British Journal of Anaesthesia, 2002, Vol. 89, No. 1 188
© 2002 The Board of Management and Trustees of the British Journal of Anaesthesia
Correspondence |
Pain and injury from epidural injection
Editor—I read with interest the case report by Absalom and colleagues,1 concerning the spinal cord injury caused by direct damage from a needle infiltrating local anaesthetic. I think the sequence of events could have been avoided if the technique had been slightly different, especially in a patient who was difficult to communicate with.Even though each anaesthetist’s practice of regional anaesthesia is different, I am sure everyone will agree that the skin is the most sensitive structure encountered during epidural injection. Use of a 16 G or 19 G epidural needle is no justification to use a 21 G needle for local infiltration. Such infiltration stings significantly. Moreover, the length of the needle is 4 cm, which is greater than the depth of the epidural space in some patients (3.5 cm).
Lidocaine at 2% hurts before it anaesthetizes the skin, but lower concentrations produce less pain. A technique I follow is to use an insulin syringe and a 28 G, 1 cm needle with 0.5% lidocaine for skin infiltration. After 30 s, I use a larger needle for infiltrating the deeper tissues. Although this technique is not based on any study, most of my patients do not experience any distress from the first injection and have acknowledged that the pain was not as bad as they expected.
S. H. G. Rao
Leicester, UK
Editor—Thank you for asking me to comment on the letter from Dr Rao. His comments are interesting, but his technique would not have avoided this specific problem as he admits he would have had to use a second larger needle to infiltrate deeper structures. This particular patient responded dramatically to the immediate, initial pain from the local infiltratory needle, and that was the reason for her spinal cord damage. Many anaesthetists avoid the use of a larger needle by using skin infiltration alone, and they would perhaps argue that that would have avoided the problem. It does, however, make one wonder how the patient would have responded to an even larger (epidural) needle placed into deeper structures, which are indeed very painful for some patients. With hindsight, I am only glad that minimal damage was done with the technique I used, and that a complete recovery of function was the ultimate outcome.
N. B. Scott
Clydebank, UK
References
1 Absalom AR, Martinelli G, Scott NB. Spinal cord injury caused by direct damage by local anaesthetic infiltration needle. Br J Anaesth 2001; 87: 512–5
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