Dangers of intraspinal (subarachnoid) injection of alcohol: Their avoidance and contraindications

DANGERS OF INTRASPINAL (SUBARACHNOID) INJECTION OF ALCOHOL: THEIR AVOIDANCE AND CONTRAINDICATIONS* ELIAS LINCOLN STERN, M.D. Surgeon,Department

of Sympathetic

Neural Surger\, S,vdenh:cm Hospital

NEW YORK CITY

T

HAT the injection of 9.5 per cent or absohrte aIcoho1 into the spinal subarachnoid space for the rehef of intractabIe pains and for sympathetic nervous system disorders is accompanied by. the risk of bIadder and rectal complicatrons, and even motor paraIysis or death has been stated repeatedIy in my previous articIes.l-’ DogIiotti and others*-l3 have aIso warued of possibIe compIications. Aird and Nafziger’” as we11 as myseIf4 have shown some of the pathoIogica1 changes which may foIIow the experimenta intraspina injection of aIcoho1 in cats. We have stressed the narrow margin of safety in dosage and technique in using this method of relieving pain. WhiIe the insertion of a spina puncture needIe into the Iumbar subarachnoid space should be a reIativeIy simpIe procedure, the introduction of a needIe by the inexperienced may be accompanied by trauma to the nerves of the cauda equina. FoIIowing such injury the effect of any introduced aIcoho1 is enhanced many times. This was clearly shown when desoxychoIic acid was combined with aIcoho1 in minute quantities and injected into cats.‘> ReIativeIy Iarge amounts produced no motor compIications whiIe very smaI1 amounts caused paraIysis and severe sensory disturbances when the nerve tissue was first traumatized. This was brought to my attention when an attending surgeon asked me to “stand by” whiIe he performed his first intraspina1 injection of aIcoho1 to reIieve a patient of pain arising from a prostatic carcinoma. He proceeded to insert the needIe in the midIine of the back between the third and fourth Iumbar spines but for some reason * From the Department

of Anatomy,

or other no spina fluid couId be obtained, aIthough the needle was poked into the spine about twelve times without success. FoIIowing this, without any difficulty at aI1, I obtained sIightIy blood tinged spina fluid on my first attempt. I did not reahze at the time that the injection of aIcoho1 foIIowing trauma such as UnquestionabIy occurred in this case, wouId be folIowed by compIications. I had done dozens of simiIar injections before and had had no compIications. However, foIIowing the injection of IO minims of absoIute aIcoho1 this patient deveIoped bIadder retention and recta1 incontinence. UndoubtedIy, the traumatized nerves ahowed the smaI1 amount of alcohol to infihrate and cause more damage than was anticipated. While the introduction of a spina needIe is reIativeIy simpIe in the Iumbar region, it is somewhat more diffrcuIt to insert in the thoracic region, especiaIIy the upper section, on account of the Iength and inchnation of the spinous processes. Moreover, the size of the interspaces is normaIIy much smaIIer than in the Iumbar region and in adults with miId or moderate degrees of productive osseous changes of their vertebra, these interspaces may be considerabIy reduced or even obIiterated compIeteIy by the bony fusion of the dorsal plates. The injection of the prescribed dosage of aIcoho1 foIIowing the accidenta puncture of the spinal cord, or injury of the spinal blood vesseIs mav cause compIications. It is therefore ad;isabIe to refrain from injecting any aIcoho1 whenever there is diffrcuIty in getting clear spina fluid, or where a sIightIy bIoody fIuid is obtained which does not clear after the removai of a

Columbia University, and the Pain Relief Clinic, Sydcnham the Manhattan General Hospital.

9’)

