- Email: [email protected]
Reply to Dr. Hammer
Letters to the Editor Safety of Spinal Endoscopy Is Contingent On Basic Image Interpretation To the Editor: I read with great interest the article entitled “Targeted Methylprednisolone Acetate/Hyaluronidase/Clonidine Injection after Diagnostic Epiduroscopy for Chronic Sciatica: A Prospective, 1-Year Follow-up Study” by Geurts et al.,1 evaluating epiduroscopy for chronic sciatica. However, it appears in Figure 2 (p 349) that with insertion of the epiduroscope a myelogram was produced, not an epidurogram as claimed. The text states that L5-S1 nerve root adhesions could be visualized by the reader. I find it disconcerting that basic fluoroscopic interpretation hindered the authors’ attempts to educate the reader on a procedure with a very high learning curve. Basic spinal fluoroscopic interpretation must be understood before learning these techniques. I would hope in the future the editors pay more attention to these important details before publication. Intrathecal injection of corticosteroids with clonodine could result in disastrous complications. I was happy to read that the patient did well. Michael Hammer, M.D. Orthopaedic Specialists of Alabama St. Vincent’s Hospital Interventional Pain Management Birmingham, Alabama
Reference 1. Guerts et al. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: A prospective, 1-year follow-up study. Reg Anesth Pain Med 2002;343-352.
Accepted for publication August 9, 2002. doi:10.1053/rapm.2002.37327
Reply to Dr. Hammer To the Editor: We apologize to Dr. Hammer and all readers of the journal that in our report1 the wrong Fig 2 has appeared by mistake. Undoubtedly, Fig 2B is a myelogram. We were so enthusiastic about the epiduroscopy images and results that during the process of editing, we did not notice that Fig 2A and B were not the original images of patient number 4. We sincerely regret this administrative error. Thus, it will be obvious that we fully agree with Dr Hammer that basic spinal fluoroscopic interpretation must be understood before applying invasive procedure
Fig 2. Patient number 4. (A) Preoperative epidurogram of a 55-year-old man (anteroposterior view) with a history of previous partial discectomy (L4/5 level), who presented with left-sided sciatica, predominantly in the L5 and S1 distribution. Note the large filling defect on the left side, extending from the S2-foramen up to the L4/5 level. (B) An epiduroscope was directed via the sacral hiatus toward the filling defect and adhesions surrounding L5 and S1 nerve roots were identified. Effective mechanical adhesiolysis was established and the left lateral epidural space opened up after injection of contrast fluid.
Regional Anesthesia and Pain Medicine, Vol 27, No 6 (November–December), 2002: pp 621–624
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Regional Anesthesia and Pain Medicine Vol. 27 No. 6 November–December 2002
techniques. We thank Dr Hammer for his most alert reaction. The original epidurogram figures are shown. J.W.M. Geurts, M.D., Ph.D. J-W. Kallewaard, M.D. J. Richardson, M.D., F.R.C.P., F.R.C.A. G.J. Groen, M.D., Ph.D. Department of Anesthesiology Rijnstate Hospital Arnhem, The Netherlands Reference 1. Geurts JWM, Kallewaard, J-W, Richardson J, Groen GJ. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: A prospective, 1-year follow-up study. Reg Anesth Pain Med 2002;27:343-352.
