Acta Anaesthesiol Scand 2007; 51: 255–260 Printed in Singapore. All rights reserved # 2006 The Authors Journal compilation # 2006 Acta Anaesthesiol Scand ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2006.1184.x Case Report Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery B. C. H. TSUI 1 , J. BURY 2 , M. BOULIANE 2 and S. GANAPATHY 3 Departments of 1 Anesthesiology and Pain Medicine and 2 Orthopedic Surgery, University of Alberta Hospitals, Edmonton, Alberta and 3 Department of Anesthesia, University of Western Ontario, London, Ontario, Canada Background: Continuous cervical epidural anesthesia can pro- vide excellent peri- and post-operative analgesia, although sev- eral factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low- current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. Methods: After Institutional Review Board approval, adult pa- tients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1–10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch res- ponses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2–8 ml/h) of ropiva- caine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. Results: Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8  2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4–7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. Conclusion: This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization. Accepted for publication 15 August 2006 Key words: cervical epidural analgesia; thoracic epidural; epidural stimulation test; continuous analgesia technique. # 2006 The Authors Journal compilation # 2006 Acta Anaesthesiol Scand C ONTINUOUS cervical epidural anesthesia (CEA) has been shown to provide excellent post-operative analgesia for patients undergoing upper extremity surgery (1–4). However, direct placement of catheters in this region is not commonly performed and therefore underutilized. In contrast, direct thoracic catheter placement is common (5–8). From this and our experience with electrical stimulation, we hypothesize that guiding catheters from thoracic to cervical regions can be performed successfully and with ease using low-current epidural stimulation and will achieve excellent analgesia in adults undergoing upper extremity surgery. Methods After Institutional Review Board approval and writ- ten informed consent, adult patients presenting for total shoulder arthroplasty were consecutively stud- ied. After sterile preparation, with the patients awake and sitting, a 17-G Tuohy needle was inserted into the mid-upper thoracic epidural space using a right paramedian approach (irrespective of surgical side). The length of a styletted 20-G epidural catheter (Epidural Positioning System using Tsui Test with FlexTip Plus Catheter, Product no. TS-05430-P; Arrow International, Inc., Reading, PA) (Fig. 1) required to reach approximately to the fifth cervical spinal level (C5) was estimated and the catheter was primed with sterile normal saline. Using a previously described procedure (9), a nerve stimulator was The principal author has a patent license agreement with Arrow International Inc., for the epidural kit described in the article. 255