I lospital, and

100

American Journal of Surgery

Stern-IntraspinaI

few cubic centimeters of fluid. UnIess the needIe point is unquestionabIy in the subarachnoid space and there is a free ffow of fluid, or, in cases of Iow pressure where fluid can be obtained by having the patient cough, or on compressing the juguIar veins, or upon aspiration with a smaI1 syringe, aIcoho1 shouId not be injected under any circumstances. As a result of a previous injection, or due to some other process, one may have difficuIty in obtaining fIuid because of an adhesive pachymeningitis causing a compIete or partia1 bIockage. WhiIe the first injection may have been done with perfect ease, subsequent attempts at this same IeveI may prove futiIe. One may then get a free ffow either one space above or beIow this IeveI without diffIcuIty. It is readiIy conceivabIe that in such a case, puncture of the cord may be done inadvertantIy, if the possibiIity of such a condition is not kept in mind. Symptoms of a partia1 or compIete transverse myeIitis may foIIow, even without the injection of any aIcoho1. OccasionaIIy in the upper thoracic region the spina fluid is heId in reIativeIy cIosed meshes by the arachnoid membrane, especiaIIy in the region of the dorsa1 suspensory Iigament of the cord which is considered a redupIication of the arachnoid membrane. It is conceivabIe that the needIe point may enter such a Iocus and fluid be obtained. Upon injection, the aIcoho1 may become enmeshed in this Iigament and remain in a concentrated form instead of becoming diIuted as occurs when injected in the “free” subarachnoid space. The approximate active percentage of aIcoho1 as it comes in contact with the nerve roots is estimated to be 20 to 23 per cent when two minutes is consumed in injecting 16 minims of absoIute aIcoho1 without barbitage. If there is interference with the norma diffusion rate, one can readiIy understand how a more concentrated soIution of aIcoho1 wiI1 produce more marked affects than anticipated. RepeatedIy, I have drawn attention to the fact that more than 8 minims of

AIcohoI

JANUARY, 193:

absoIute aIcoho1 injected between the second and third Iumbar spines wiI1 invariably cause bIadder compIications, whereas above or below this IeveI, as much as 16 minims have been injected without bIadder or recta1 compIications ensuing. This was vividIy brought to my attention when I tabuIated and summarized the resuIts of my first fifty injections.2 Others found the same compIications. Upon further investigation, almost invariabIy, more than 8 minims was found to have been injected between the second and third Iumbar spines. This expIains the compIications reported by Tureen and Gitt13 in their Case II. The bIadder compIication which may occur resuIts from a sensory rather than a motor paraIysis, as undoubtedIy at this IeveI the sensory nerves from the bIadder are affected, the bIadder becomes distended and dribbIing occurs from the overAow. In some cases, this distention and retention may not be recognized by patient or physician, and back pressure and infection may foIIow. As seen in experimenta animaIs, a pyonephrosis may deveIop, with marked diIatation and uIceration of bIadder and ureters, which may be fata in time. BIadder retention with injection at this IeveI may occur despite the fact that onIy one side of the vesical innervation is affected. OccasionaIIy bladder retention may continue onIy tweIve to cathererization forty-eight hours. SteriIe and the administration of urinary antiseptics are indicated when retention persists. With the Iarger doses of 16 minims of aIcoho1 injected between the third and fourth, or fourth and fifth Iumbar spines, recta1 incontinence may foIIow, especiaIIy when the hips are eIevated too high. This aIIows for the aIcoho1 to “fiI1” the entire Iower end of the dura1 sac and as a resuIt the Iower sacra1 and coccygea1 nerves of both sides are affected. CompIete ana anesthesia foIIows and the sphincters usuaIIy become reIaxed so that the patient Ioses a11 sensation and soiIs the bedcIothes.l’j In other cases the sphincters retain their

Nt,u

SI,RILS

VOI.

SSXV,

No.

1

Stern-Intraspinal

tone and only sensation is Iost, so that the rectum and colon become distended with feces. Such a condition if unrecognized, may cause a marked toxemia from autointoxication, intestina1 obstruction and death. Such retention warrants the use of daily enemata. 1 have observed repeatedly that chronic constipation has frequentI? disappeared completely in patients receivmg intraspina1 aIcoho1 inJections for the relief of intractable pain. I beIieve that alcohoI at the proper Ie\:els may affect the sympathetic nerves of the coIon and rectum so as to remove the inhibiting affect of these nerves. What is accomphshed by sympathectomy for Hirschprung’s disease, may therefore we11 occur with the intraspinal injection of alcohol. NaturaIIy, onIy those cases of “atonic” constipation wouId be benefited in this way. With only uniIatera1 desensitization of the anus, recta1 incontinence does not occur. It is therefore important not to eIevate the buttocks of the patient too high. A maximum dose of IO to I 2 minims of absoIute aIcoho1 shouId be injected in the Iast two spaces. This may expIain the comphcation in Case I reported by Tureen and Gitt.13 Since the introduction of this method of relieving pain, a number of variations in technique have been used. WhiIe good results may be obtained by keeping the patient in position 0nIy fifteen minutes after the injection has been compIeted, some have sought to accentuate the effects by keeping the patient in position for three to six hours16 and even tweIve hours. This is apt to aIIow the aIcoho1 to remain “undiluted” too long and compIications may resuIt. Patients shouId not be kept in the IateraI position for more than one-haIf to one hour at the most. This probably heIps explain the compIications in Case I by the mentioned authors. There is a finesse in securing the proper degree of action which can only be obtained b;v experience. Too great a concentration, too Iarge a dose, or the maintenance of the IateraI position too long may cause more

