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An anatomical study of lumbar epidural catheterization
© Jiang et al. 2015
Received: 5 January 2015
Accepted: 29 May 2015
Published: 23 June 2015
We herein provide an analysis of lumbar epidural catheterization, which outlines a detailed anatomical description of the epidural anatomy, and may improve the success rate of neuraxial cannulation.
Lumbar epidural catheters were placed in 50 adult embalmed cadavers. After catheterization, the lumbar dura and connecting structures between the epidural space and the vertebral body were separated. The positional relationship between the catheter and the posterior epidural space were observed and photographed.
Amongst the 50 specimens, the epidural catheter curled into a circle in three cases, entered the intervertebral foramen in two cases, and caused epidural venous damage in five cases.
Meningo-vertebral ligaments exist in the posterior epidural space and connect to the venous plexus, which may contribute to epidural catheter failure, uneven distribution of anaesthesia and epidural hemorrhage. Our study provides anaesthesiologists with a better understanding of the anatomy and may mitigate complications of lumbar epidural catheter placement.
Meningo-vertebral ligaments have been described between the dura mater and the lumbosacral spinal canal . These structures may be responsible for intermittent failure of epidural catheterization. To explore the anatomical reasons for epidural catheterization failure, reveal the relationship between the dorsal meningo-vertebral ligaments, and thereby lower the failure occurrence rate and its related complications. This research simulated the insertion of epidural catheters in cadaveric specimens and observed the relationship between the relevant structures.
The study was approved by Medical Ethics Committee of Southern Medical University affiliated Zhujiang Hospital, China. After obtaining informed consent from relative, fifty adult embalmed cadavers were analyzed at the Department of Anatomy, Southern Medical University, China. These included 28 male cadavers and 22 female cadavers with a median age of 55 years (range: 43–72). All cadavers had intact lumbosacral anatomy. Cadavers with known lumbosacral deformities, lumbosacral diseases or previous spine surgery were excluded from the analysis.
An 18-gauge Tuohy needle (Haining green health medical products Ind. Sdn. Bhd, China) was used and the epidural space was identified via a midline approach at the L3-L4 interspace using the loss-of-resistance-to-air technique. After the epidural space was located, a 20-gauge multiorifice catheter was threaded through the cranially directed tip of the epidural needle to the 15 cm mark. The needle was removed, and the catheter was left 6 cm into the epidural space. The spine was transected at the level of the intervertebral disc between T12 and L1. The posterior aspect of the vertebral column was exposed from L1 to S1 by dissecting the paraspinous musculature. The relationship of epidural catheter with the surrounding tissue was observed. The dura mater was then carefully reflected ventrally to expose and isolate the meningo-vertebral ligaments from the peridural membrane using blunt dissection and any extradural fat was removed. The dural sac was elevated to identify the meningo-vertebral ligaments. The distribution, morphology, number, orientation, and sites of origin and insertion of the meningo-vertebral ligaments were observed. All results were photographed and recorded.
The relationship of epidural catheter with the surrounding tissue
Meningo-vertebral ligaments and their attachment sites
Distribution of membrane vertebral ligament and the incidence of abnormal catheterization (%)
Occurrence rate of dorsal meningovertebral ligaments
Incidence of catheter exit through the foramen
Incidence of catheter curled into a circle
Venous plexus puncture rate
It is commonly accepted that the epidural space is a continuous compartment containing fat, lymphatics, arteries, loose areolar connective tissue, spinal nerve roots, and an extensive plexus of veins [2, 3]. However, recent studies have suggested that meningo-vertebral ligaments are present between the lumbosacral spinal canal wall and the surrounding dura. Meningo-vertebral ligaments scattered in the epidural space with adipose tissue on their surface separate the epidural space into compartments of different sizes and shapes , which results in discontinuity of the epidural space, resulting in uneven distribution of injectate, thereby contributing to unilateral or partial anaesthesia after injection of local anaesthetic . The failure rate for neuraxial labor analgesia is reported as high as 12 % . When the initial epidural placement and infusion does not result in an adequate block, anesthesiologists often perform 2 different maneuvers to salvage the catheter: partial withdrawal of the catheter or infusion of additional medication . If all these 2 maneuvers couldn’t lead to a successful analgesia, anaesthetist should try other maneuvers such as replacement of the epidural catheter or a combined spinal epidural anaesthesia.
