Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942004000600012
Brazilian Journal of Anesthesiology
Clinical Information

Injeção subaracnóidea inadvertida de corticóide em tratamento de dor crônica da coluna lombar: relato de caso

Accidental subarachnoid steroid injection during chronic lumbar pain treatment: case report

Simone Maria D'Angelo Vanni

http://dx.doi.org/10.1590/S0034-70942004000600012 Braz J Anesthesiol, vol.54, n6, p.821-825, 2004
PDF Português
PDF English
Downloads: 0
Views: 1371

Resumo

JUSTIFICATIVA E OBJETIVOS: Antes que os corticóides fossem utilizados no espaço peridural para o tratamento de dor crônica da coluna lombar, a injeção subaracnóidea desses agentes era a escolha. A técnica subaracnóidea pode levar a sérias complicações com seqüelas neurológicas, embora alguns autores ainda a preconizem. O objetivo deste relato é mostrar um caso de injeção inadvertida de corticóide associado ao anestésico local no espaço subaracnóideo, quando da realização de punção peridural para tratamento de dor na coluna lombar. RELATO DO CASO: Paciente do sexo masculino, 46 anos, acompanhado pela neurocirurgia por apresentar ciatalgia à direita, há 9 meses, sem melhora com o tratamento clínico, devido a protrusão discal L4-L5 comprovada por estudo tomográfico, sem déficit neurológico. Foi realizada punção peridural para tratamento da dor, em L4-L5 com agulha 17G, e injetados 10 ml de solução contendo 4 ml de bupivacaína a 0,25%, 80 mg de metilprednisolona e 4 ml de solução fisiológica a 0,9%. Apesar de não se ter constatado refluxo de líquor, após 5 minutos da injeção ocorreram bloqueios sensitivo em T4 e motor em T6, associados à diminuição da pressão arterial e freqüência cardíaca. CONCLUSÕES: As punções subaracnóideas acidentais com associação de corticóides para tratamento de dor podem apresentar complicações. Os seus riscos são inúmeros, variando de sintomas temporários leves a lesões nervosas e, inclusive, na medula espinhal. O paciente em questão não apresentou nenhuma seqüela da injeção subaracnóidea inadvertida, provavelmente por ter sido injeção única.

Palavras-chave

COMPLICAÇÕES, DOR, DROGAS

Abstract

BACKGROUND AND OBJECTIVES: Before epidural steroids were used in chronic lumbar pain, subarachnoid injection of these agents was the treatment of choice. Although still preconized by some authors, this technique may lead to severe complications with neurological sequelae. This report aimed at describing a case of accidental subarachnoid injection of steroid associated to local anesthetics during epidural puncture to treat lumbar pain. CASE REPORT: Male patient, 46 years old, followed by neurosurgery for presenting right sciatic pain for 9 month, refractory to clinical treatment due to L4-L5 disk protrusion confirmed by CT scan, without neurological deficit. Epidural puncture for pain treatment was performed in L4-L5 with 17G needle and 10 mL solution were injected containing 4 mL of 0.25% bupivacaine, 80 mg methylprednisolone and 4 mL of 0.9% saline. Although there has not been CSF reflux, 5 minutes after injection there were sensory block in T4 and motor block in T6, associated to blood pressure and heart rate decrease. CONCLUSIONS: Accidental subarachnoid injections with the association of steroids for pain relief may cause adverse effects. There are several risks, varying from mild transient symptoms to nervous injuries, including spinal cord injuries. Our patient had no sequelae from the accidental subarachnoid injection, probably because it has been a single injection.

Keywords

COMPLICATIONS, DRUGS, PAIN

References

Nelson DA, Landau WM. Intraespinal steroids: history, efficacy, accidentality, and controversy with review of United States Food and Drug Administration reports. J Neurol Neurosurg Psychiatry. 2001;70:433-443.

Gertzbein SD, Hollopeter M, Hall SD. Analisys of circumferential lumbar fusion outcome in the treatment of degenerative disc disease of the lumbar spine. J Spinal Disord. 1998;11:472-478.

