SummaryTransforaminal epidural injection is an effective method for treating spinal pain but can cause devastating complications that result from accidental vascular uptake of the injectate or a direct vascular injury. We prospectively evaluated the patient factors that might be associated with intravascular uptake during transforaminal epidural injections. A total of 2145 injections were performed on 1088 patients under contrast-enhanced real-time fluoroscopic guidance. The collected data included the patient's age, sex, body mass index, diagnosis, injection level, side of injection, history of spinal surgery at the targeted level, and the number of injections at the targeted site. The overall incidence of intravascular injection was 10.5% (224 ⁄ 2145). The highest incidence was at the cervical level (28 ⁄ 136; 20.6%), followed by the sacral level (111 ⁄ 673; 16.5%), the thoracic level (23 ⁄ 280; 8.2%) and the lumbar level (64 ⁄ 1056; 6.1%). The difference was significant for the cervical and sacral level compared with the lumbar and thoracic levels (p < 0.001). Intravascular injection was not associated with the other patient characteristics studied. Transforaminal epidural injection is an effective method for treating radicular pain [1] and is superior to other forms of therapeutic epidural injections [2,3]. This is a target-specific approach that facilitates better ventral epidural flow to the target site with a smaller volume of injectate. Although serious complications are rare [4,5], there are several reports of paraplegia or quadriplegia from spinal cord infarction [6,7], brainstem infarction [8,9], cortical blindness [10], coma or death [7,11]. The presumptive reasons for these serious complications are needle-induced direct mechanical injuries or vascular spasm in the vertebral or radicular arteries, as well as embolus formation of the particulate steroid [6,7,12,13]. In previous reports, the incidence of accidental intravascular needle placement during fluoroscopically-guided transforaminal epidural injection ranged from 9.9% to 32.8% and varied according to the spinal level [14][15][16][17]. It is recommended that contrast-enhanced real-time fluoroscopy be used to confirm correct needle placement and prevent intravascular injection during the procedure [15,18]. Knowledge of the associated factors may also help to reduce the incidence of intravascular needle placement but there is limited information on these. In particular, there are no reports on whether the patient's previous spinal surgery, body mass index (BMI) and repeated injection at the same site influence the risk of intravascular uptake. The incidence of intravascular injection during transforaminal injection in the thoracic region has not been reported. We therefore prospectively evaluated the incidence and factors associated with intravascular injection during transforaminal epidural injection.

Since it was first described in 1978 the abdominal cocoon continues to he a rare cause of intestinal obstruction. So far this rare condition where the small intestine is encased in a fibrous membrane has been reported only in females. Diagnosis is usually made at laparotomy and the treatment of choice is lysis of adhesions. Proper recognition of this benign condition will result in the correct management of it and prevent unnecessary bowel resections. Five new cases including one male patient, together with a review of previous reports in the English literature, are presented.

Four cases of emphysematous pyelonephritis are reported and the pathogenesis, surgical implications and preferred mode of management are discussed. We have not found percutaneous drainage to be useful, but feel there is an important place for surgical drainage alone because of the potential for renal recovery and the risks of emergency nephrectomy.

No abstract

SummaryWe investigated the forces required to remove thoracic epidural catheters to determine the effect of patient position on removal. Eighty-four patients undergoing open thoracotomy and thoracic patient-controlled epidural analgesia were enrolled. Catheterisation was performed under fluoroscopic guidance before surgery, and the patients were allocated to one of three position groups for removal: prone; sitting; and lateral. On the third postoperative day, the peak tension during withdrawal in the assigned position was measured. No differences in mean (SD) forces were found between groups: prone 1.61 (0.39) N, Thoracic epidural catheters are usually removed without complications. Although shearing or breakage of an epidural catheter during removal is a rare occurrence, it may require surgical extraction [1,2]. Shearing or breakage of an epidural catheter may result from unintended trauma during insertion or removal [3,4]. Some papers have evaluated the factors (position, sex, age, height, length of catheter under skin, etc.) possibly affecting the necessary withdrawal force for lumbar epidural catheters and spinal catheters [4][5][6][7][8]. However, there are no studies regarding factors affecting the withdrawal forces required for thoracic epidural catheters. Differences in anatomy and techniques used to identify the epidural space mean data cannot automatically be extrapolated from lumbar to thoracic epidural catheters. In particular, the position of patients could plausibly influence catheter removal as in lumbar epidural epidural catheters [5,6]. Therefore, we investigated the effects of patient position (prone, sitting or lateral flexed) on the withdrawal forces necessary to remove thoracic epidural catheters. We also evaluated the influence of other factors such as sex, age, height, body mass index (BMI), the depth from the skin to the epidural space, the angle made by the skin and the Tuohy needle and the length of the catheter in the epidural space on withdrawal forces. MethodsThis prospective randomised study was approved by the Institutional Review Board of our institute and written informed consent was obtained from all participants.Eighty-four patients, aged 25-75 years, undergoing elective open thoracotomy and thoracic patient-controlled epidural analgesia (PCEA) for postoperative pain control were consecutively enrolled in this study. Exclusion criteria included: an allergy to contrast media; general contraindications to thoracic epidural catheterisation (blood clotting disorders, infection at the proposed insertion site, patient