Meningo-vertebral ligaments located within the epidural space may contribute to epidural catheter placement failure . The location of these structures can be unpredictable with 38 % of meningo-vertebral ligaments located in the middle of the subdural cavity, 32 % in the left side subdural cavity, and another 30 % next to right side of subdural cavity . Our study found three epidural catheters curled into a circle in 3 cases, with one catheter curled into the shape of a “9”. We hypothesise that these structures may contribute to catheter knotting within the epidural space . The conclusion of some reports is that insertion of excessive amounts of catheter into the epidural space is a causative factor in knot formation . Some authors have recommended the insertion of no more than 4 cm of catheter into the epidural space and some others no more than 5 cm [12, 13]. According to the study of Aslanidis T et al. , the 6 cm of catheter left into the epidural space in the current case was not excessive. This may not become apparent until removal of the catheter, at which time, catheter fracture may occur. Irregardless, when removing an epidural catheter, one should hesitate when resistance is encountered, change position and then slowly attempt to remove the catheter again. If necessary, surgical assistance should be sought [15, 16].
Epidural catheter was placed at the L3-L4 interspace. As it was seen at Table 1, the highest frequency of catheter curling occured at the same level. Bridenbaugh et al. reported that 48 % of the catheters coiled at the insertion site . One possible reason is that a large number of meningo-vertebral ligaments at the L3-L4 interspace blocked the catheter tip. At the same time, an abrupt change of direction of the catheter tip in the epidural needle tip make it difficult to insert the catheter. Maybe, all the two reasons resulted in a higher incidence of catheter curling at the L3-L4 interspace.
Others have reported that 5 % of epidural catheters travel caudally or exit the intervertebral foramen . In our study, there were two cases in which the epidural catheter traveled into the intervertebral foramen, and we hypothesise that this course may have been due to variant meningo-vertebral ligaments. In such cases, the epidural injectate would course laterally into the intervertebral foramen resulting in nerve root rather than epidural spread of the injectate.
In this study, we observed five cases where the catheter punctured the internal vertebral venous plexus. Unintended venous injury may occur during lumbar epidural catheter placement, with an estimated incidence rate of 5–7 % . Yaakov berlin et al. found that patients whose catheters were threaded 7 cm into the epidural space had the highest incidence (17.5 %) of intravenous catheter placement as compared to patients whose catheters were threaded 3 or 5 cm . They speculated that more catheter was threaded into the epidural space the greater was the likelihood of encountering a vein. If not recognized, local anaesthetics will enter into the systemic circulation, potentially resulting in seizure, cardiovascular toxicity, circulatory failure or death [19, 20].
Our study found that the meningo-vertebral ligaments directly connected to the wall of the spinal microvasculature in the location of lamina and ligamentum flavum. These structures were entwined with, but not adherent to the vascular walls. Earlier studies have reported that small blood vessels were found in fetal tissue specimens of meningo-vertebral ligaments [21, 22]. When performing epidural catheter placement, if the needle inadvertently damages blood vessels connected to this ligament, the risk of developing an epidural hematoma is hypothesised to increase. Vascular structures connecting to the meningo-vertebral ligaments are mostly venous, these veins lack valves and exist in a space where compression can result in catastrophic outcomes.
No inadvertent dural puncture was reported in our study. The incidence of inadvertent dural puncture ranges between 0.19-0.5 % of epidural catheter placements. Adverse events may result from direct mechanical injury or adverse physiological responses. Inadvertent dural puncture and postdural puncture headache, direct neural injury, total spinal anesthesia, and subdural block have been commonly reported.
Meningo-vertebral ligaments become thicker as they occur more caudally, with the thickest ligament at L5-S1. At the caudal levels, the meningo-vertebral ligaments are firmly connected with the ligamentum flavum, which may be the reason that intraoperative dural tearing occurs more commonly during surgery at the L4-L5 and L5-S1 levels .
The major limitation of this study is the lack of clinical data from live patients. Preserved cadaveric specimens, while the only suitable study population for the research which we undertook, are limited by the changes in the tissue structure with death and fixation of the body with formalin. It is well known that tissue fixation and its associated desiccation can lead to tissue shrinkage. The use of formalin may have contributed to an overestimation of the strength of the ligaments than they are in vivo. Maybe, it is one of the reasons why the incidence (10 %) of intravenous catheter placement in our study was much lower than that (17.5 %) in vivo.
In short, meningo-vertebral ligaments are present in lumbosacral epidural retrodiscal space with various shapes. They divide the epidural space into compartments of various sizes, which are sometimes connected with the venous plexus and can be implicated as a cause of epidural catheter failure, uneven distribution of anaesthesia and epidural hemorrhage. Anaesthesiologists should be aware of the existence of these ligaments, and their potential role in the failure of epidural anaesthesia.
We would like to acknowledge Manjing Fang, Junchang, Zuquan Yang (Department of Anesthesiology, Shenzhen Nanshan District Maternity & Child Healthcare Hospital) and Changqing Ma (Department of Anesthesiology, Zhujiang Hospital, Southern Medical University) who have made substantial contributions to the study or preparation of the manuscript.
