Cervical Epidural- case Cervical Epidural- case reportsreports

Dr Ashok Jadon, MD DNBDr Ashok Jadon, MD DNBSr. Consultant & HOD Sr. Consultant & HOD AnaesthesiaAnaesthesiaTata Motors Hospital, Jamshedpur Tata Motors Hospital, Jamshedpur

Ca-Breast with CRPS Ca-Breast with CRPS

CRPS with Carcinoma CRPS with Carcinoma BreastBreast 47 yr Female47 yr Female Shoulder Injury & pain >1 Shoulder Injury & pain >1

months (2months)months (2months) Chest pain 1 month= 3monthsChest pain 1 month= 3months Breast Lump (large, firm, axillary Breast Lump (large, firm, axillary

nodes ve+) FNAC positivenodes ve+) FNAC positive Radical mastectomy+ axillary Radical mastectomy+ axillary

clearanceclearance

Preoperative assessment Preoperative assessment & plan ( Ca with CRPS)& plan ( Ca with CRPS)

Severely swollen, allodynia, immobile Severely swollen, allodynia, immobile right upper limbright upper limb

Depressed, continuous crying pt.Depressed, continuous crying pt. Concerns Concerns

– To manage CRPSTo manage CRPS– Postoperative analgesia/ physiotherapyPostoperative analgesia/ physiotherapy– lymph-edema 20-60%lymph-edema 20-60%

OptionsOptions– GA+ parenteral narcotics (neurogenic pain)GA+ parenteral narcotics (neurogenic pain)– GA + stellate gang block ( short duration)/ GA + stellate gang block ( short duration)/

Catheter technique (easier said than done)Catheter technique (easier said than done)– Other options………Other options………

IntroductionIntroduction

Complex regional pain syndrome Complex regional pain syndrome (CRPS) is a disorder of the extremities.(CRPS) is a disorder of the extremities.

A diagnosis of CRPS requires the A diagnosis of CRPS requires the presence of regional pain and sensory presence of regional pain and sensory changes following a noxious event.changes following a noxious event.

The pain is more severe than The pain is more severe than expected from the injury which caused expected from the injury which caused it.it.

IntroductionIntroduction

CRPS frequently begins following:CRPS frequently begins following:– An injuryAn injury– SurgerySurgery– A vascular event such as a myocardial infarction or A vascular event such as a myocardial infarction or

strokestroke It is characterized by:It is characterized by:

– PainPain– Swelling/edemaSwelling/edema– Limited range of motionLimited range of motion– Vasomotor instabilityVasomotor instability– Skin changes/abnormal skin colorSkin changes/abnormal skin color– Patchy bone demineralizationPatchy bone demineralization– Temperature changesTemperature changes– AtrophyAtrophy

IntroductionIntroduction

Two types of CRPS have been Two types of CRPS have been recognized:recognized:– Type I:Type I:

No definable nerve lesion is present.No definable nerve lesion is present. Represents about 90% of clinical cases.Represents about 90% of clinical cases.

– Type II:Type II: A definable nerve lesion is present.A definable nerve lesion is present. Formerly termed causalgia.Formerly termed causalgia.

EtiologyEtiology

The pathogenesis of CRPS is unclear.The pathogenesis of CRPS is unclear. Trivial InjuryTrivial Injury It is thought to involve the formation of It is thought to involve the formation of

a reflex arc after an inciting event.a reflex arc after an inciting event. The reflex arc follows the routes of the The reflex arc follows the routes of the

sympathetic nervous system.sympathetic nervous system. It is modulated by cortical centers It is modulated by cortical centers

which produce peripheral vascular which produce peripheral vascular changes.changes.

EtiologyEtiology

A proposed mechanism for the A proposed mechanism for the persistent pain and allodynia is the persistent pain and allodynia is the release of inflammatory mediators and release of inflammatory mediators and pain producing peptides by peripheral pain producing peptides by peripheral nerves, including:nerves, including:– Substance PSubstance P– Neuropeptide YNeuropeptide Y– Calcitonin gene related peptideCalcitonin gene related peptide– IL-6, IL-8, IL-1betaIL-6, IL-8, IL-1beta– Tumor necrosis factor alphaTumor necrosis factor alpha

DiagnosisDiagnosis

Autonomic testing and bone scintigraphy Autonomic testing and bone scintigraphy can provide an early clue to diagnosis.can provide an early clue to diagnosis.

Radiology studies can be helpful later in Radiology studies can be helpful later in the course of illness.the course of illness.

Response to treatment is a Response to treatment is a often a useful diagnostic test.often a useful diagnostic test.