AIcohol

A,nuic;in Jwrn:ll

(11\III~(.I\

101

marked effects than desired. Too small a dose, insuffIcient concentration, or more rapid diffusion may cause no effects at al1. In either event, a singIe experience of failure to reIieve pain, or an unexpected bIadder or recta1 complication should not cause any refIection on the efficacy of the method. There is no question of the value of this method to relieve intractable pain, as evidenced by numerous reports appearing in increasing numbers.’ Personal experiences with several hundred of these injections convinces me of its value. OccasionaIIy the doctor is confronted with the patient suffering agonizing pain and who with the famiIy, expects miracuIous relief from a single injection. The doctor may be incfined to inject an extra good dose, onIy to be chagrined b?- the occurrence of unpleasant complications. It is much better to expIain to the patient and his famiIy that occasionally more than one injection may be necessary, especiaII_v where pain is biIatera1 or over more than three segments. It is also ad\-isabIe to inform them that relief may not come unti1 the Iapse of severa days, or even one, two or even three weeks. In any event it is much better to repeat the injection with smaI1 doses, to “fee1 one’s way,” and be guided by the sensory affects of each injection than to attempt to cover too wide an area with a singIe dose. )Vhen relief does come immediateIy and compIeteIy, the effect is miracuIous and when it Iasts for tweIve to eighteen months, the patient is most grateful. The need for more than a single injection in some cases has not been emphasized in previous reports. Another deviation that has been tried by others with resuIting bIadder or rectal compIications is to turn the patient on his abdomen instead of his back after the injection is compIeted. This tends to affect both sides, so that too marked an action is obtained on the afferent pathways. When motor weakness or “paralysis” foIIows an intraspina1 injection, providing no damage is done to nerve tissue by the needle, these compIications are usuaIIy

102

American

Journal

of Surgery

Stern-IntraspinaI

transitory and depend again on the dosage and concentration. This motor paraIysis is not due to a direct action on the anterior roots when the smaIIer doses are used. Motor weakness or paraIysis may foIIow onIy the interruption of muscIe, tendon and joint sensations, without the interruption of the anterior or motor roots.“j Just as with ordinary spina anesthesia, the patient is unabIe to move his Iimbs because the anesthetic soIution has affected the dorsa1 roots onIy,” so with the Iarger doses of aIcoho1, al1 afferent sensations may be causing a more permanent interrupted, anesthesia with weakness or disabiIity. This condition usuaIIy cIears rapidIy unIess so much aIcoho1 has been introduced that the anterior roots or spina cord itseIf have been affected. This may result in a true motor paraIysis, accompanied by trophic uIcerations, bIadder and recta1 compIications, inanition and death. OccasionaIIy a chemica1 meningismus foIIows an intraspina1 injection. This is the exception. The patient deveIops pains up and down the spine, headache and sIight rigidity and retraction of the head which may become aIarming. The spina fluid ceI1 may reach 20 to 30 per cu. mm. in twenty-four hours, and the fluid itseIf be Treatment by repeated under pressure. puncture may be indicated, as we11 as sedatives and coId compresses to the head. This condition may Iast for one to four days and may set in onIy after three days have eIapsed fohowing the injection. AIcohoI taken at random may contain spores. OnIy steriIe aIcoho1 Htered and boiIed under pressure shouId be used. This can be obtained in ampouIes. WhiIe respiratory paraIysis and death may occur theoreticaIIy in humans if aIIowed to sit up immediateIy after spina no such compIication aIcoho1 injection, has been caIIed to my attention. Experimentahy, if one aIlows even a few minims of aIcoho1 to come near the meduIIary centers, respiration may cease and after fifteen to twenty minutes the heart stops beating. It is therefore imperative for the

