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From the Department of Anesthesia, BC Women’s Hospital, Vancouver, British Columbia, Canada.
Address correspondence to: Dr. Joanne Douglas, Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, B.C. V6H 3N1, Canada. Phone: 604-875-2158; Fax: 604-875-2733; E-mail: jdouglas{at}cw.bc.ca
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Clinical findings: Recently the authors have received requests for epidural anesthesia in three women with tattoos over the midline of their lumbar spine. In one patient the tattoo covered her entire back. In the other two, it was possible to locate a lumbar interspace that did not have tattoo pigment in the overlying skin. All three women received uneventful epidural analgesia.
A Medline and EMBASE search for relevant publications using the keywords: epidural, spinal, tattoos, tattooing, complications did not find any reports of complications from inserting a needle through a tattoo. As none were found, the literature on tattoos and on coring with neuraxial anesthesia was reviewed to see if neuraxial anesthesia might be problematic if the needle passed through the tattoo. Coring is a complication of neuraxial anesthesia that may lead to epidermoid tumours in the subarachnoid space. Theoretically, a pigment-containing tissue core from a tattoo could be deposited into the epidural, subdural or subarachnoid spaces, leading to later neurological complications.
Conclusions: There is no information in the literature about possible risks from inserting needles through tattoos during the performance of neuraxial anesthesia. This report discusses the possible implications.
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The second woman had a tattoo that completely covered her back extending to the mid-axillary line bilaterally. There was no pigment free area. The anesthesiologist inserted the epidural through the tattoo as labour was painful and prolonged and she ultimately required a Cesarean section.
A third woman had a butterfly tattoo that was midline, extending 2 cm to each side. Fortunately, it was located over the L4–5 interspace, leaving the L2–3 and L3–4 interspaces available. The epidural was successfully inserted at L2–3.
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Coring
Hollow needles, with or without a stylet, entrap tissue fragments (cores) in their bore as they pass to deeper structures.1,2 Injection through these needles may then result in this entrapped tissue being deposited in the deeper site. In 1956 Choremis et al. reported on five children who developed iatrogenic epidermoid tumours in the epidural and subarachnoid spaces following multiple spinal injections of antibiotics.3 The authors postulated that during lumbar puncture a "core" of tissue containing epidermal elements was picked up as the nonstyletted needle passed through the skin and was subsequently injected into the subarachnoid or epidural space. The cells of the core then grew into an epidermoid tumour.3 Since that time numerous other cases have been reported including some in adults4–8 and one involving spinal anesthesia in a parturient.8 This latter case had two lumbar punctures as a child and a third at age 33 for "diagnostic purposes". She then had a fourth for spinal anesthesia for childbirth and subsequently developed an epidermoid tumour.
Although nonstyletted needles have been implicated in "coring", the newer styletted spinal needles also cause coring. Campbell et al. microscopically examined the needle tips of 25-gauge Quincke and Whitacre needles for evidence of coring after failed attempts to identify the subarachnoid space.9 Tissue cores were found in 80% of the Quincke needles and 41% of the Whitacre needles. Most of the tissue was blood clot or fat. No epidermal tissue was found. In this study, the spinal needle was inserted after a small nick had been made in the skin with a larger needle.9 In another study, Puolakka et al. microscopically examined the needle tips of 27-gauge modified Quincke, modified Sprotte and modified Whitacre needles after they had passed through a fluorescein disinfectant scrubbed back into the subarachnoid space in cadavers.10 Visible fluorescent tissue particles were seen in 27-gauge modified Quincke (56%), Sprotte (37%) and Whitacre needles (37%). Epithelial cells and muscle fibres were observed in the Quincke needles, fewer were seen in the Whitacre group and only a few epithelial cells in the Sprotte group. In a study of caudal anesthesia in children, coring occurred in 54% of needles used for caudal injection.11 Epidermal tissue was found in 33% of the positive samples, fat in 67% and blood material in 26%.
Ozyurt et al. collected 1 mL of cerebral spinal fluid (CSF) immediately after inserting a spinal needle (22-, 25- and 27-gauge Quincke needles) into the subarachnoid space.12 The CSF was examined for epithelial cells. The authors found benign squamous cells in the CSF from each size of needle with more present in the larger gauge needle.
Tattoos
During the tattooing process the needles penetrate the epidermis into the dermis and pigment is deposited along the entire needle tract. Only pigment that is in the dermis remains permanently. After the tattoo has healed, the pigment is engulfed by dermal macrophages and carried to regional lymphatics and perivascular lymph nodes.13 The pigment that remains in the loose fibrous connective tissue of the dermis gives colour to the tattoo. What are the possible implications (consequences) for the anesthesiologist? Theoretically introducing a needle through the pigmented tattoo may result in a tissue core that contains pigment. This could be injected into the epidural, subdural or subarachnoid spaces.
In the past, the pigments used for tattooing were inorganic and included titanium dioxide, cadmium sulphide, chromic oxide, cadmium selenide, red cinnabar, iron oxide and carbon.14 Although more organic pigments are being used currently neither the individual being tattooed nor the tattoo artist may know the composition of the ink.
Complications of tattoos
Various reactions have been associated with tattoos including allergic, pseudolymphoma and granulomatous or lichenoid reactions.15 Mercury ions, chromium III ions or cobalt II ions induce allergic reactions. Other reported problems associated with tattooing include transmission of hepatitis B and C16 and localized infections at the site of the tattoo. There is a case report of a spinal epidural abscess that occurred two weeks following a tattoo on a buttock.17 Other reported complications include a superficial burn in the tattoo18 and pain in the area of the tattoo,19 both during magnetic resonance imaging scanning.
