1. ASPECTOS TÉCNICOS
DE LOS BLOQUEOS
EPIDURALES
Dra. Marta Perepérez
Sº de Anestesia y
Reanimación
CLÍNICA UBARMIN

2. ESPACIO EPIDURAL
“Injected material displaces the dura forward and inward,
producing a stretch of the nerve roots that leads to lysis of neural
adhesions.”
Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain
and/or low back pain. Spine J. 2009 Jun; 9 (6): 509-17.

3. FÁRMACOS
FALTA DE CONSENSO
A FAVOR MAYORITARIAMENTE DE MEZCLA DE:
CCO + AL

4. FÁRMACOS
DOLOR → LA REACCIÓN INFLAMATORIA
↓
ALIVIO → INTERRUPCIÓN SÍNTESIS DE CITOQUINAS
Burnett C. Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol, 2008, Aug; 21 (4):452-6.
↓
CCO → DISMINUYEN:
• El edema
• La vasodilatación capilar
• La proliferación de fibroblastos
• La cicatrización
• La síntesis de PLA2

5. FÁRMACOS
¿QUÉ CCO?
Depo-Medrol
ND VE
Trigon
Manchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.

6. FÁRMACOS
¿QUÉ PERIODICIDAD?
Manchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.

7. FÁRMACOS
¿QUÉ PERIODICIDAD?
Marinangeli F, Ciccozzi A, Donatelli F, Paladini A, Varrassi G. Clinical use of spinal or epidural steroids. Minerva Anestesiol. 2002
Jul-Aug;68(7-8):613-20.
Steroidal toxicity seems to be related to the
polyethylenic glycole vehicle. Anyway, slow release
formulations contain less concentrated polyethylenic
glycole. The epidural administration, a correct dilution
of steroid with local anesthetics solution and/or saline
solution, and a limited number of injections (no more
than three) allows a significant reduction of steroid
neurotoxicity.

8. FÁRMACOS
CCO DE ACCIÓN PROLONGADA
Noe CE, Haynsworth RF Jr. Comparison of epidural Depo_medrol vs. Aqueous betamethasone in patients with low back pain. Pain
Pract. 2003 Sep; 3 (3):222-5
↓
ACETATO DE METILPREDNISOLONA (40-80 mg) Y
ACETÓNIDO DE TRIAMCINOLONA (80 mg)
Robinson D et al.The effects of different doses of lumbosacral epidural steroids for patients with lumbosacral radiculopathy and
spinal stenosis. Ameriacan Academy of Pain Medicine. 22nd Annual Meeting. February 22-25, 2006.
Owlia M B, Salimzadeh A, Alishiri Gh, Haghighi A. Comparison of two doses of corticosteroid in epidural steroid injection for lumbar
radicular pain. Singapore Med J 2007; 48 (3) : 24-45.

9. FÁRMACOS
AL
↓
PROS Y CONTRAS DE LOS AL:
• Capacidad de romper el círculo vicioso: Dolor muscular,
espasmo, isquemia, dolor
• Beneficio psicológico
• Comprobación de la inyección epidural
• CONTRAS: HipoTA, bloqueo sensitivo y motor prolongado
↓
VOLUMEN
↓
DEPENDE DE LA VÍA DE ABORDAJE

10. VÍAS DE ABORDAJE
CAUDAL INTERLAMINAR TRANSFORAMINAL
30-40mL 8-12mL 2-4 mL

11. VÍAS DE ABORDAJE
EFICACIA SUPERIOR DE LAS VÍAS INTERLAMINAR Y TRANSFORAMINAL
VS LA CAUDAL
EFICACIA SUPERIOR DE LA VÍA TRANSFORAMINAL EN HERNIAS
TRANSFORAMINALES Y EN ESTENOSIS DE CANAL
Lee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection in
lumbosacral herniated disk and spinal stenosis. J Back Musculoskelet Rehabil. 2009;22(2):83-9.

12. VÍAS DE ABORDAJE
Abordaje intraforaminal
PARAPLEJIA (Houten JK, Erico TJ. Paraplegia after lumbosacral nerve root
block: report of three cases. Spine J 2002; 2:70-75.) ( Glaser SE and Falco F.
Paraplegia following thoracoumbar transforaminal epidural steroid injection, pain
Physician 2005; 8:309-314.) (Epidural Steroids in the Management of Chronic Spinal Pain: A
Systematic review. Pain Physician 2007, 10:185-212.)
MAYOR DIFICULTAD TÉCNICA

13. COMPLICACIONES
3 TIPOS
•DERIVADAS DEL USO DE AL
•DERIVADAS DE LA TÉCNICA
•DERIVADAS DEL USO DE CCO

14. COMPLICACIONES: por la técnica
293.050 epidurales
de las cuales 27.975
eran para control de
dolor crónico
T. M. Cook, D. Counsell and J. A. W. Wildsmith. Major complications of central neuraxial block: report on the Third National
Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 102 (2): 179–90 (2009).

15. COMPLICACIONES: por el uso de CCO

16. COMPLICACIONES: otras
• CPPD
• REACCIONES VASOVAGALES
• DOLOR LOCAL O EXACERBACIÓN DE LA RADICULOPATÍA DURANTE LA
PUNCIÓN
• ARACNOIDITIS Y NEUROTOXICIDAD
• LIPOMATOSIS EPIDURAL
• MENORRAGIA O AMENORREA

17. CONCLUSIONES
• La inyección epidural conjunta de CCO y de AL se ha
demostrado eficaz.
• Las 3 vías de administración son válidas.
• El tipo de CCO y la periodicidad de los BED deben
individualizarse en cada centro: protocolización (Cohen
SP, Hayek SM, Datta S, Bajwa ZH, Larkin TM, Griffith S, Hobelmann G, Christo PJ, White R. Incidence and root
cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010
Mar;112(3):711-8.
• Es fundamental la adopción de medidas de
seguridad para el paciente: s/t estudio preoperatorio,
monitorización, ingreso 7-10 horas y seguimiento
efectos secundarios.

18. GRACIAS

19. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine
epidural steroid injection: two case reports. Pain Med. 2009 Nov;10(8):1389-94.
OBJECTIVE: To present two case reports of a rare but devastating injury after image-guided,
lumbar transforaminal injection of steroids, and to explore features in common with previously
reported cases. BACKGROUND: Image (fluoroscopic and computed tomography [CT])-guided,
lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular
pain. Complications associated with these procedures are rare, but can be severe. CASE
REPORTS: An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal
injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided,
right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients
developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately
after the procedures. Magnetic resonance imaging scans were consistent with spinal cord
infarction. There was no evidence of intraspinal mass or hematoma.
CONCLUSION: These cases consolidate a pattern emerging in the literature. Distal cord and
conus injury can occur following transforaminal injections at lumbar levels, whether injection is on
the left or right. This conforms with the probability of radicular-medullary arteries forming an
arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which
promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this
complication can be reduced, and potentially eliminated, by the utilization of particulate free
steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary
injection of local anesthetic.