AIcohoI

JANUARY,

,937

doctor to be responsibIe personaIIy for the maintenance of the patient’s position with the head kept Iow. WhiIe patients have gotten out of bed two hours after the injection, this procedure is not advocated since severe headaches are apt to foIIow. It is therefore better to see that the patient is thoroughIy evacuated and the bIadder emptied before the injection is started. After three hours have elapsed, the patient may safeIy sit up but shouId be kept quiet in bed for at Ieast twenty-four hours. FoIIowing the three hours, in exceptiona cases, IavoratorypriviIeges may be aIIowed, but the use of the bedpan and urina1 is preferabIe. FoIIowing an injection of aIcoho1, the patient sometimes perspires profusely and therefore should be protected from draughts and we11 covered. As a ruIe, the procedure is unaccompanied by any pain or shock. ShouId the may be patient fee1 weak, stimuIants given by a drinking tube without eIevating the patient’s head. In one case of intractabIe asthma, the patient deveIoped a typica shock condition about six hours after the injection.6 The patient had been under the constant influence of adrenaIin before the injection. FoIIowing the aIcoho1 injection, her asthma promptIy stopped, and the adrenaIin was discontinued. The sudden withdrawal of adrenaIin may have induced the shock reaction. The patient, however, promptIy responded to stimuIants of adrenalin, caffeine and intravenous gIucose soIution. In determining the dosage, an important point to be kept in mind is the fact that the aduIt femaIe spina cana may be smaIIer than the aduIt maIe spine. One should use somewhat smaIIer doses in the femaIe in order not to get too profound an effect. CONTRAINDICATIONS

Patients with very extensive uIcerating cancers are apt to bIeed after intraspina1 aIcoho1 injection. The fear of this, however,

NPil

Stlu1s

lor..

_xsxv.

No.

I

Stern-IntraspinaI

should not prevent giving the sufferer relief in most such cases. Patients with diabetic or arterioscIerotic gangrene of the extremity may get reIief from this procedure, but if infection is present it may spread more rapidIy after due to the increased aIcoho1 injectIon, vascuIarit>-. Ordinary necrosis due to gangrene, without spreading ceIIuIitis, may demarcate and hea compIeteIy after intraspina injection of aicoho1, even when bone is exposed and infected. Patients with poIycythemia may deveIop an increase in their red ceI1 count foIIowing injection. In a patient who is apt to have emboIic phenomena, this must be borne in mind. I have found that the red ceI1 count may increase as much as two miIIion in twenty-four hours and the hemogIobin increase twenty per cent. The exact cause for this has not been determined. An interesting finding has been an increase in the eosinophiIes in some cases to as much as tweIve per cent in twenty-four hours, whiIe the tota white ceI1 count remains unchanged. The exact significance of this aIso is not known. Certain aIIergic cases may react badIy when aIcoho1 is injected intraspinaIIy. WhiIe the amount of protein normaIIy in the spina fluid is smaI1, the aIcoho1 may precipitate some and change its chemistry so as to cause a reaction. The possibiIity of the Schwartzmann reaction occurring intraspinaIIy shouId aIso be investigated. The case of asthma cited had a profound sensory anesthesia with transitory bIadder and recta1 incontinence and diffIcuIty in moving the Iower Iimbs. This might have been caused by an aIIergic reaction since the technique of the injection was perfect. Injections shouId not be made through infected areas or metastatic deposits. Acute surgica1 conditions or Iesions requiring surgery shouId not be injected, unIess the condition is hopeIess and operation impossibIe. In any obscure case, injection shouId not be given unti1 a11 methods of investigation have been tried. SpinaI cord tumors shouId

AIcohoI

Amencan

Journal

of Sorgc’, i

‘03

be especiaIIy kept in mind. The remova of pain as a symptom may make the diagnosis more dlffIcuIt on the one hand, but may shift the pain cIoser to the site of the Iesion on the other. Referred pains ma\. trave1 via the sympathetic nerves, which when bIocked at one IeveI, may enter the cord at a different IeveI. This was most interestingIy demonstrated in a patient with upper Ieft sided chest pains. When bIocked, the pain centered over the left kidney and x-ray examination then revealed a smaI1 stone in her right kidney which never had caused any urinary signs or symptoms. The injection of aIcoho1 shouId not be done above the first thoracic vertebra on account of the danger to the phrenic and meduIIary nerve centers. One shouId not expect this method to reIieve every case of cancer pain; no procedure is IOO per cent perfect. Pains arising from Iesions in bones are more dif?icuIt to relieve than pains arising from soft tissue Repeated injections often stop cancers. pain where the first injection has had no effect. One shouId not be ready to condemn this method as to its efficacy from a singIe failure. Drug addicts may continue to compIain of pain in spite of aIcoho1 injections. Chronic sufferers shouId therefore be injected before they become drug addicts. SUMMARY I. BIadder and recta1 incontinence are the most frequent compIications after the intraspina1 injection of aIcoho1 but can be avoided by foIIowing accurateIy the detaiIs of technique and dosage. Modifications of technique are accompanied by danger. No more than 8 minims shouId be injected between the second and third lumbar spines. 2. BIadder and recta1 compIications can be avoided by Iimiting the action of the aIcoho1 to one side at a time. 3. Loss of muscIe, tendon and joint sense may cause somatic motor “paraIysis,” which is usuaIIy transitory.

