Cervical epidural

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Cervical Epidural

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Cervical epidural

  1. 1. Cervical Epidural- case reports Dr Ashok Jadon, MD DNB Sr. Consultant & HOD Anaesthesia Tata Motors Hospital, Jamshedpur Ca-Breast with CRPS
  2. 2. CRPS with Carcinoma Breast <ul><li>47 yr Female </li></ul><ul><li>Shoulder Injury & pain >1 months (2months) </li></ul><ul><li>Chest pain 1 month= 3months </li></ul><ul><li>Breast Lump (large, firm, axillary nodes ve+) FNAC positive </li></ul><ul><li>Radical mastectomy+ axillary clearance </li></ul>
  3. 3. Preoperative assessment & plan ( Ca with CRPS) <ul><li>Severely swollen, allodynia, immobile right upper limb </li></ul><ul><li>Depressed, continuous crying pt. </li></ul><ul><li>Concerns </li></ul><ul><ul><li>To manage CRPS </li></ul></ul><ul><ul><li>Postoperative analgesia/ physiotherapy </li></ul></ul><ul><ul><li>lymph-edema 20-60% </li></ul></ul><ul><li>Options </li></ul><ul><ul><li>GA+ parenteral narcotics (neurogenic pain) </li></ul></ul><ul><ul><li>GA + stellate gang block ( short duration)/ Catheter technique (easier said than done) </li></ul></ul><ul><ul><li>Other options……… </li></ul></ul>
  4. 4. Introduction <ul><li>Complex regional pain syndrome (CRPS) is a disorder of the extremities. </li></ul><ul><li>A diagnosis of CRPS requires the presence of regional pain and sensory changes following a noxious event. </li></ul><ul><li>The pain is more severe than expected from the injury which caused it. </li></ul>
  5. 5. Introduction <ul><li>CRPS frequently begins following: </li></ul><ul><ul><li>An injury </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>A vascular event such as a myocardial infarction or stroke </li></ul></ul><ul><li>It is characterized by: </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Swelling/edema </li></ul></ul><ul><ul><li>Limited range of motion </li></ul></ul><ul><ul><li>Vasomotor instability </li></ul></ul><ul><ul><li>Skin changes/abnormal skin color </li></ul></ul><ul><ul><li>Patchy bone demineralization </li></ul></ul><ul><ul><li>Temperature changes </li></ul></ul><ul><ul><li>Atrophy </li></ul></ul>
  6. 6. Introduction <ul><li>Two types of CRPS have been recognized: </li></ul><ul><ul><li>Type I: </li></ul></ul><ul><ul><ul><li>No definable nerve lesion is present. </li></ul></ul></ul><ul><ul><ul><li>Represents about 90% of clinical cases. </li></ul></ul></ul><ul><ul><li>Type II: </li></ul></ul><ul><ul><ul><li>A definable nerve lesion is present. </li></ul></ul></ul><ul><ul><ul><li>Formerly termed causalgia. </li></ul></ul></ul>
  7. 7. Etiology <ul><li>The pathogenesis of CRPS is unclear. </li></ul><ul><li>Trivial Injury </li></ul><ul><li>It is thought to involve the formation of a reflex arc after an inciting event. </li></ul><ul><li>The reflex arc follows the routes of the sympathetic nervous system. </li></ul><ul><li>It is modulated by cortical centers which produce peripheral vascular changes. </li></ul>
  8. 8. Etiology <ul><li>A proposed mechanism for the persistent pain and allodynia is the release of inflammatory mediators and pain producing peptides by peripheral nerves, including: </li></ul><ul><ul><li>Substance P </li></ul></ul><ul><ul><li>Neuropeptide Y </li></ul></ul><ul><ul><li>Calcitonin gene related peptide </li></ul></ul><ul><ul><li>IL-6, IL-8, IL-1beta </li></ul></ul><ul><ul><li>Tumor necrosis factor alpha </li></ul></ul>
