Overcoming the tattoo risk for spinal anaesthesia in caesarean section

Introduction
Recently a 26-year-old lady was admitted for elective caesarean section for breech presentation. Preanaesthetic back examination revealed an extensive tattoo covering the entire of her lumbar region with no possibility of performing spinal anaesthesia without penetrating pigment containing skin. After reviewing the literature and discussing the risks and benefits in an open manner with the patient, a general anaesthetic was performed for this elective caesarean section. Fortunately there were no complications for mother or baby.

Literature suggests a theoretical risk of coring of pigment-containing material during neuroaxial block through a tattoo which could lead to serious complications1,2.

It has been demonstrated that tissue coring takes place with hollow needles, with or without a stylet3,4. Ozyurt et al showed squamous epithelial cells in the CSF immediately after spinal needle insertion into the subarachnoid space5. Other authors document microspically the coring of tissue with Sprotte, Quincke and Whitacre spinal needles6,7.

Coring is believed to be the cause of reported epidermoid tumours in the subarachnoid and epidural space following spinal needle insertion8. The composition of tattoo ink is unpredictable and different organic and inorganic pigments have been used, many of which are not meant for this purpose by the chemical industry.

Chemically induced arachnoiditis has been shown with preservative containing local anaesthetics and it seems logical that similar reactions could occur with deposition of tattoo pigment in the subarachnoid or epidural space9.

Given the evidence of tissue coring and the nature of chemicals used in tattoos there could be severe implications in performing a neuroaxial block over a tattoo. Despite this, we were only able to find one documented case of minor complication10. This involved a lumbar epidural for labour pain in a lady with an extensive lumbar tattoo.

The patient reported some transient burning sensation over the area, but with no neurological sequalae. The lack of documented complications may reflect low numbers, or even the fact that complications may take time to develop. In the Western world more than 80 million people have tattoos, with almost 50% of all tattoos being performed on women11.

In recent years body tattooing on unusual sites such as the lumbar area have increased in popularity. There is very little information to quantify the risk of spinal anaesthesia in patients with extensive lumbar tattoos.

In these cases, should the theoretical risk of spinal anaesthesia through a tattoo outweigh the demonstrated risk of general anaesthesia?

References

  1. Douglas MJ, Swenerton JE. Epidural anesthesia in three parturients with lumbar tattoos: A review of possible implications. Canadian Journal of Anesthesia 2002; 49: 1057-1060.
  2. Kuczkowski KM. Controversies in labor: Lumbar tattoo and labor analgesia. Arc Gynecol Obstet 2006; 274: 310-312.
  3. Charlebois PA. Coring: The unseen menace. Can Anaesth Soc J 1966; 13:585-597.
  4. Brandus V. The spinal needle as a carrier of foreign material. Can Anaesth Soc J 1968; 15: 197-201.
  5. Ozyurt G, Mogol EB, Tolunay S, Kerimoglu B. Tissue coring with spinal needles. Reg Anesth Pain Med 2000; 25: 665.
  6. Campbell DC, Douglas MJ, Taylor G. Incidence of tissue coring with the 25-guage Quincke and Whitacre spinal needles. Reg Anesth 1996; 21: 582-585.
  7. Puolakka R, Andersson LC, Rosenberg PH. Microscopic analysis of three different spinal needle tips after experimental subarachnoid puncture. Reg Anesth Pain Med 2000; 25: 163-169.
  8. Gardner DJ, O'Gorman AM, Blundell JE. Intraspinal epidermoid tumour: Late complication of lumbar puncture. CMAJ 1989; 141: 223-225.
  9. Sklar EM, Quencer RM, Green BA, Montalvo BM, Post MJ. Complications of epidural anesthesia: MR appearance of abnormalities. Radiology 1991; 181: 549- 554.
  10. Kuczkowski KM. Labour analgesia in a parturient with lumbar tattoo: A routine management or not? Canadian Journal of Anesthesia 2004; 51:93.
  11. Armstrong ML. Career-orientated women with tattoos. Image, J Nurs Sch 1991; 23: 215-220.
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