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Epidural spread depends on the approach used for posterior lumbar plexus block

Dublin, Ireland

To the Editor:

I read with interest Ho and Karmakar’s article¹ on the use of combined lower limb blockade in a patient with aortic stenosis. I have also successfully performed a similar technique without continuous sedation, in two female septuagenarians undergoing hip fracture repair with concurrent moderate and severe aortic stenosis respectively. However, unlike their patient, in these women arterial blood pressure was maintained within 20% of baseline and alpha agonist administration was unnecessary. Neither patient had clinical evidence of epidural spread, which may have occurred in the authors’ patient as they mention that her dementia precluded an accurate assessment.

Unfortunately epidural-like spread occurring after posterior lumbar plexus block is variable with one factor being the approach taken. The approach quoted has an incidence of epidural spread of 16%.² The approach I used is one described recently by Capdevila and colleagues.³ This modification of Winnie and co-workers’ original description has the insertion point more medial and at the L4 level so avoiding medial orientation of the needle. The incidence of epidural-like spread is 1.8 to 6.5% without hemodynamic sequelae.^3,4

What exact mechanisms and factors contribute to epidural-like spread are unknown, although spread may occur anterior to the vertebral bodies in a similar fashion as reported by one of the authors following thoracic paravertebral block⁵ or via epidural placement of the block needle. Until these factors are known I would recommend this newer approach if utilizing this anesthetic technique, especially as adverse hemodynamic consequences could be fatal in this patient population.

References

1 Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic nerve block for reduction of hip fracture in a patient with severe aortic stenosis. Can J Anesth 2002; 49: 946–50.[Abstract/Free Full Text]

2 Parkinson SK, Mueller JB, Little WL, Bailey SL. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 1989; 68: 243–8.[Abstract/Free Full Text]

3 Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg 2002; 94: 1606–13.[Abstract/Free Full Text]

4 De Biasi P, Lupescu R, Burgun G, Lascurain P, Gaertner E. Continuous lumbar plexus block: use of radiography to determine catheter tip location. Reg Anesth Pain Med 2003; 28: 135–9.[Medline]

5 Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth 2000; 84: 263–5.[Abstract/Free Full Text]

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Reply:

Manoj K. Karmakar and Anthony M.-H. Ho
CJA 2004 51: 517. [Full Text]  

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