Epidural analgesia and lumbar tattoos: 20 years of uncertainty

Mesa Suárez, P.; Pulido Barba, M.; Portilla Huerta, D.

doi:10.1016/j.redare.2022.04.004

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"apellidos" => "Portilla Huerta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Área en Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Puerto Real, Puerto Real, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Puerto Real, Puerto Real, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Analgesia epidural y tatuajes lumbares: 20 años de incertidumbre" ] ] "textoCompleto" => "This year marks the 20th anniversary of the publication of the article by our Canadian colleagues M.J. Douglas and J.E. Swenerton<a class="elsevierStyleCrossRef" href="#bib0005">1</a> in which they questioned the safety of placing an epidural catheter for obstetric analgesia in 3 women with lower back tattoos. They managed to place the catheter in an area free of ink in 2 patients, and in the third they placed it in the tattooed area. In 2002, they voiced their concerns about possible future neurological complications arising from puncturing an area containing pigments. They themselves admitted that they had little information and that they really “did not know”.Since the end of the 1950s, isolated cases or case series describing squamous cell tumours in patients who underwent lumbar punctures in their childhood began to appear in the literature.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Most concerned the generation of a core of epidermal tissue inside hollow bevelled needles. As the drug drags the core along with it as it is injected into the meninges through the hollow needle, thus producing an intradural epidermal implant. With the appearance of styletted spinal needles with a pencil instead of a bevelled tip, the tissue coring phenomenon was replaced by entrapment of epidermal cells.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>These articles led our colleagues, and many others after them, to ask: can pigmented cells implanted in the epidural space following insertion of an epidural needle through tattooed skin cause future complications in pregnant women?Fortunately, histology studies have now characterised most of the cells found in needles after lumbar punctures as non-nucleated cells from the stratum corneum of the epidermis. Evidence from a study undertaken by researchers from the Universidad Estatal de Sao Paulo showed that spinal puncture through the tattooed skin of rabbits can trigger acute inflammatory changes in the meninges and areas of thickening with adhesions.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>We are less fortunate, however, in terms of access to clinical practice guideline and consensus documents from scientific societies that would allow us to make evidence-based recommendations. A search in the most popular databases (PubMed®, EMBASE, UptoDate®) sheds little light on the management of pregnant women with lower back tattoos who request labour analgesia.Anaesthesiologists called to the delivery room to place an epidural catheter in a tattooed pregnant woman will have to choose between: examining the tattoo in search of an area free of ink; performing a paramedian approach; making a skin incision to reach deeper territories free of pigment; resigning themselves to puncturing the tattooed skin; or not placing the catheter. Only a few will choose the latter course of action.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>All these choices are as real as they are valid. This is how things stood in 2002, and how they still stand in 2022. When will we receive clear instructions? How long do we have to wait for consensus guidelines? After 20 years of waiting, the question has now come of age.FundingNo funding.Conflict of interestNo conflicts of interest." 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Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Reg Anesth" "fecha" => "1996" "volumen" => "21" "paginaInicial" => "582" "paginaFinal" => "585" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8956397" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can an inflammatory reaction in the meninges, caused by spinal puncture through tattooed skin, evolve into adhesive arachnoiditis? An experimental model in rabbits" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.A. da Silva" 1 => "I. Leite Ferraz" 2 => "R. Santos Zuza" 3 => "C. Camara" 4 => "M. Alencar Marques" 5 => "V.M. de Vasconcelos Machado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/rapm-2018-100085" "Revista" => array:6 [ "tituloSerie" => "Reg Anesth Pain Med" "fecha" => "2019" "volumen" => "44" "paginaInicial" => "355" "paginaFinal" => "359" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30635505" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumbar tattoos and neuroaxial anesthesia in obstetrics: practice survey in Languedoc-Roussillon, France" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.C. Sleth" 1 => "B. Guillot" 2 => "N. 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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 70. Issue 7.

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