Blurred Vision as the only Symptom of a Positive Epidural Test Dose

Perispinal etanercept: a new therapeutic paradigm in neurology

“…Batson's plexus is an extensive inter connected plexus of veins that surrounds the spine and is distributed along the entire length of the spine, from the sacrum to the neck, communicating freely with the pelvic and prostatic venous plexuses caudally and with the cerebral venous system via extensive interconnections at the base of the cranium [23,[40][41][42]. Among the unique features of Batson's plexus is the fact that it lacks venous valves, so flow within this system is bidirectional [23,[40][41][42]87,88]. The functional and anatomic continuity of the vertebral venous system with the cerebral venous system led this author to select the name 'cerebrospinal venous system' to designate the combination of the cerebral venous system with the vertebral venous plexus [40].…”

Perispinal Delivery of CNS Drugs

“…The accuracy of Breschet’s pioneering descriptions has been confirmed by a multitude of subsequent anatomic and clinical studies [ 1 , 17 , 19 – 23 , 25 , 27 , 28 , 30 , 31 , 47 , 48 ] (review [ 17 ]). The First Edition of Gray’s Anatomy (1858) states: “The veins of the spine are described and illustrated from the well-known work of Breschet (Gray 1858, Preface [ 39 ])… .…”

“…Batson’s finding that dye injected into a peripheral catchment area of Batson’s plexus could reach the cerebral veins is supported by clinical and pathological findings [ 19 , 31 , 52 , 67 , 68 ], including observations of bilateral blurred vision occurring within 1 min of injection of a 3 mL test dose of lidocaine meant for epidural analgesia [ 31 ] 6 : “We believe her blurred vision was a result of direct test dose intracranial venous system dissemination via Batson’s vertebral venous plexus … . Batson’s vertebral venous plexus … communicates directly with … the intracranial venous system.” Vallejo et al [ 31 ]. …”

“…“We believe her blurred vision was a result of direct test dose intracranial venous system dissemination via Batson’s vertebral venous plexus … . Batson’s vertebral venous plexus … communicates directly with … the intracranial venous system.” Vallejo et al [ 31 ].…”

“…Blood within the EVVP communicates with the deeper, valveless, bidirectional venous plexuses comprising the remainder of the CSVS [ 1 , 6 – 25 ]. Bidirectional and retrograde blood flow between the spinal and cerebral divisions of the CSVS is made possible by the absence of venous valves within the internal vertebral venous plexus [ 1 , 19 – 31 ]. The anatomical basis for perispinal administration of etanercept has its origins in the detailed studies of the CSVS published in 1819 and 1829 by the French anatomist Gilbert Breschet [ 21 , 22 ] (Figs.…”