The utility of fluoroscopic guidance in thoracic epidural placement.
* It is equally likely that what ensured that the catheter was correctly placed was that epidural placement was performed by a "physician staff member of the Division of Pain Management", who presumably (though this information was not provided) regularly performs thoracic placement of epidural spinal cord stimulation leads via the paramedian approach, as is common practice, the key point thereby being that the utilization of an experienced operator, rather than the use of fluoroscopy as such, ensured that the catheter was correctly placed.
* The methodology described for fluoroscopy fails to convince that it was in fact helpful in confirming epidural placement of the catheter, as there is no comment as to whether a lateral view was performed to confirm that the catheter was within the vertebral canal, or that an epidurogram with contrast was performed to confirm even epidural placement. Without these simple steps being performed, there can be no assurance of correct placement, and also a failure to make the most of fluoroscopy use.
* Significant improvements in clinical outcomes can be achieved with considered use of pharmacological agents in the epidural solution. There has been much work done in this area and readers (and the paper's authors) would do well to refer to the recent Acute Pain Guidelines produced by ANZCA (2).
* There are secondary issues in advocating the routine use of X-ray guidance in that it carries a not insignificant risk associated with irradiation of the patient, proceduralist and theatre staff. Also, such a technique adds an extra burden on the already stretched resource of theatre time.
In summary, Hooten and colleagues' paper does little to provide convincing evidence to advocate the routine use of fluoroscopy in thoracic epidural placement, but rather could be viewed as showing the positive benefits of an experienced operator (as is the case for most procedures) and the poor analgesic efficacy of purely local anaesthetic-containing epidural solutions, especially at the thoracic level.
Department of Anaesthesia and Pain
Royal North Shore Hospital,
Sydney, New South Wales
(1.) Hooten WM, Karanikolas M, Swarm R, Huntoon MA. Postoperative Pain Management following bilateral lung volume reduction surgery for severe emphysema. Anaesth Intensive Care 2005; 33:591-596.
(2.) ANZCA Acute Pain Management. Scientific Evidence. 2nd Ed, National Health and Medical Research Council, Canberra, Australia 2005.
The principal author would like to thank Dr Pattullo for the thoughtful critique of our study methodology and conclusions. In the methods section of our paper it was stated, "Successful advancement of the catheter under fluoroscopic guidance served as confirmation that the epidural needle and catheter were correctly positioned in the epidural space". Dr Pattullo's criticism that our methods failed to "make the most of fluoroscopy use" is accurate in that definitive fluoroscopic techniques, including use of contrast material and lateral fluoroscopic views, were not employed to confirm placement of the catheter within the epidural space. While this criticism is accepted, fluoroscopy was also used, as stated in our methods section, to ensure the "epidural catheter ... tip was in the midline position at the level of the superior aspect of the fourth thoracic vertebral body". All physicians involved in our study were experienced in the placement of thoracic epidural catheters. However, no level of technical expertise could have ensured catheter position to the precision described herein without use of fluoroscopy. Therefore, the "key point" advocated by Dr Pattullo that "utilization of an experienced operator rather than ... fluoroscopy ... ensured that the catheter was correctly placed" does not fully reflect our rationale for use of fluoroscopy in this unique clinical setting. In light of Dr Pattullo's comments, the closing statement of our manuscript should be edited to read as follows, "the use of fluoroscopy ensured that each patient had an 'optimally midline positioned' thoracic epidural catheter."
W. M. HOOTEN
Departments of Anesthesiology and Psychiatry
Mayo College of Medicine,
Charlton, Rochester, MN,
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|Author:||Pattullo, G.; Hooten, W.M.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Letter to the editor|
|Date:||Jun 1, 2006|
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