrom [2] also came to this conclusion. The use of CEA in tetraplegia is and must be used only in exceptional cases. If the usual surgical techniques seem to be inadequate for a given
J. Deschodt et al. / Hand Clin 18 (2002) 441–447
patient, and if the surgeon wishes to assess muscle tonicity and the effect of tenodesis in vivo, CEA may be used. The patients in the authors’ series have been sosatisfied with the technique that this dynamic approach to the tetraplegic upper leg may be as advantageous for the patient as it is for the surgeon.
Acknowledgments The authors express their thanks to MarieFrance Deschodt who teaches English in Montpellier for re-reading this manuscript. References [1] Baylot D, Mahul P, Navez ML, Hajjar J, Prades JM, Auboyer C. Anesthe´sie pe´ridurale cervicale. Ann Fr Anesth Reanim 1993;12:483–92. [2] Nystrom UME, Nystrom NA. Continuous cervical epidural anesthesia in reconstructive hand surgery. Journal Hand Surg 1997;22A:906–12.
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[3] Stevens RA, Frey K, Sheikh T, Kao TC, MikatStevens M, Morales M. Time course of the effects of cervical epidural anesthesia on pulmonary function. Reg Anesth Pain Med 1998;23:20–4. [4] Hogan Q. Epidural catheter tip position and distribution of injectate evaluated by computed tomography. Anesthesiology 1999;90:964–70. [5] Buchheit T, Crews JC. Lateral cervical epidural catheter placement for continuous unilateral upper extremity analgesia and sympathetic block. Reg Anesth Pain Med 2000;25:313–317. [6] Deschodt J, Mailhe D, Lubrano JF, Jullien Y, du Cailar J, Allieu Y. Selective sensitive block by cervical epidural analgesia for hand surgery and rehabilitation. Ann Chir Main 1988;7:217–21. [7] Biboulet P, Deschodt J, Capdevila X, Landreau L, Aubas P, du Cailar J, et al. Hemodynamic effects of 0.375% versus 0.25% bupivacaine during cervical epidural anesthesia for hand surgery. Reg Anesth 1995;20:33–40. [8] Capdevila X, Biboulet P, Rubenowitch J, SerreCousine O, Peray P, Deschodt J, et al. The effects of cervical epidural anesthesia with bupivacaine on pulmonary function in conscious patients. Anesth Analg 1998;86:1033–8.
Cervical epidural anesthesia in tetraplegia Jacques Deschodt, MDa,*, Jean-Franc¸ois Lubrano, MDa, Miche`le Kassim, MDa, Yves Allieu, MDb a Department of Anesthesia, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France Orthopaedic and Upper Limb Surgery Department, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
b
Cervical epidural anesthesia (CEA) allows a patient to move his or her upper limb and provides optimal conditions for secondary tendon surgery. Nevertheless, this technique can have some adverse effects and requires good training in epidural anesthesia. The authors have used CEA in 10 operations in seven tetraplegic patients who underwent tendon transfer. The technique is time consuming, but all the patients in the series were able to participate in the tendon transfer adjustment. Because the incidence of inadvertent subarachnoid puncture is high, the greatest care must be taken. Under certain conditions, CEA can be used for tetraplegic patients who are undergoing upper limb surgery. The authors introduced CEA for hand and upper extremity surgery during the 1980s. The aim was to provide surgeons with the ability to check the accuracy of lesion correction in vivo during secondary tendon surgery. This could be done only if the patient (1) was awake enough to understand the surgeon’s commands and (2) was able to move his or her fingers actively to carry out these commands. To accomplish this, a locoregional anesthetic technique must be used to provide selective sensory block (ie, no or partial motor block) during the procedure. In the authors’ experience with tenolysis, tenoarthrolysis, tendon graft, and tendon transfer for the peripheral paralytic hand, only CEA possessed such selective action. In this chapter, the authors briefly describe their experience with CEA in more than 100 procedures and discuss the technique, repercussions, and indications pertaining to hand surgery. The
* Corresponding author. E-mail address: [email protected] (J. Deschodt).
