Hoftman Nir N, Ferrante F Michael
Department of Anesthesiology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA 90095-7403, USA.
Reg Anesth Pain Med. 2009 Jan-Feb;34(1):12-6. doi: 10.1097/AAP.0b013e31819339cf.
: Subdural injection is a well-known but often poorly recognized complication of neuraxial anesthesia/analgesia. This report aims to further describe the clinical presentation of subdural injection by analyzing radiographically proven cases. A new diagnostic algorithm is then proposed.
: A literature search identified 70 radiographically confirmed cases of subdural injection. The prevalence of numerous presenting characteristics and their relationship to the volume of injected local anesthetics were examined. The ability of 2 previously published diagnostic paradigms to detect proven subdural injection was compared with that of a newly proposed algorithm.
: The dermatomal distribution of sensory blockade was excessive in 74% of cases, restricted in 17%, and neither in 9%. Motor blockade and respiratory depression were associated with larger local anesthetic injection volumes (median volume = 14 vs. 8 mL [P <.009] and 15 vs. 10 mL [P <.035], respectively), but segmental spread and cardiovascular depression were not. Only 33% of cases were positive for 2 or more of Collier's criteria; Lubenow et al.'s diagnostic paradigm detected 71% of cases. We propose a diagnostic algorithm structured as a "roadmap," whereby the clinician inputs the assumed neuraxial block (epidural vs. subarachnoid), and distribution of sensory blockade (excessive, restricted, neither). Specific minor criteria are then applied to diagnose subdural injections. This algorithm detected 93% of subdurals with excessive sensory block distribution, and all of those with restricted and normal distribution.
: Radiographically proven subdural injections were used to further define the clinical presentation of subdural analgesia/analgesia and a new diagnostic algorithm is proposed.
硬膜下注射是神经轴索麻醉/镇痛一种广为人知但常未被充分认识的并发症。本报告旨在通过分析经影像学证实的病例进一步描述硬膜下注射的临床表现。随后提出一种新的诊断算法。
文献检索确定了70例经影像学证实的硬膜下注射病例。研究了众多呈现特征的发生率及其与局部麻醉药注射量的关系。将2种先前发表的诊断范式检测经证实的硬膜下注射的能力与新提出的算法进行了比较。
感觉阻滞的皮节分布在74%的病例中过度，17%受限，9%无异常。运动阻滞和呼吸抑制与较大的局部麻醉药注射量相关（中位注射量分别为14 vs. 8 mL [P <.009]和15 vs. 10 mL [P <.035]），但节段性扩散和心血管抑制则不然。只有33%的病例符合2项或更多Collier标准；Lubenow等人的诊断范式检测出71%的病例。我们提出一种诊断算法，构建为“路线图”，临床医生据此输入假定的神经轴索阻滞（硬膜外 vs. 蛛网膜下）以及感觉阻滞的分布情况（过度、受限、无异常）。然后应用特定的次要标准来诊断硬膜下注射。该算法检测出93%感觉阻滞分布过度的硬膜下注射病例，以及所有感觉阻滞分布受限和正常的病例。
利用经影像学证实的硬膜下注射进一步明确硬膜下镇痛/麻醉的临床表现，并提出一种新的诊断算法。