Saal JS, Franson RC, Dobrow R. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine. 1990;15:674-678.

Robecci A, Capra R. Hydrocortisone (compound F); first clinical experiments in the field of rheumatology. Minerva Med. 1952;43:1259-1263.

Lievre JA, Bloch-Michel H, Attali P. Trans-sacral injection; clinical and radiological study. Bull Mem Soc Med Hop. 1957;73:1110-1118.

Gardner WJ, Goebert HW, Sehgal AD. Intraspinal corticosteroids in the treatment of sciatica. Trans Am Neurol Assoc. 1961;86:214-215.

Sehgal AD, Gardner WJ, Dohn DF. Pantopaque "arachnoidites" treatment with subarachnoid injection of corticosteroids. Cleve Clinic Q. 1962;29:177-188.

Sehgal AD, Gardner WJ. Place of intrathecal metylprednisolone acetate in neurological disorders. Trans Am Neurol Assoc. 1963;88:275-276.

Sehgal AD, Tweed DC, Gardner WJ. Laboratory studies after intrathecal corticosteroids in plasma and cerebrospinal fluid. Arch Neurol. 1963;9:64-68.

Winnie AP, Hartman JT, Meyers HL. Pain clinic II. Intradural and extradural corticosteroids for sciatica. Anesth Analg. 1972;51:990-1003.

Power RA, Taylor GJ, Fyfe IS. Lumbar epidural injection of steroid in acute prolapsed intervertebral discs. A prospective study. Spine. 1992;17:453-455.

Renfrew DL, Moore TE, Kathol MH. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol. 1991;12:1003-1007.

White AH. Injection techniques for the diagnosis and treatment of low back pain. Orthop Clin North Am. 1983;14:553-567.

Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in management of lumbar nerve root compression. Br Med J. 1973;2:635-637.

Lutze M, Stendel R, Vesper J. Periradicular therapy in lumbar radicular syndromes: methodology and results. Acta Neurochir. 1997;139:719-724.

Nelson DA. Intraspinal therapy using methilprednisolone acetate. Spine. 1993;18:278-286.

Dougherty JH, Fraser RA. Report of two cases. J. Neurosurg.. 1978;48:1023-1025.

McLain RF. Point of view. Spine. 1997;22:1562.

Dereux J, Vandenhaute A, Deheck M. Arachnoidits appearing during treatment by subaracnoid hydrocortisone injections. Rev Neurol. 1956;94:301-304.

Goebert HW, Jallo SJ, Gardner WJ. Painful radiculopathy treated with epidural injections of procaine and hydrocortisone acetate results in 113 patients. Anesth Analg. 1961;40:130-134.

El-Khoury GY, Ehara S, Weinstein JN. Epidural steroid injection a procedure ideally performed with fluoroscopic control. Radiology. 1998;168:554-557.

Bernat JL. Intraspinal steroid therapy. Neurology. 1981;31:168-171.

Vanbuskirk C, Poffenbarger AL, Capriles LF. Treatment of multiple sclerosis with intrathecal steroids. Neurology. 1964;14:595-597.

Goldstein NP, McGuckin WF, Mckenzie BF. Experimental intrathecal administration of methilprednisolone acetate in multiple sclerosis. Trans Am Neurol Assoc. 1970;95:243-244.

Nelson DA, Vates TS, Thomas RB. Complications from intrathecal steroid therapy in patients with multiple sclerosis. Acta Neurol Scand. 1973;49:176-188.

Nelson DA. Arachnoiditis from intrathecally given corticosteroids in the treatment of multiple sclerosis. Arch. Neurol. 1976;33:373.

Wilkinson HA. Intrathecal Depo-Medrol: a literature review. Clin J Pain. 1992;8:49-56.

ivera VM. Safety of intrathecal steroids in multiple esclerosis. Arch Neurol. 1989;46:718-719.

5dd6dda00e8825731e13f286 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections