Brazilian Journal of Pain
https://brjp.org.br/article/doi/10.5935/2595-0118.20210008
Brazilian Journal of Pain
Case Report

Epidural needle fragment related low back pain. Case report

Lombalgia incapacitante causada por fragmento retido de agulha peridural. Relato de caso

Daniela de-Matos; Henrique Cabral; Ricardo Pereira

Downloads: 0
Views: 21

Abstract

BACKGROUND AND OBJECTIVES: Facet syndrome has increasingly been recognized as one the most common causes of chronic low back pain, despite the significant diagnostic challenges imposed by its protean manifestations. Lumbar zygapophyseal degenerative changes are considered the main etiologic agent in cases of facet-associated lumbar pain, with iatrogenic causes rarely involved, particularly those related to retained foreign bodies following invasive medical or surgical procedures. Only three similar reported cases were found in the literature.

CASE REPORT: Female patient, 36 years old, presented significant chronic low back pain due to a Tuohy needle fragment retained in upper part of left L1-L2 facet joint and adjacent tract of the medial branch of the dorsal nerve corresponding to the suprajacent level, following epidural anesthesia performed for elective cesarean section. Failure of conservative treatment and pain intensity led to invasive treatment, with surgical removal of the needle fragment as a stand-alone procedure. Clinical response was favorable, and no additional procedures were necessary thus far. Possible difficulties in diagnosing facet syndrome and the surgical strategy for such an uncommon case are discussed.

CONCLUSION: In the case of a rare etiology of low back pain, a particularly accurate clinical and imaging correlation is important to achieve an adequate therapeutic plan. Such plan must encompass an optimal knowledge of spine anatomy and lumbar pain-related mechanisms. Foreign elements that could be responsible for mechanical injury or local inflammatory phenomena contributing to chronic pain should be considered for removal as part of the treatment strategy

Keywords

Chronic pain, Foreign bodies, Needles, Low back pain

Resumo

JUSTIFICATIVA E OBJETIVOS: A síndrome facetária é reconhecidamente uma das causas mais comuns de dor lombar crônica, embora as suas manifestações bastante diversas coloquem importantes desafios diagnósticos. Atribui-se à doença degenerativa das zigapófises lombares a principal etiologia do quadro doloroso a elas associado, sendo as causas iatrogênicas relativamente raras, sobretudo as relacionadas com corpos estranhos retidos após procedimentos médicos. Existem unicamente três casos semelhantes reportados na literatura.

RELATO DO CASO: Paciente do sexo feminino, 36 anos, com dor lombar crônica importante relacionada com fragmento de agulha peridural quebrado e retido na região da articulação facetária L1-L2 e do ramo medial do ramo dorsal do nível suprajacente, durante o procedimento de anestesia pré-parto. A falha do tratamento conservador e a intensidade do quadro álgico fizeram com que se optasse por tratamento invasivo, nesse caso com remoção cirúrgica do fragmento retido, com boa resposta clínica e sem necessidade de procedimentos adicionais. Discutem-se as razões para possíveis dificuldades diagnósticas do quadro de síndrome facetário e a estratégia terapêutica num caso incomum.

CONCLUSÃO: Numa situação de etiologia rara de dor lombar crônica, uma adequada correlação clínico-imagiológica é da maior importância. O plano terapêutico deve envolver um ótimo conhecimento da anatomia da coluna e dos mecanismos que podem contribuir para a dor lombar. A remoção de elementos estranhos que possam ser responsáveis por lesão mecânica ou fenômenos inflamatórios locais, como este corpo estranho, deve ser uma opção a ter em conta no tratamento.

Palavras-chave

Agulhas, Dor crônica, Dor lombar, Reação a corpo estranho

References

Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-47.

Fatoye F, Gebrye T, Odeyemi I. Real-world incidence, and prevalence of low back pain using routinely collected data. Rheumatol Int. 2019;39(4):619-26.

Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5(15).

Vardeh D, Mannion RJ, Woolf CJ. Toward a mechanism-based approach to pain diagnosis. J Pain. 2016;17(9 Suppl):T50-69.

Collier C. Epidural catheter breakage a possible mechanism. Int J Obstet Anesth. 2000;9(2):87-93.

You J, Cho Y. Foraminal stenosis complicating retained broken epidural needle tip -A case report. Korean J Anesthesiol. 2010;59(Suppl):S69.

Abou-Shameh M, Lyons G, Roa A, Mushtaque S. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth. 2006;15(2):178-9.

Lonnée H, Fasting S. Removal of a fractured spinal needle fragment six months after caesarean section. Int J Obst Anesth. 2014;23(1):95-6.

Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008;31(2):165-9.

Kalichman L, Li L, Kim D, Guermazi A, Berkin V. Facet joint osteoarthritis and low back pain in the community-based population. Spine. 2008;33(23):2560-5.

Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A. Facet joint syndrome from diagnosis to interventional management. Insights Imaging. 2018;9(5):773-89.

Manchikanti L, Singh V, Pampati V, Damron KS, Barnhill RC, Beyer C. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001;4(4):308-16.

Piraccini E, Calli M, Corso RM, Byrne H, Maitan S. Abdominal and pelvic pain an uncommon sign in lumbar facet joint syndrome. Minerva Anestesiol. 2017;83(1):104-5.

Kuo CS, Hu HT, Lin RM, Huang KY, Lin PC, Zhong ZC. Biomechanical analysis of the lumbar spine on facet joint force and intradiscal pressure--a finite element study. BMC Musculoskelet Disord. 2010;11:151.

Falco FJE, Manchikanti L, Datta S, Sehgal N, Geffert S, Onyewu O. An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician. 2012;15(6):E869-907.

Manchikanti L, Hirsch JA, Falco FJ, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop. 2016;7(5):315-37.

Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med. 2009;10(6):1035-45.

Schwarzer AC, Wang SC. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 1995;20(8):907-12.

Maataoui A, Vogl TJ, Khan MF. Magnetic resonance imaging-based interpretation of degenerative changes in the lower lumbar segments and therapeutic consequences. World J Radiol. 2015;7(8):194-7.

Freund W, Weber F, Meier R, Klessinger S. Magnetic resonance imaging can detect symptomatic patients with facet joint pain A retrospective analysis. J Clin Med Exp Images. 2017;1:27-36.


Submitted date:
07/01/2020

Accepted date:
01/09/2021

60873ee3a9539505e77b4253 brjp Articles

BrJP

Share this page
Page Sections