104

American Journal

of Surgery

Stern-IntraspinaI

4. ExcessiveIy

Iarge doses may cause true motor paraIysis by affecting the anterior roots or even the cord itseIf. 3. Trauma to nerve tissue at the time of the injection increases the action of the aIcoho1. 6. Patients shouId be kept with the head Iowered, eIse meduIIary complications may occur. 7. Repeated smaIIer doses shouId be used rather than a singIe Iarge dose. 8. Infections of the spina coIumn not we11 IocaIized, extensive bIeeding cancers, diabetic or arterioscIerotic gangrene accompanied by spreading ceIIuIitis, polycytheor mia Vera, acute surgica1 conditions chronic Iesions requiring surgery shouId not be injected. Where surgery is contraindicated or the case is hopeIess the pain may be reIieved by this method. 9. Every attempt shouId be made to find the cause of obscure pain before resorting to this method of relief. FoIIowing the reIief of pain every effort shouId be continued to arrive ar: a positive diagnosis. IO. Drug addicts may not be heIped by spina injections. Chronic sufferers shouId receive their injections before they become habituated to narcotics. I I. IntraspinaI aIcoho1 injections should be given onIy by those possessing a knowIedge of the physics of the method, and the detaiIs of the anatomy, especiaIIy of the sympathetic nervous system. REFERENCES I. STERN, ELIAS LINCOLN. IntraspinaI Injection of AIcohoI for herpes zoster. Med. Jour. and Rec., 138: 479-80 (Dec. 20) 1933. 2. Idem. ReIief of intractabIe pain by the Intraspina (subarachnoid) injection of aIcoho1. Am. Jour. Surg., 25: 217-27 (Aug.) 1934.

AIcohoI

JANUARY,,937

3. Zdem. The IntraspinaI (subarachnoid) injection of alcohol for thrombo-angiitis obliterans. Med. Rec., 141: 5 (Mar. 6) 1935: 4. Zdem. Progress in spinal anesthesia; reIief of pain by subarachnoid aIcoho1 injections: experimental studies. Clin. Med. and Surg., 43: 7-12 (Jan.) 1936. 5. Zdem. The intraspinal (subarachnoid) injection of aIcoho1 for the reIief of pain and for sympathetic nervous system disorders. Med. Record, 143: 327-331 (April 15) 1936. 6. Zdem. The intraspina1 injection of aIcoho1 for the reIief of chronic bronchia asthma. In process of publication. 7. Zdem. Chronic painfu1 conditions amenabIe to relief by the intraspina1 (subarachnoid) injection of aIcoho1. In process of publication. 8. DOGLIOTTI, A. M. Traitment des syndromes douloureaux de Ia p&riph&ie per la aIcooIisation subarachnoidienne des recines postCrieures a Ieur kmergence de Ia moelIe &pin&e. Presse mtd., No. 67 (Aug. 22) 1931. 9. Zdem. Recent methods of anaIgesia and anesthesia. Med. Rec., 140: 347 (Oct. 3) 1934. IO. Zdem. AntaIgic therapeutic methods accessible to anesthetists. Anest. w A&g., 14: 150 (July-

August)

19x5.

I I. GOFF. C. W. Sciatic neuralgia controlIed bv intraspina (subarachnoid) injections of ethy1 &ohol. Am. Jour. Surg., 32: 17 (April) 1936. 12. SLOANE, P. Syndrome referabIe to the cauda equina following the intraspinal injection of aIcoho1 for the reIief from pain. Arch. Neur. and Psych., 34: 1120 (Nov.) 1935. 13. TUREEN, L. L. and GITT, J. J. Cauda equina syndrome foIIowing subarachnoid injection of alcohol. J. A. M. A., 106: 18 (May 2) 1936. 14. AIRD, R. B. and NAFFZIGER, H. C. Experimental injection of ethy1 aIcoho1 into the Iumbar subarachnoid space; with neuropathologica1 studies (in cats). West. J. Surg., Oh., eY+Gyn., 43: 377 (July) 1935. 15. LICHTMAN, S. S. and STERPU, E. L. Influence of biIe saIts on the nervous system following intraspina1 usage. Proc. Sot. Exp. Bio. @ Med., 32: 1201-4, 1935. 16. M. D., New York. Hypotonia and paraIysis after subarachnoid injection of alcohol. Letter to the Editor, J. A. M. A., 106: 13 (Mar. 28) 1936. 17. WILENSKY, A. I. Form and function of the dorsa1 roots in spina anesthesia. Am. Jour. Surg., 17: 22632 (Aug.) 1932.