- Shi B, Li X, Li H, Ding Z. The morphology and clinical significance of the dorsal meningovertebra Ligaments in the lumbosacral epidural space. Spine. 2012;37:E1093–8.View ArticlePubMedGoogle Scholar
- Cheng PA. The anatomical and clinical aspects of epidural anesthesia. Part I. Anesth Analg. 1963;42:398–406.View ArticlePubMedGoogle Scholar
- Bauer M, George JE, Seif J, Farag E. ecent Advances in Epidural Analgesia. Anesthesiology Research and Practice. 2012. p. Article ID: 309219.Google Scholar
- Jagla G, Walocha J, Rajda K, Dobrogowski J, Wordliczek J. Anatomical aspects of epidural and spinal analgesia. Adv Palliative Med. 2009;8:135–46.Google Scholar
- Hogan Q. Distribution of solution in the epidural space: examination by cryomicrotome section. Reg Anesth Pain Med. 2002;27:150–6.View ArticlePubMedGoogle Scholar
- Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth. 2004;13:227–33.View ArticlePubMedGoogle Scholar
- Arendt K, Segal S. Why epidurals do not always work. Rev Obstet Gynecol. 2008;1(2):49–55.PubMedPubMed CentralGoogle Scholar
- Savolaine ER, Pandya JB, Greenblatt SH, Conover SR. Anatomy of the human lumbar epidural space: new insights using CT-epidurography. Anesthesiology. 1988;68:217–20.View ArticlePubMedGoogle Scholar
- Benchao SHI, Hongliang LI, Zihai DING, Xibing Zhang. Anatomic study and clinical significance of the dorsal meningovertebral ligaments in lumbosacral region. Chinese J Spine Spinal Cord. 2011;21(12):1006–10.Google Scholar
- Arnaoutoglou HM, Tzimas PG, Papadopoulos GS. Knotting of an epidural catheter: a rare complication. Acta Anaesthesiol Belg. 2007;58:55–7.PubMedGoogle Scholar
- Gabopoulou Z, Mavrommati P, Chatzieleftheriou A, Vrettou V, Konstandinidou M, Velmachou K. Epidural catheter entrapment caused by a double knot after combined spinal-epidural anesthesia. Reg Anesth Pain Med. 2005;30:588–9.View ArticlePubMedGoogle Scholar
- Brichant JF, Bonhomme V, Hans P. On knots in epidural catheters: a case report and a review of the literature. Int J Obstet Anesth. 2006;15:159–62.View ArticlePubMedGoogle Scholar
- Angle PJ, Hussain K, Morgan A. High quality labour analgesia using small gauge epidural needles and catheters. Can J Anaesth. 2006;53:263–7.View ArticlePubMedGoogle Scholar
- Aslanidis T, Fileli A, Pyrgos P. Management and visualization of a kinked epidural catheter. Hippokratia. 2010;14:294–6.PubMedPubMed CentralGoogle Scholar
- Sakuma N, Hori M, Suzuki H, Hashimoto Y, Kameyama E, Horinouchi T, et al. A sheared off and sequestered epidural catheter: a case report Masui. Japanese J Anesthesiology. 2004;53:198–200.Google Scholar
- Dam-Hieu P, Rodriguez V, de Cazes Y, Quinio B. Computed tomography images of entrapped epidural catheter. Reg Anesth Pain Med. 2002;27:517–9.View ArticlePubMedGoogle Scholar
- Bridenbaugh LD, Moore DC, Bagdi I, Bridenbaugh PO. The position of plastic tubing in continuous-block techniques: an x-ray study of 552 patients. Anesthesiology. 1967;29:1047–9.View ArticleGoogle Scholar
- Beilin Y, Bernstein HH, Zucker-Pinchoff B. The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space. Anesth Analg. 1995;81:301–4.PubMedGoogle Scholar
- Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51:285–7.View ArticlePubMedGoogle Scholar
- Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology. 1997;86:277–84.View ArticlePubMedGoogle Scholar
- Hamid M, Fallet-Bianco C, Delmas V, Plaisant O. The human lumbar anterior epidural space morphological comparison in adult and fetal specimens. Surg Radiol Anat. 2002;24:194–200.View ArticlePubMedGoogle Scholar
- Geers C, Lecouvet FE, Behets C, Malghem J, Cosnard G, Lengelé BG. Polygonal deformation of the dural sac in lumbar epidural lipomatosis anatomic explanation by the presence of meningovertebral ligaments. American J Neuroradiology. 2003;24:1276–82.Google Scholar
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