  9. 9. Diagnosis <ul><li>Autonomic testing and bone scintigraphy can provide an early clue to diagnosis. </li></ul><ul><li>Radiology studies can be helpful later in the course of illness. </li></ul><ul><li>Response to treatment is a often a useful diagnostic test. </li></ul>
  10. 10. Management <ul><li>A multidisciplinary management approach </li></ul><ul><li>Psychological Assessment and Counseling </li></ul><ul><li>Physical and Occupational Therapy </li></ul><ul><li>Medications that appear to resolve pain significantly better than placebo include agents in the following classes: </li></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Bisphosphonates </li></ul></ul><ul><ul><li>Oral glucocorticoids </li></ul></ul><ul><ul><li>Nasal calcitonin </li></ul></ul>
  11. 11. Invasive Treatment <ul><li>Invasive treatments include: </li></ul><ul><ul><li>Tender point injections </li></ul></ul><ul><ul><li>Nerve stimulation </li></ul></ul><ul><ul><li>Epidural clonidine </li></ul></ul><ul><ul><li>Regional sympathetic nerve block </li></ul></ul><ul><ul><li>Ganglion blocks </li></ul></ul><ul><ul><li>Intravenous regional blocks </li></ul></ul><ul><ul><li>Dorsal column spinal cord stimulation </li></ul></ul><ul><ul><li>Sympathectomy </li></ul></ul>
  12. 12. Cervical epidural for Mastectomy <ul><li>Breast nerve supply T3-T6 </li></ul><ul><li>Axillary area C5-T2 </li></ul><ul><li>Cervical epidural coverage </li></ul>
  13. 13. Cervical epidural for Mastectomy <ul><li>Pavel Michalek et al: Cervical Epidural Anesthesia for Combined Neck and Upper Extremity Procedure: A Pilot Study (Anesth Analg 2004;99:1833–6) </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>
  14. 14. Decision for Cervical Epidural <ul><li>Deterrents </li></ul><ul><li>No practical experience </li></ul><ul><li>High precision technique </li></ul><ul><li>Serious consequences </li></ul><ul><li>Supportive </li></ul><ul><li>Experience of epidural </li></ul><ul><li>Fluoroscopic guide </li></ul><ul><li>Pathetic, pain concerns </li></ul><ul><li>Challenge </li></ul>
  15. 16. Drugs & Dosages <ul><li>3ml 2% xylocaine with adrenaline </li></ul><ul><li>7ml 2% xylocaine with adrenaline </li></ul><ul><li>IV sedation </li></ul><ul><li>after 40 mint 10ml 2% xylocaine with adr. </li></ul><ul><li>Postoperative: 0.125% bupivacaine, 60ml+150µg clonidine @ 2-3ml/hr </li></ul>
  16. 21. Response to Therapy <ul><li>A regional sympathetic nerve block or regional perfusion block can be useful both therapeutically and diagnostically. </li></ul><ul><li>Abrupt relief from pain and dysesthesia is typically transient and suggests a diagnosis of CRPS. </li></ul>
  17. 22. Epidural in CRPS <ul><li>Timothy R. Lubenow. Continuous Epidural Sympatholytic Infusion for the Treatment of Complex Regional Pain Syndrome (CRPS): Efficacy and Complications Anesthesiology 2004; 101: A979 </li></ul><ul><li>C. Lundborg. Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I). Anaesthesiologica Scandinavica 2002;43(6):  667 - 678 </li></ul>
  18. 23. Cervical Epidural Other Uses <ul><li>Mastectomy – 4 </li></ul><ul><li>Bilateral # upper limb- 1 </li></ul><ul><li>Corrective elbow surgery; failed brachial, Bad chest </li></ul>
  19. 28. Thank you
  20. 29. Disclaimer <ul><li>Consent to present the photographs & identity has been taken from all the patients included in presentation. </li></ul>

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