硬膜外镇痛反复失败：与硬膜外脂肪有关联？

Repeated failure of epidural analgesia: an association with epidural fat?

作者信息

Lang Scott A, Korzeniewski Peter, Buie Donald, Du Plessis Stephan, Paterson Kimiko, Morris Gary

机构信息

Departments of Anesthesia, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada.

出版信息

Reg Anesth Pain Med. 2002 Sep-Oct;27(5):494-500. doi: 10.1053/rapm.2002.34323.

DOI:10.1053/rapm.2002.34323

PMID:12373698

Abstract

BACKGROUND AND OBJECTIVES

To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis).

CASE REPORT

A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established.

CONCLUSION

We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.

摘要

背景与目的

报告一例硬膜外镇痛反复失败且硬膜外间隙存在异常大量脂肪（硬膜外脂肪增多症）的患者病例。

病例报告

一名44岁女性因择期小肠切除术入院。置入L(1 - 2)硬膜外导管用于术后镇痛。患者在全身麻醉苏醒时及恢复室的最初2小时内均未表现出疼痛。在恢复室患者感觉舒适时，对冰敷的感觉减退水平评估提示硬膜外导管功能正常（感觉平面达T(10)）。进入恢复室两小时后，患者开始诉说疼痛加剧。通过导管又给予6 mL 0.25%布比卡因。患者疼痛减轻，但仍较明显，且T(10)平面以上感觉阻滞的证据极少。随后，置入T(10)硬膜外导管。测试证实导管在T(10)水平的硬膜外间隙位置正确。给予5 mL 0.25%布比卡因的试验剂量后，患者疼痛迅速完全缓解。然而，冰敷感觉减退平面未超过T(10)水平。大约1小时后，患者再次诉说不适加剧。无任何感觉阻滞的证据，给予8 mL 1%利多卡因推注也无反应。对患者进行全面检查后，除硬膜外导管功能异常外，未发现其他疼痛原因。在T(8 - 9)水平置入第三根硬膜外导管。给予10 mL 0.5%布比卡因试验剂量再次证实该导管位于硬膜外间隙。冰敷感觉减退平面局限于T(7) - T(9)的狭窄双侧区域。两小时后镇痛失败。拔除硬膜外导管，随后患者的疼痛通过静脉自控镇痛（PCA）吗啡进行处理。磁共振成像（MRI）扫描显示脊髓背侧从C(5) - C(7)以及从T(3) - T(9)存在广泛的硬膜外脂肪。确立了无症状硬膜外脂肪增多症的影像学诊断。