Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea.
Pain Pract. 2019 Sep;19(7):762-766. doi: 10.1111/papr.12802. Epub 2019 Jul 10.
Cervical epidural steroid injection (CESI) with local anesthetics is commonly used to treat neck pain and radicular pain of the upper extremity. Local anesthetic systemic toxicity (LAST) occurs shortly after injection as a complication; however, delayed onset is a very rare event, especially in central nervous system (CNS) block.
We present a case in which delayed onset of LAST occurred in a patient who received CESI for cervical and arm radiating pain due to a cervical disc protrusion. We performed the interlaminar approach for CESI using fluoroscopic guidance. After confirming the location of the epidural space using the loss of resistance technique and spreading of contrast agent (Telebrix 30), a mixture of 0.25% levobupivacaine 12.5 mg (5 mL in volume), hyaluronidase 1,500 IU (1 mL), dexamethasone 5 mg (1 mL), and normal saline 3 mL was administrated. After 50 minutes of injection, the patient showed CNS toxicity (unconsciousness, seizure) with normal blood pressure and tachycardia; therefore, she was immediately sedated with intravenous midazolam (3 mg), and 15 L/min of oxygen was administered. The patient fully recovered after 30 minutes of sedation without any sequelae.
Delayed onset of LAST is a rare complication of a common procedure in CESI, so it is important to be aware of this complication and the presentation of toxicity.
颈椎硬膜外类固醇注射（CESI）联合局部麻醉药常用于治疗颈部疼痛和上肢神经根性疼痛。局部麻醉药全身毒性（LAST）是在注射后不久作为并发症发生的；然而，迟发性发作是一种非常罕见的事件，尤其是在中枢神经系统（CNS）阻滞中。
我们报告了一例因颈椎间盘突出导致颈臂放射痛而行 CESI 的患者出现迟发性 LAST 的病例。我们在荧光透视引导下进行经椎间孔入路 CESI。在使用阻力丧失技术和造影剂扩散（Telebrix 30）确认硬膜外腔位置后，我们使用 0.25%左布比卡因 12.5mg（5ml 体积）、透明质酸酶 1500IU（1ml）、地塞米松 5mg（1ml）和生理盐水 3ml 的混合物进行注射。注射后 50 分钟，患者出现 CNS 毒性（意识丧失、抽搐），血压和心率正常；因此，立即给予静脉注射咪达唑仑（3mg）镇静，并给予 15L/min 的氧气。镇静 30 分钟后，患者完全恢复，无任何后遗症。
迟发性 LAST 是 CESI 中常见操作的罕见并发症，因此了解这种并发症及其毒性表现非常重要。