results expressed (mean SD) are based on a series of 70 consecutive patients. Additionally, the authors relate their experience with hand surgery in the tetraplegic patient. Technical aspects Anatomic note The brachial plexus is the target for CEA during hand surgery. The epidural space is closed at its upper extremity at the level of the foramen magnum but is opened in the caudal way. Thus, if anesthesia of the cervical dermatomes C3–C5 and the upper thoracic dermatomes is constant, the spread of block may overreach into the lower thoracic segments. Puncture All epidural punctures are performed on the day of operation in the operating room. Patients are medicated 45 minutes before procedure, and this premedication must be sedative enough to block pain but not to prevent the patient’s cooperation. Currently, intramuscular midazolam, 5.0 to 7.5 mg, plus pethidine, 25 to 50 mg, are used. After the placement of routine monitors (eg, noninvasive oscillometric blood pressure measurement, continuous-lead II electrocardiography, pulse oximetry, end-tidal carbon dioxide via nasal line that also allows 2 L/min oxygen administration), the patient is moved into the lateral decubitus position on the operative side. This is more comfortable for the patient than the sitting position used by others [1–3]. The patient’s shoulders then are twisted forward to bear the cervical spine. The cervical spine is flexed on the thorax and its axis is positioned parallel to the side of the operating table. A 16-gauge
0749-0712/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 1 8 - 5
442
J. Deschodt et al. / Hand Clin 18 (2002) 441–447
Tuohy needle is advanced with the bevel cephalad in the epidural space, which can be identified by the loss-of-resistance technique to air injection or by the hanging-drop technique. A 19-gauge endholed catheter with stylet is introduced 3 to 4 cm cephalad in the epidural space. If a rehabilitation under CEA is planned, the catheter should be tunneled subcutaneously. The tip of the catheter is always located radiologically (iopamidol 300:2 mL) to detect an abnormal position and to see precisely its relation to the brachial plexus. Anesthesia After a test dose (2 mL) of lidocaine 2% with adrenaline, CEA is induced. The volume induction of local anesthesia is approximately 0.50 to 0.75 mL for one segment to be blocked (ie, total volume 5–10 mL). The local anesthetic used for induction is bupivacaine 0.375% and, if needed, an additional volume can be injected at 30 minutes to obtain the desired anesthetic spread. Clonidine (1 lg/kg) and fentanyl (1.0–1.5 lg/kg) are added to the bupivacaine. The spread of block, sensory cephalad and caudal levels, are checked by the loss of cold sensation with an ether-soaked swab. The motor block is assessed on a scale from 0 to 5 using the Highet and Holmes scale. Anesthesia is maintained by continuous infusion of bupivacaine 0.25% in the epidural space. The surgical procedure is performed with the use of a pneumatic tourniquet, which causes an ischemic paralysis after approximately 30 minutes. When the surgeon wants to test the repair, the tourniquet must be deflated for a few (3 2) minutes until the patient can move his fingers (M3–M4) actively, allowing an adjustment of the tendon stretch. When the procedure is finished, the epidural catheter may be used for painless rehabilitation so long as the patient’s safety is ensured. In the authors’ hospital, the rehabilitation is performed in the recovery room two or three times daily for as long as necessary (1–10 days; mean 3.6 days). Clinical features of cervical epidural anesthesia Nerve block Sympathetic, sensory, and motor nerves are affected by CEA. The block is bilateral, as it is for any epidural anesthesia, but asymmetry is common [4]. Placing the catheter laterally in the epidural space to block only the affected side has
been proposed for analgesia [5], but the low doses of local anesthetic used might not be enough for a surgical procedure and may explain the complete asymmetry of the block. The authors also try to obtain a lateral, cervical epidural catheter placement; moreover, they move the operating table in the horizontal plane in relation to the catheter tip position to spread the local anesthetic further to the operated side. Lower and upper thoracic sympathetic chain block is constant, followed by an increase in blood flow in the upper limbs. This could be of interest for replantation [2]. Horner’s syndrome can occur with miosis, scleral and face hyperemia, and sometimes ptosis and nasal congestion. Because keeping the lower level of CEA off the upper thoracic segments (T1–T5) is impossible, the sympathetic tone of the heart is decreased. Sensory block always involves the cervical and the brachial plexus at the upper level. The lower level is usually around T5 (T2–T10; mean T4.88 1.92). Motor block of the upper leg is always present, and hand-grip power is decreased by approximately 40% (93 27 kg before CEA, 56 43 kg after CEA; P < 0.05; n ¼ 12). Motion against gravity (M3), however, is always preserved, which explains why CEA is the only way to obtain a differential sensory block. Cardiovascular effects Cardiovascular effects are related closely to sympathetic block intensity and are all the more important because pre-CEA sympathetic tone is high. Clinically, the fall in systolic and diastolic blood pressures 30 minutes after the