Accepted for publication August 20, 2002. doi:10.1053/rapm.2002.37325
Cauda Equina Syndrome After Intradiscal Electrothermal Therapy To The Editor: Intradiscal electrothermal therapy (IDET) has become increasingly popular for the management of low back pain. First described by Saal and Saal in 2000,1 the device was approved by the Food and Drug Administration in March 1998 for the coagulation and decompression of disc material. The procedure is recommended for those patients with degenerative disc disease who complain of nonspecific pain in the lumbar spine, but do not have significant disc herniation or nerve root compression and who have a normal neurologic examination. IDET is proposed to be a safe procedure, yet a single case report describes cauda equina syndrome after the procedure.2 Herein, I report another case of cauda equina syndrome following the IDET procedure. The patient was a 65-year-old female referred to me for pain medicine consultation 12 months after the IDET. Prior to the procedure, the patient had chronic nonspecific lumbar spine pain. A pre-IDET computerized tomography scan did not show a lumbar disc herniation, but she did have an annular disruption at the L4-5 disc. Magnetic resonance imaging was not done because of her pacemaker. Pre-IDET neurologic examination was within normal limits. She had no history of bowel or bladder dysfunction. Provocative discography revealed pain at the L3-4 and L4-5 levels. She subsequently underwent IDET at the L3-4 and L4-5 discs. The IDET 17-gauge introducer needles and thermal catheters (SpineCath, Oratec Interventions, Inc, Menlo Park, CA) were placed with fluoroscopic guidance. The electrode was heated to 90° centigrade over 18 minutes and maintained for 4 minutes. During the procedure, she complained of transient burning pain in both lower
extremities. The physician performing the procedure again ascertained proper needle and catheter placement with lateral and anterior-posterior fluoroscopic views. Following the procedure, the patient complained of weakness in both lower extremities, and had neurogenic bowel and bladder as well as saddle anesthesia. She was treated aggressively with steroids administered intravenously, but had no significant change in acute symptoms. Postprocedural electrophysiologic studies demonstrated the following: an inability to obtain an F-wave latency in the right peroneal nerve, denervation of L5 and S1 nerve roots bilaterally, and denervation of L4 and L5 nerve roots on the right. Twelve months later, she continues to complain of burning pain in both lower extremities, but has return of bowel and bladder function. She currently is being treated with anticonvulsants, amitriptyline, and hydrocodone. This is the second reported case of cauda equina syndrome following the IDET procedure that I am aware of. It is concerning that neither case was reported by the treating physician. The IDET procedure is relatively new, and complications possibly related to it may not be readily reported because of potential litigation. It is recommended that any complications possibly associated with IDET be reported to a referenced journal or the manufacturer so that any pattern of adverse outcome can be evaluated by scientific and/or manufacturer investigation. William E. Ackerman III, M.D.
The Pain Medicine Consultants Group, P.A. Little Rock, Arkansas References 1. Saal JS, Saal JA. Management of chronic discogenic low back pain with a thermalintradiscal catheter: A preliminary report. Spine 2000;25:382-388. 2. Hsia AW, Isaac K, Katz JS. Cauda equina syndrome from intradiscal electrothermal therapy. Neurology 2000;55:320.
Accepted for publication August 15, 2002. doi:10.1053/rapm.2002.37120
Clinical Hypnosis Instead of Drug-Based Sedation for Procedures Under Regional Anesthesia To the Editor: Clinical hypnosis has been used in psychotherapy for a long time, although the neural mechanism behind this induced trance state remains unclear.1,2 Its utilization for sedation3 or analgesia4 in the operating room has also been described. We retrospectively surveyed 48 patients undergoing different surgical procedures under regional anesthesia (epidural, spinal, or axillary plexus block). We used clin-
Reference 1. Guerts et al. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: A prospective, 1-year follow-up study. Reg Anesth Pain Med 2002;343-352.
Accepted for publication August 9, 2002. doi:10.1053/rapm.2002.37327
Reply to Dr. Hammer To the Editor: We apologize to Dr. Hammer and all readers of the journal that in our report1 the wrong Fig 2 has appeared by mistake. Undoubtedly, Fig 2B is a myelogram. We were so enthusiastic about the epiduroscopy images and results that during the process of editing, we did not notice that Fig 2A and B were not the original images of patient number 4. We sincerely regret this administrative error. Thus, it will be obvious that we fully agree with Dr Hammer that basic spinal fluoroscopic interpretation must be understood before applying invasive procedure
Fig 2. Patient number 4. (A) Preoperative epidurogram of a 55-year-old man (anteroposterior view) with a history of previous partial discectomy (L4/5 level), who presented with left-sided sciatica, predominantly in the L5 and S1 distribution. Note the large filling defect on the left side, extending from the S2-foramen up to the L4/5 level. (B) An epiduroscope was directed via the sacral hiatus toward the filling defect and adhesions surrounding L5 and S1 nerve roots were identified. Effective mechanical adhesiolysis was established and the left lateral epidural space opened up after injection of contrast fluid.
