The impact of fluoroscopic confirmation of thoracic imaging on accuracy of thoracic epidural catheter placement on postoperative pain control

Tabish Aijaz,1 Kenneth D Candido,1–3 Utchariya Anantamongkol,1 Gleb Gorelick,4 Nebojsa Nick Knezevic1–3 1Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; 2Department of Anesthesiology, University of Illinois, Chicago, IL, USA; 3Department of Surgery, University of Illinois, Chicago, IL, USA; 4Department of Radiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA Background: Thoracic epidural analgesia (TEA) provides superior postoperative pain control compared to parenteral opioids after major thoracic and abdominal surgeries. However, some studies with respect to benefits of continuous TEA have shown mixed results. The purpose of this study was to determine the rate of successful TEA catheter insertion into the epidural space using contrast fluoroscopy and the impact of placement location on postoperative analgesia and opioid use. Patients and methods: After Advocate health care institutional review board approval, we conducted a prospective, open-label, single intervention study on patients undergoing thoracic or upper abdominal surgery. A thoracic paramedian epidural approach and a loss of resistance to saline technique were used to place an epidural catheter above the T11 level and fluoroscopic images with injected contrast were taken to locate the catheter tip in the epidural space. Results: Twenty-five subjects were included in the study, of which 3 catheters (12%) were not identified as being in the epidural space. We found an average difference of 1.5 vertebral levels between clinical and radiological assessments of catheter tips. Thirteen catheters (52%) were more than 1 vertebral level away from the clinically assessed level. No significant difference was found in the pain scores at 1, 24, and 48 hours after surgery between patients with correct versus incorrect catheter placement. Less opioids were used in the correct catheter placement group at 24 hours (256 morphine milligram equivalent [MME] vs 201 MME) and at 48 hours after surgery (250 MME vs 173 MME), but it was not statistically significant (p=0.149 and p=0.068, respectively). Conclusion: Improvement in assuring success in the technique for TEA catheter placement following major thoracic or upper abdominal surgery exists, for which contrast-enhanced fluoroscopy might be a promising solution. Keywords: postoperative analgesia, epidurogram, thoracic epidural analgesia, neuraxia