induction of anesthesia is approximately 5% to 10% (114 26 mm Hg vs. 123 15 mm Hg for systolic blood pressure and 63 13 mm Hg vs. 67 10 mm Hg for diastolic; P < 0.01 and P < 0.05, respectively). Bradycardia (15% to 25%) allowed by vagal dominance is even more important (66 12 bpm vs. 79 17 bpm; P < 0.001). Only one patient in the authors’ first series had shown a highly important fall in blood pressure that was caused by a large anesthetic spread. Lower level T10 [6] and, generally, CEA are well tolerated in American Society of Anesthesiology (ASA) 1-2 patients. The slight reduction of the cardiac index is the primary consequence of the decrease in heart rate [7]. Respiratory effects Taking into account motor blockade, one can expect a phrenic and upper intercostal nerve paresis or paralysis. Clinically, no shortness of breath is
J. Deschodt et al. / Hand Clin 18 (2002) 441–447
observed; neither paradoxical abdominal breathing nor arterial blood gasometry shows any significant change. Recently, the effects of CEA on pulmonary function have been studied by two authors. Capdevila et al. [8] showed a decrease ( 20%–25% of the diaphragmatic course) in tidal and other volumes during CEA C2–T5 with bupivacaine 0.25%. Stevens et al. [3] observed similar results with lidocaine 2% but he described a shortness of breath that resolved spontaneously in one patient. A pulmonary function impairment, therefore, is clearly a possibility during CEA. If this occurs, an anesthesiologist would be the most optimal person to perform the appropriate method for assuming the patient’s ventilation. Indications The indications for a particular treatment arise from the surgeon’s experience, the patient’s informed desires, and the anesthesiologist’s determination of whether the technique is feasible and appropriate. Presently, the authors recommend CEA for hand surgery when the surgeon considers intraoperative active motion essential for a good surgical outcome. Tenolysis, tendon grafts, and tendon transfers for the paralytic hand all satisfy this criterion. In some special instances, CEA can be used for tetraplegic hand surgery. Aside from surgery, there is sometimes an indication for the treatment of a complex regional pain syndrome that affects the whole upper extremity.
443
a position as possible. Lowering the patient’s blood pressure further, however, is dangerous. Respiratory system problems A few patients exhibit a lesion level that spares diaphragmatic function; however, their vital capacity and ventilation are reduced because of the intercostal paralysis. Anesthesia, therefore, must not lessen the diaphragm’s activity or must do so as little as possible. Consequently, the concentration of local anesthetic should be low; bupivacaine 0.25% is used as the base local anesthetic (the authors have not yet tested ropivacaine). Nevertheless, an acute respiratory failure can occur, and the patient must be warned that general anesthesia might become necessary in such an event. Technical point of view Because osteosynthesis sometimes prevents flexion of the cervical spine on the thorax, the space between the spinous process is often too narrow to admit access to the epidural space.
Use of cervical epidural anesthesia in tetraplegia Patients Because tetraplegic patients generally do not exhibit much anxiety about their upcoming surgery, premedication is not necessary. A good explanation of the anesthetic technique, its benefit, and its risks allows patients to give informed consent. Cardiovascular problems Before anesthesia, resting blood pressure is commonly low and sinus bradycardia usually occurs. Despite these conditions of low sympathetic tone, one must bear in mind that autonomic hyperreflexia is possible. This sympathetic discharge can be produced by any cutaneous stimulus (ie, a distention of either the bladder or the rectum). Before anesthesia, therefore, the bladder must be catheterized and a rectal injection administered, while placing the patient in as comfortable
Fig. 1. Photoradiograph showing cervical spine osteosynthesis and catheter tip position.
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The usual puncture level (C7–D1) cannot always be used, particularly if there is osteosynthesis of the posterior column (Fig. 1), and the puncture must be performed either at a higher level (ie, C4–C5, where the epidural space is narrow) or at a lower level (ie, T1–T2, where the lower the puncture is, the more difficult anesthesia administration becomes, because the tip of the catheter moves off the brachial plexus). The epidural space often is altered in front of the spinal cord injury and the osteosynthesis. Because synechial adherences stand in the way of the epidural catheter, if the dura mater adheres to the ligamentum flavum, then introducing the catheter is impossible and can cause unintentional punctures of the subarachnoid to occur more frequently than usual. These adherences also can reduce the speed of local anesthetic diffusion. Radiographs can be difficult to read because of the superposition of the osteosynthesis material; hence, shifting the angle of incidence is sometimes necessary to see the catheter tip. Local anesthetic solutions The bupivacaine concentration used is 0.25% and boluses must be injected progressively because the lower level of anesthesia cannot be well defined. Induction of anesthesia, therefore, may last a particularly long time.