Of greater concern is a report of three patients who developed brachial plexus neuropathies with muscle atrophy.20 All had tattoos adjacent to the area of atrophy. The author postulated that the tattoo induced focal chronic neuromuscular dysfunction, possibly due to an immune-mediated reaction or a toxic effect of the pigment. As chemically induced arachnoiditis can occur following epidural anesthesia with local anesthetics containing preservatives,21 might not a similar reaction occur from pigment?
Will nicking the skin prior to inserting an epidural or spinal needle as done by Campbell et al.9 avoid picking up tissue cores containing pigment? It would seem reasonable. Obviously the size of the nick has to be larger than the needle being inserted and should penetrate through the dermis. Whether these precautions provide adequate protection is unknown.
To date, there are no reports of complications from inserting a needle through a tattoo. This could be because they do not occur. However, the lack of reported complications could reflect the fact that in the past fewer patients (pregnant and non-pregnant) had tattoos involving the midline of their lower back. The number of patients having neuraxial anesthesia through a pigmented tattoo would have been correspondingly small. Additionally, epidermoid tumours and arachnoiditis do not occur immediately but develop over time. It may be too early to see any long-term consequences.
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2 Brandus V. The spinal needle as a carrier of foreign material. Can Anaesth Soc J 1968; 15: 197–201.[Medline]
3 Choremis C, Economos D, Papadatos C, Gargoulas A. Intraspinal epidermoid tumours (cholesteatomas) in patients treated for tuberculous meningitis. Lancet 1956; 2: 437–9.
4 Tabaddor K, Lamorgese JR. Lumbar epidermoid cyst following single spinal puncture. Case report. J Bone Joint Surg Am 1975; 57: 1168–9.
5 Gardner DJ, O’Gorman AM, Blundell JE. Intraspinal epidermoid tumour: late complication of lumbar puncture. CMAJ 1989: 141: 223–5.[Medline]
6 Halcrow SJ, Crawford PJ, Craft AW. Epidermoid spinal cord tumour after lumbar puncture. Arch Dis Child 1985; 60: 978–9.[Abstract]
7 Reina MA, Lopez-Garcia A, Dittmann M, de Andres JA, Blazquez MG. Iatrogenic spinal epidermoid tumors. A late complication of spinal puncture (Spanish). Rev Esp Anestesiol Reanim 1996; 43: 142–6.[Medline]
8 McDonald JV, Klump TE. Intraspinal epidermoid tumors caused by lumbar puncture. Arch Neurol 1986; 43: 936–9.[Abstract]
9 Campbell DC, Douglas MJ, Taylor G. Incidence of tissue coring with the 25-gauge Quincke and Whitacre spinal needles. Reg Anesth 1996; 21: 582–5.[Medline]
10 Puolakka R, Andersson LC, Rosenberg PH. Microscopic analysis of three different spinal needle tips after experimental subarachnoid puncture. Reg Anesth Pain Med 2000; 25: 163–9.[Medline]
11 Goldschneider KR, Brandom BW. The incidence of tissue coring during the performance of caudal injection in children. Reg Anesth Pain Med 1999; 24: 553–6.[Medline]
12 Ozyurt G, Mogol EB, Tolunay S, Kerimoglu B. Tissue coring with spinal needles (Letter). Reg Anesth Pain Med 2000; 25: 665.[Medline]
13 Sperry K. Tattoos and tattooing. Part II: gross pathology, histopathology, medical complications, and applications. Am J Forensic Med Pathol 1992; 13: 7–17.[Medline]
14 Baumler W, Eibler ET, Hohenleutner U, Sens B, Sauer J, Landthaler M. Q-switch laser and tattoo pigments: first results of the chemical and photophysical analysis of 41 compounds. Lasers Surg Med 2000; 26: 13–21.[Medline]
15 Schwartz RA, Mathias CG, Miller CH, Rojas-Corona R, Lambert WC. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis 1987; 16: 198–202.[Medline]
16 Haley RW, Fischer RP. Commercial tattooing as a potentially important source of hepatitis C infection: clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status. Medicine 2001; 80: 134–51.[Medline]
17 Chowfin A, Potti A, Paul A, Carson P. Spinal epidural abscess after tattooing. Clin Infect Dis 1999: 29: 225–6.[Medline]
18 Vahlensieck M. Tattoo-related cutaneous inflammation (burn grade I) in a mid-field MR scanner (Letter). Eur Radiol 2000; 10: 197.[Medline]
19 Kreidstein ML, Giguere D, Freiberg A. MRI interaction with tattoo pigments: case report, pathophysiology, and management. Plast Reconstr Surg 1997; 99: 1717–20.[Medline]
20 Steiner I, Farcas P, Wirguin I. Tattoo-related brachial plexopathies with adjacent muscle atrophy (Letter). Ann Intern Med 2000; 133: 158–9.
21 Sklar EM, Quencer RM, Green BA, Montalvo BM, Post MJ. Complications of epidural anesthesia: MR appearance of abnormalities. Radiology 1991; 181: 549–54.
22 Mandabach MG, McCann DA, Thompson GE. Body art: another concern for the anesthesiologist. Anesthesiology 1998; 88: 279–80.
This article has been cited by other articles:
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  N. Kluger, J.-C. Sleth, and B. Guillot Lumbar tattoos and lumbar puncture: the emperor's new clothes? Can J Anesth, October 1, 2007; 54(10): 855 - 855. [Full Text] [PDF]
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K. M. Kuczkowski Labour analgesia in a parturient with lumbar tattoo: a routine management? or not? Can J Anesth, January 1, 2004; 51(1): 93 - 93. [Full Text]
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M. J. Douglas and J. E. Swenerton REPLY Can J Anesth, January 1, 2004; 51(1): 93 - 93. [Full Text]
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