ASPECTOS TÉCNICOS

DE LOS BLOQUEOS

EPIDURALES

Dra. Marta Perepérez

Sº de Anestesia y

Reanimación

CLÍNICA UBARMIN

ESPACIO EPIDURAL

“Injected material displaces the dura forward and inward,

producing a stretch of the nerve roots that leads to lysis of neural

adhesions.”Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain

and/or low back pain. Spine J. 2009 Jun; 9 (6): 509-17.

FÁRMACOS

FALTA DE CONSENSO

A FAVOR MAYORITARIAMENTE DE MEZCLA DE:

CCO + AL

FÁRMACOS

DOLOR → LA REACCIÓN INFLAMATORIA

↓

ALIVIO → INTERRUPCIÓN SÍNTESIS DE CITOQUINAS Burnett C. Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol, 2008, Aug; 21 (4):452-6.

↓

CCO → DISMINUYEN:

• El edema

• La vasodilatación capilar

• La proliferación de fibroblastos

• La cicatrización

• La síntesis de PLA2

FÁRMACOS

¿QUÉ CCO?

Depo-Medrol

Trigon

ND VE

Manchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.

FÁRMACOS

¿QUÉ PERIODICIDAD?

Manchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.

FÁRMACOS

¿QUÉ PERIODICIDAD?

Marinangeli F, Ciccozzi A, Donatelli F, Paladini A, Varrassi G. Clinical use of spinal or epidural steroids. Minerva Anestesiol. 2002

Jul-Aug;68(7-8):613-20.

Steroidal toxicity seems to be related to the

polyethylenic glycole vehicle. Anyway, slow release

formulations contain less concentrated polyethylenic

glycole. The epidural administration, a correct dilution

of steroid with local anesthetics solution and/or saline

solution, and a limited number of injections (no more

than three) allows a significant reduction of steroid

neurotoxicity.

FÁRMACOS

CCO DE ACCIÓN PROLONGADANoe CE, Haynsworth RF Jr. Comparison of epidural Depo_medrol vs. Aqueous betamethasone in patients with low back pain. Pain

Pract. 2003 Sep; 3 (3):222-5

↓

ACETATO DE METILPREDNISOLONA (40-80 mg) Y ACETÓNIDO DE TRIAMCINOLONA (80 mg)

Robinson D et al.The effects of different doses of lumbosacral epidural steroids for patients with lumbosacral radiculopathy and

spinal stenosis. Ameriacan Academy of Pain Medicine. 22nd Annual Meeting. February 22-25, 2006.

Owlia M B, Salimzadeh A, Alishiri Gh, Haghighi A. Comparison of two doses of corticosteroid in epidural steroid injection for lumbar

radicular pain. Singapore Med J 2007; 48 (3) : 24-45.

FÁRMACOS

AL

↓

PROS Y CONTRAS DE LOS AL:

• Capacidad de romper el círculo vicioso: Dolor muscular,espasmo, isquemia, dolor

• Beneficio psicológico

• Comprobación de la inyección epidural

• CONTRAS: HipoTA, bloqueo sensitivo y motor prolongado

↓

VOLUMEN

↓

DEPENDE DE LA VÍA DE ABORDAJE

VÍAS DE ABORDAJE

CAUDAL

30-40mL

INTERLAMINAR

8-12mL

TRANSFORAMINAL

2-4 mL

VÍAS DE ABORDAJE

EFICACIA SUPERIOR DE LAS VÍAS INTERLAMINAR Y TRANSFORAMINAL

VS LA CAUDAL

EFICACIA SUPERIOR DE LA VÍA TRANSFORAMINAL EN HERNIAS

TRANSFORAMINALES Y EN ESTENOSIS DE CANAL

Lee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection in

lumbosacral herniated disk and spinal stenosis. J Back Musculoskelet Rehabil. 2009;22(2):83-9.

VÍAS DE ABORDAJE

Abordaje intraforaminal

PARAPLEJIA (Houten JK, Erico TJ. Paraplegia after lumbosacral nerve root

block: report of three cases. Spine J 2002; 2:70-75.) ( Glaser SE and Falco F.

Paraplegia following thoracoumbar transforaminal epidural steroid injection, pain

Physician 2005; 8:309-314.) (Epidural Steroids in the Management of Chronic Spinal Pain: A

Systematic review. Pain Physician 2007, 10:185-212.)

MAYOR DIFICULTAD TÉCNICA

COMPLICACIONES

3 TIPOS

•DERIVADAS DEL USO DE AL

•DERIVADAS DE LA TÉCNICA

•DERIVADAS DEL USO DE CCO

COMPLICACIONES: por la técnica

T. M. Cook, D. Counsell and J. A. W. Wildsmith. Major complications of central neuraxial block: report on the Third National

Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 102 (2): 179–90 (2009).

293.050 epidurales

de las cuales 27.975

eran para control de

dolor crónico

COMPLICACIONES: por el uso de CCO

COMPLICACIONES: otras

• CPPD

• REACCIONES VASOVAGALES

• DOLOR LOCAL O EXACERBACIÓN DE LA RADICULOPATÍA DURANTE LA

PUNCIÓN

• ARACNOIDITIS Y NEUROTOXICIDAD

• LIPOMATOSIS EPIDURAL

• MENORRAGIA O AMENORREA

CONCLUSIONES

• La inyección epidural conjunta de CCO y de AL se ha

demostrado eficaz.

• Las 3 vías de administración son válidas.

• El tipo de CCO y la periodicidad de los BED deben

individualizarse en cada centro: protocolización (Cohen

SP, Hayek SM, Datta S, Bajwa ZH, Larkin TM, Griffith S, Hobelmann G, Christo PJ, White R. Incidence and root

cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010

Mar;112(3):711-8.

• Es fundamental la adopción de medidas de

seguridad para el paciente: s/t estudio preoperatorio,

monitorización, ingreso 7-10 horas y seguimiento

efectos secundarios.

GRACIAS

Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine

epidural steroid injection: two case reports. Pain Med. 2009 Nov;10(8):1389-94.

OBJECTIVE: To present two case reports of a rare but devastating injury after image-guided,

lumbar transforaminal injection of steroids, and to explore features in common with previously

reported cases. BACKGROUND: Image (fluoroscopic and computed tomography [CT])-guided,

lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular

pain. Complications associated with these procedures are rare, but can be severe. CASE

REPORTS: An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal

injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided,

right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients

developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately

after the procedures. Magnetic resonance imaging scans were consistent with spinal cord

infarction. There was no evidence of intraspinal mass or hematoma.

CONCLUSION: These cases consolidate a pattern emerging in the literature. Distal cord and

conus injury can occur following transforaminal injections at lumbar levels, whether injection is on

the left or right. This conforms with the probability of radicular-medullary arteries forming an

arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which

promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this

complication can be reduced, and potentially eliminated, by the utilization of particulate free

steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary

injection of local anesthetic.