As for other indications for CEA, fentanyl (1 lg/kg) can be used. Oral clonidine not only reduces the hypertensive effect of autonomic hyperreflexia but also increases the bradycardia. Through the epidural route, this drug exhibits a strongly sedative effect that may not be desirable. Results Patients and procedures Seven tetraplegic patients (four female, three male) underwent surgery on the upper limb using CEA. Patient age, weight, and height ranged from 19 to 30 years (22.6 3.6), 45 to 66 kg (56 9), and 155 to 175 cm (167 9), respectively. Overall, 10 procedures (Table 1) were performed (two patients underwent surgery for both upper limbs, and one patient underwent a revision of a key grip procedure). Osteosynthesis appeared three times on the posterior column, three times on the anterior column, and once on both columns in a single case. In nine cases, the operations were a key grip procedure, with brachioradialis tendon transfer being performed on the flexor pollicis longus in two of the nine cases. A boutonniere deformity repair was performed in the remaining case. The operating time from the induction of anesthesia to the end of the procedure ranged from 80
Table 1 Surgical data Level of tetraplegia
Cervical spine osteosynthesis
1 2 3 4
C5 C6 C6 C7
Anterior Posterior Posterior Posterior
5
C6
Anterior
6
Same patient as case 4
Same patient as case 4
7 8
C6 C5
9
Same patient as case 7 Same patient as case 7
Anterior Anterior and posterior Same patient as case 7 Same patient as case 7
Case no.
10
Tourniquet time (minutes)
Operating time (minutes)
Key grip Key grip Key grip Active key grip (BR to FPL), left side Boutonniere deformity repair Active key grip (BR to FPL), right side Key grip, left side Key grip
50 120 20 120 55 65 30
90 150 380 240
Key grip revision, left side Key grip, right side
Procedure
60
80
105
110
60 70 130
180 220
125 30
240
130
Abbreviations: BR to FPL, brachioradialis tenclon transfer to the flexor pollicis longus.
00
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to 380 minutes (192 89). Total tourniquet time ranged from 60 to 175 minutes, and half the procedures required twice the tourniquet time. Within 5 minutes after tourniquet deflation, all patients recovered active motion of their hands (Fig. 2). In one case, stretching the tendon transfer again was necessary. Anesthesia The epidural space was reached five times via the T1–T2 interspace, three times via the C7–D1 interspace, one time via the T2–T3 interspace, and one time via the C6–C7 interspace. In one case, the administration was particularly difficult and time consuming to achieve. In two cases, an inadvertent subarachnoid puncture required a second attempt for epidural space identification. No postdural puncture headache was observed in these cases.
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The volume of bupivacaine 0.25% that was used for the induction ranged from 3 to 13 mL (7.0–32.5 mg). The total bupivacaine dosage injected during the procedure was approximately 20 mg/h. Fentanyl, 50 to 75 lg, was used in seven cases. Clonidine was not tested. In half the cases, no intravenous sedative drug was needed. In the other half, midazolam (1–2 mg) achieved mild sedation. In six cases, the anesthesia was not adequate, and until an epidural bolus of local anesthetic could be effective, an intravenous bolus of fentanyl was necessary to provide sufficient anesthesia (total dose 25–100 lg). Eight of the anesthetic procedures were uneventful. One patient suffered painful paresthesia in the upper arm during the epidural injection. Another patient experienced apnea immediately after the induction-dose injection (bupivacaine,
Fig. 2. (A, B) Illustration of active motion and adjustment of the key grip during the procedure.
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15 mg, plus fentanyl, 50 lg). This patient was ventilated for approximately 30 minutes with a facial mask and afterward recovered adequate pulmonary function. During this time, the patient’s pupils were in an intermediate mydriasis state. No cardiovascular distress was observed, however, and the patient had no recollection of the incident. The other patients never complained of shortness of breath. The cardiovascular effects were similar with those observed among nontetraplegic patients (ie, mild decrease in blood pressure and bradycardia). At some point during the anesthesia, five patients experienced a heart rate of less than 45 bpm, with a minimum of 40 bpm for one patient. As is commonly seen during CEA, attracting the patient’s attention caused the heart rate to increase immediately. In one case, intravenous atropine (0.25 mg) was injected. Discussion Cervical epidural anesthesia for tetraplegic upper leg surgery is not actually restful. Identification and catheterization of the epidural space is difficult, as is the management of local anesthetic injections. This is because the lower anesthetic threshold is unknown, and the patient can become suddenly aware of pain, particularly after the tourniquet deflation, which usually is followed by a decrease in both sensory and motor block. The anesthetist, therefore, must be especially attentive to the patient’s respiratory system, keeping him or her focused during what can