Abstract ID: A10

Abstract Title: Thoracic epidural anesthesia is a good alternative for permanent thoracic spinal cord stimulator placement: Review of fifteen cases and suggestions for management.

Poster Type: Either


ABSTRACT BODY

Introduction: General endotracheal anesthesia is routinely used for placement of a permanent thoracic spinal cord stimulator by the thoracic laminotomy approach. The advantages of general anesthesia in this setting include a "quiet" surgical field, and a secure airway in the prone position. Disadvantages of general anesthesia include the need for endotracheal intubation, the use of inhalational or intravenous agents ,and the use of neuromuscular blocking agents. Furthermore, the ability to confirm successful stimulator placement and to assess the patient's neuraxis for complications like an epidural hematoma are impaired until the patient emerges from anesthesia. As an alternative to general anesthesia we report our experience using fluoroscopically guided thoracic epidural anesthesia for the implantation of permanent spinal cord stimulators via a thoracic laminotomy in 15 patients.

Methods:
We review our experience with epidural anesthesia in fifteen patients for thoracic laminotomy for the implantation of permanent spinal cord stimulators for chronic lower extremity pain. We discuss appropriate patient selection, preoperative preparation, intraoperative positioning, monitoring, local anesthetic choice and dosing. Fluoroscopically guided thoracic epidural catheter placements were performed after the patients were prepped and draped in the surgical (prone) position. This anesthetic alternative represents the adaptation of a common chronic pain clinic approach which frequently uses fluoroscopic guidance in the prone position. We illustrate for the operating room anesthesiologist the steps we have taken to ensure patient safety and the success of the regional anesthetic. We illustrate these steps which include: 1.assuring adequate fluoroscopic visualization before prepping the patient 2. Positioning the patient with adequate (comfortable) kyphosis for optimal visualization of the target interspace(s) 3. Knowing the radiologic landmarks for the performance of a safe thoracic epidural in the prone position (see fig 1) 4. Recognizing the pattern of contrast spread in the epidural space in the prone and lateral projection and (see fig 1 and 2) 5. Practicing safe dosing techniques.

Signifant advantages of this alternative approach include the ability to "fine tune" lead placement in an awake patient, rapid recovery, avoidance of airway manipulation, and the avoidance of general anesthesitics. Like Lind (who reported the use of spinal anesthesia for this procedure), we found that the ability to stimulate the spinal cord to cover the patient's pain map was not significantly hampered by regional anesthesia(1).


As the series progressed, we were able to take advantage of the regional technique to program the stimulator immediately after surgery, and to avoid the recovery room stay for several cases. Future studies are planned to compare the regional technique to general anesthesia with regard to cost efficacy, length of stay and patient satisfaction.


Reference:
1. Lind G, Meyerson BA, Winter J, Linderoth B: Implantation of Laminotomy Electrodes for Spinal Cord Stimulation in Spinal Anesthesia with Intraoperative Dorsal Column Activation.
Neurosurgery 53:1150-1154,2

ATTACHED FILES







Reg Anesth Pain Med 2004; 29(2):A10