Management Management

A multidisciplinary management A multidisciplinary management approach approach

Psychological Assessment and Counseling Psychological Assessment and Counseling Physical and Occupational TherapyPhysical and Occupational Therapy Medications that appear to resolve pain Medications that appear to resolve pain

significantly better than placebo include significantly better than placebo include agents in the following classes:agents in the following classes:– AnticonvulsantsAnticonvulsants– BisphosphonatesBisphosphonates– Oral glucocorticoidsOral glucocorticoids– Nasal calcitoninNasal calcitonin

Invasive TreatmentInvasive Treatment

Invasive treatments include:Invasive treatments include:– Tender point injectionsTender point injections– Nerve stimulationNerve stimulation

–Epidural clonidineEpidural clonidine– Regional sympathetic nerve blockRegional sympathetic nerve block– Ganglion blocksGanglion blocks– Intravenous regional blocksIntravenous regional blocks– Dorsal column spinal cord stimulationDorsal column spinal cord stimulation– SympathectomySympathectomy

Cervical epidural for Cervical epidural for MastectomyMastectomy

Breast nerve Breast nerve supply T3-T6supply T3-T6

Axillary area C5-Axillary area C5-T2T2

Cervical Cervical epidural epidural coveragecoverage

Cervical epidural for Cervical epidural for MastectomyMastectomy Pavel Michalek et al: Cervical Epidural Anesthesia

for Combined Neck and Upper Extremity Procedure: A Pilot Study (Anesth Analg 2004;99:1833–6)

Stevensabac Rom A. Cervical and high thoracic epidural anesthesia as the sole anesthetic for breast surgery. Technique in Regional Anaesthesia

& Pain Management 1998;2(1):13-18. Kedar S. Joshi et al. A Combination of Two Regional

Techniques for Modified Radical Mastectomy (A Different Approach). Indian Journal of Anaesthesia 2008; 52 (1):98-105

Decision for Cervical Decision for Cervical EpiduralEpidural

DeterrentsDeterrents No practical No practical

experienceexperience High precision High precision

techniquetechnique Serious Serious

consequences consequences

SupportiveSupportive Experience of Experience of

epiduralepidural Fluoroscopic Fluoroscopic

guideguide Pathetic, pain Pathetic, pain

concernsconcerns ChallengeChallenge

Drugs & DosagesDrugs & Dosages

3ml 2% xylocaine with adrenaline3ml 2% xylocaine with adrenaline 7ml 2% xylocaine with adrenaline7ml 2% xylocaine with adrenaline IV sedationIV sedation after 40 mint 10ml 2% xylocaine after 40 mint 10ml 2% xylocaine

with adr.with adr. Postoperative: 0.125% Postoperative: 0.125%

bupivacaine, 60ml+150µg bupivacaine, 60ml+150µg clonidine @ 2-3ml/hrclonidine @ 2-3ml/hr

Response to TherapyResponse to Therapy

A regional sympathetic nerve A regional sympathetic nerve block or regional perfusion block block or regional perfusion block can be useful both therapeutically can be useful both therapeutically and diagnostically.and diagnostically.

Abrupt relief from pain and Abrupt relief from pain and dysesthesia is typically transient dysesthesia is typically transient and suggests a diagnosis of CRPS.and suggests a diagnosis of CRPS.

Epidural in CRPSEpidural in CRPS

Timothy R. Lubenow. Timothy R. Lubenow. Continuous Epidural Continuous Epidural Sympatholytic Infusion for the Treatment of Sympatholytic Infusion for the Treatment of Complex Regional Pain Syndrome (CRPS): Complex Regional Pain Syndrome (CRPS): Efficacy and Complications Efficacy and Complications Anesthesiology 2004; Anesthesiology 2004;

101: A979101: A979 C. Lundborg. C. Lundborg. Clinical experience using intrathecal Clinical experience using intrathecal

(IT) bupivacaine infusion in three patients with (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I). complex regional pain syndrome type I (CRPS-I). AnaesthesiologicaAnaesthesiologica ScandinavicaScandinavica 2002;43(6): 2002;43(6):  667 - 678 667 - 678

Cervical Epidural Cervical Epidural Other UsesOther Uses Mastectomy – 4Mastectomy – 4 Bilateral # upper limb- 1Bilateral # upper limb- 1 Corrective elbow surgery; failed Corrective elbow surgery; failed

brachial, Bad chestbrachial, Bad chest

DisclaimerDisclaimer

Consent to present the Consent to present the photographs & identity photographs & identity has been taken from all has been taken from all the patients included in the patients included in presentation. presentation.