be a long procedure. Additionally, urging the patient to participate actively during the surgical adjustments is essential to obtain active motion, because tetraplegic patients already find this motion difficult to achieve without anesthesia. Although there is usually some sensitivity left in the upper limbs of tetraplegic patients, it becomes tremendously difficult for those who have lost all sensation. Only a patient’s strong will, boosted by a conscientious anesthetist, can achieve this motion. In the end, patients were satisfied with their anesthesia, and two patients agreed to undergo the same technique several times. Comparing the authors’ experience with that of others is difficult because there have been no published reports. The recent study of CEA in reconstructive hand surgery [2] concerns nontetraplegic patients and concludes that CEA is safe and reliable while emphasizing the difficulty of comparing it with other techniques. The authors’ experience
in secondary tendon surgery brings them to the same conclusion, despite being convinced of the benefits of CEA. In the authors’ series of tetraplegic patients, one proved to be problematic. The rapid diffusion of the local anesthetic solution (bupivacaine, 6 mL, plus fentanyl, 50 lg) into the brain (via the cerebrospinal fluid) likely caused his apnea. The unintentional subarachnoid puncture that occurred in a previous epidural-space catheterization might have furthered that diffusion. The simultaneous appearance of a relative mydriasis is characteristic of a block of the parasympathetic system. No alarm sign was observed after the test dose (bupivacaine 1 mL) had been injected 5 minutes earlier, but fentanyl was not present in that test dose. A drug interaction may have occurred in this patient and she had undergone another procedure a few months earlier and a few months later without any incident. Furthermore, another patient whose earlier procedure was uneventful was given a total dose of bupivacaine 12 ml, and fentanyl, 75 lg, to induce anesthesia. At the time of the second procedure, an inadvertent. Other patients, however, had undergone another procedure a few months earlier and a few months later without any incident. Furthermore, two more patients whose earlier procedures were uneventful were given a total dose of bupivacaine, 12 mL, and fentanyl, 75 lg, to induce anesthesia. At the time of the second procedure, an inadvertent subarachnoid puncture occurred and a second attempt was necessary to reach the epidural space. The total dose for induction of anesthesia was 3 mL of bupivacaine, emphasizing that, when subarachnoid punctures occur, one must either give up the technique, or proceed carefully because the diffusion speed and the power of local anesthetic solutions clearly increase.
Summary The primary result of this series is that each patient participated actively during his or her procedures. The concept of selective sensory block, therefore, which was the authors’ overriding reason for using CEA in secondary tendon surgery, also may be beneficial to tetraplegic patients. Nystrom and Nystrom [2] also came to this conclusion. The use of CEA in tetraplegia is and must be used only in exceptional cases. If the usual surgical techniques seem to be inadequate for a given
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patient, and if the surgeon wishes to assess muscle tonicity and the effect of tenodesis in vivo, CEA may be used. The patients in the authors’ series have been sosatisfied with the technique that this dynamic approach to the tetraplegic upper leg may be as advantageous for the patient as it is for the surgeon.
Acknowledgments The authors express their thanks to MarieFrance Deschodt who teaches English in Montpellier for re-reading this manuscript. References [1] Baylot D, Mahul P, Navez ML, Hajjar J, Prades JM, Auboyer C. Anesthe´sie pe´ridurale cervicale. Ann Fr Anesth Reanim 1993;12:483–92. [2] Nystrom UME, Nystrom NA. Continuous cervical epidural anesthesia in reconstructive hand surgery. Journal Hand Surg 1997;22A:906–12.
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[3] Stevens RA, Frey K, Sheikh T, Kao TC, MikatStevens M, Morales M. Time course of the effects of cervical epidural anesthesia on pulmonary function. Reg Anesth Pain Med 1998;23:20–4. [4] Hogan Q. Epidural catheter tip position and distribution of injectate evaluated by computed tomography. Anesthesiology 1999;90:964–70. [5] Buchheit T, Crews JC. Lateral cervical epidural catheter placement for continuous unilateral upper extremity analgesia and sympathetic block. Reg Anesth Pain Med 2000;25:313–317. [6] Deschodt J, Mailhe D, Lubrano JF, Jullien Y, du Cailar J, Allieu Y. Selective sensitive block by cervical epidural analgesia for hand surgery and rehabilitation. Ann Chir Main 1988;7:217–21. [7] Biboulet P, Deschodt J, Capdevila X, Landreau L, Aubas P, du Cailar J, et al. Hemodynamic effects of 0.375% versus 0.25% bupivacaine during cervical epidural anesthesia for hand surgery. Reg Anesth 1995;20:33–40. [8] Capdevila X, Biboulet P, Rubenowitch J, SerreCousine O, Peray P, Deschodt J, et al. The effects of cervical epidural anesthesia with bupivacaine on pulmonary function in conscious patients. Anesth Analg 1998;86:1033–8.