Regional Anesthesia and Pain Medicine, Vol 27, No 6 (November–December), 2002: pp 621–624
621
622
Regional Anesthesia and Pain Medicine Vol. 27 No. 6 November–December 2002
techniques. We thank Dr Hammer for his most alert reaction. The original epidurogram figures are shown. J.W.M. Geurts, M.D., Ph.D. J-W. Kallewaard, M.D. J. Richardson, M.D., F.R.C.P., F.R.C.A. G.J. Groen, M.D., Ph.D. Department of Anesthesiology Rijnstate Hospital Arnhem, The Netherlands Reference 1. Geurts JWM, Kallewaard, J-W, Richardson J, Groen GJ. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: A prospective, 1-year follow-up study. Reg Anesth Pain Med 2002;27:343-352.
Accepted for publication August 20, 2002. doi:10.1053/rapm.2002.37325
Cauda Equina Syndrome After Intradiscal Electrothermal Therapy To The Editor: Intradiscal electrothermal therapy (IDET) has become increasingly popular for the management of low back pain. First described by Saal and Saal in 2000,1 the device was approved by the Food and Drug Administration in March 1998 for the coagulation and decompression of disc material. The procedure is recommended for those patients with degenerative disc disease who complain of nonspecific pain in the lumbar spine, but do not have significant disc herniation or nerve root compression and who have a normal neurologic examination. IDET is proposed to be a safe procedure, yet a single case report describes cauda equina syndrome after the procedure.2 Herein, I report another case of cauda equina syndrome following the IDET procedure. The patient was a 65-year-old female referred to me for pain medicine consultation 12 months after the IDET. Prior to the procedure, the patient had chronic nonspecific lumbar spine pain. A pre-IDET computerized tomography scan did not show a lumbar disc herniation, but she did have an annular disruption at the L4-5 disc. Magnetic resonance imaging was not done because of her pacemaker. Pre-IDET neurologic examination was within normal limits. She had no history of bowel or bladder dysfunction. Provocative discography revealed pain at the L3-4 and L4-5 levels. She subsequently underwent IDET at the L3-4 and L4-5 discs. The IDET 17-gauge introducer needles and thermal catheters (SpineCath, Oratec Interventions, Inc, Menlo Park, CA) were placed with fluoroscopic guidance. The electrode was heated to 90° centigrade over 18 minutes and maintained for 4 minutes. During the procedure, she complained of transient burning pain in both lower
extremities. The physician performing the procedure again ascertained proper needle and catheter placement with lateral and anterior-posterior fluoroscopic views. Following the procedure, the patient complained of weakness in both lower extremities, and had neurogenic bowel and bladder as well as saddle anesthesia. She was treated aggressively with steroids administered intravenously, but had no significant change in acute symptoms. Postprocedural electrophysiologic studies demonstrated the following: an inability to obtain an F-wave latency in the right peroneal nerve, denervation of L5 and S1 nerve roots bilaterally, and denervation of L4 and L5 nerve roots on the right. Twelve months later, she continues to complain of burning pain in both lower extremities, but has return of bowel and bladder function. She currently is being treated with anticonvulsants, amitriptyline, and hydrocodone. This is the second reported case of cauda equina syndrome following the IDET procedure that I am aware of. It is concerning that neither case was reported by the treating physician. The IDET procedure is relatively new, and complications possibly related to it may not be readily reported because of potential litigation. It is recommended that any complications possibly associated with IDET be reported to a referenced journal or the manufacturer so that any pattern of adverse outcome can be evaluated by scientific and/or manufacturer investigation. William E. Ackerman III, M.D.
The Pain Medicine Consultants Group, P.A. Little Rock, Arkansas References 1. Saal JS, Saal JA. Management of chronic discogenic low back pain with a thermalintradiscal catheter: A preliminary report. Spine 2000;25:382-388. 2. Hsia AW, Isaac K, Katz JS. Cauda equina syndrome from intradiscal electrothermal therapy. Neurology 2000;55:320.
Accepted for publication August 15, 2002. doi:10.1053/rapm.2002.37120
Clinical Hypnosis Instead of Drug-Based Sedation for Procedures Under Regional Anesthesia To the Editor: Clinical hypnosis has been used in psychotherapy for a long time, although the neural mechanism behind this induced trance state remains unclear.1,2 Its utilization for sedation3 or analgesia4 in the operating room has also been described. We retrospectively surveyed 48 patients undergoing different surgical procedures under regional anesthesia (epidural, spinal, or axillary plexus block). We used clin-