"Tramp stamps" and anesthesia

[FutrCRNA]

I'm not sure if this is the place to ask this question, but "regionals" seemed like the best category. (If not, maybe one of the moderators can move it.) One of my friends just called and asked about those tattoos that go across the lower back (tramp stamps) and whether or not having one there might be a problem should she ever need a spinal/epidural. And, if it might pose a problem, is there a specific area of the spinal cord she should avoid. No use trying to talk her out of the tattoo...she's determined. (Why can't she be like the rest of us and put it on her foot?!) To be helpful, she had the intended tattoo air-brushed on her back and sent me the pic. I can't figure out how to include it here, but it looks like the tat would be around L4 - S2, give or take (still not good at judging that).

I just wondered if anyone had heard about the issue of tattoo ink causing problems if in a spinal/epidural area (i.e. the needle going through the ink and carrying it into the cord area). And, if so, could you explain the clinical implications for me.

(Man, the things we do for our friends. I'll be lucky to show my face on this forum again...)

[LouCRNA]

:why: Tramp Stamps? Seriously, you want to call them "tramp stamps"? That is soooo not funny. :buttkick:

I have read some information regarding tattoos and neuraxial blocks. A couple issues that come to mind from the articles I read are the possibility of introducing ink (which may contain metallic particles and harbor pathogens) into the CNS, and then also I recall reading some special risk about red ink in particular (though I don't remember what exactly). In any case, I always try to avoid tracking through a tattoo when doing a spinal or epidural, and I chart that I have avoided it. If I can't avoid it, well, then I can't avoid it, but I chart that possible risks related to needle placement through tattoo ink were discussed with the patient. If your friend's will really be below the L4 level, it should be avoidable. If I have time later, I'll do a quick search to see if I can track those articles down.

[FutrCRNA]

:why: Tramp Stamps? Seriously, you want to call them "tramp stamps"? That is soooo not funny. :buttkick:


Heeyy! Don't shoot the messenger - I didn't make up the name!!!:chairshot:

[NursePink]

Haha That discussion came up at work the other day - the infamous "a$$ hat". This midline tattoo is predicted to be @ L1 - L4.


http://www.cja-jca.org/content/vol49/issue10/images/small/02-30.gif

Here are a coupla articles I found:

Canadian Journal of Anesthesia 49:1057-1060 (2002) - "Epidural anesthesia in three parturients with lumbar tattoos: a review of possible implications"

http://releases.usnewswire.com/GetRelease.asp?id=35254

Here is a clip from the Canadian Journal Discussion section:

Tattoos
During the tattooing process the needles penetrate the epidermis into the dermis and pigment is deposited along the entire needle tract. Only pigment that is in the dermis remains permanently. After the tattoo has healed, the pigment is engulfed by dermal macrophages and carried to regional lymphatics and perivascular lymph nodes.13 The pigment that remains in the loose fibrous connective tissue of the dermis gives colour to the tattoo. What are the possible implications (consequences) for the anesthesiologist? Theoretically introducing a needle through the pigmented tattoo may result in a tissue core that contains pigment. This could be injected into the epidural, subdural or subarachnoid spaces.

In the past, the pigments used for tattooing were inorganic and included titanium dioxide, cadmium sulphide, chromic oxide, cadmium selenide, red cinnabar, iron oxide and carbon.14 Although more organic pigments are being used currently neither the individual being tattooed nor the tattoo artist may know the composition of the ink.

Complications of tattoos
Various reactions have been associated with tattoos including allergic, pseudolymphoma and granulomatous or lichenoid reactions.15 Mercury ions, chromium III ions or cobalt II ions induce allergic reactions. Other reported problems associated with tattooing include transmission of hepatitis B and C16 and localized infections at the site of the tattoo. There is a case report of a spinal epidural abscess that occurred two weeks following a tattoo on a buttock.17 Other reported complications include a superficial burn in the tattoo18 and pain in the area of the tattoo,19 both during magnetic resonance imaging scanning.

Of greater concern is a report of three patients who developed brachial plexus neuropathies with muscle atrophy.20 All had tattoos adjacent to the area of atrophy. The author postulated that the tattoo induced focal chronic neuromuscular dysfunction, possibly due to an immune-mediated reaction or a toxic effect of the pigment. As chemically induced arachnoiditis can occur following epidural anesthesia with local anesthetics containing preservatives,21 might not a similar reaction occur from pigment?

Will nicking the skin prior to inserting an epidural or spinal needle as done by Campbell et al.9 avoid picking up tissue cores containing pigment? It would seem reasonable. Obviously the size of the nick has to be larger than the needle being inserted and should penetrate through the dermis. Whether these precautions provide adequate protection is unknown.

To date, there are no reports of complications from inserting a needle through a tattoo. This could be because they do not occur. However, the lack of reported complications could reflect the fact that in the past fewer patients (pregnant and non-pregnant) had tattoos involving the midline of their lower back. The number of patients having neuraxial anesthesia through a pigmented tattoo would have been correspondingly small. Additionally, epidermoid tumours and arachnoiditis do not occur immediately but develop over time. It may be too early to see any long-term consequences.



I'm with Ikomore on this one... if I can avoid it, I will. Does it stop me from putting in a spinal or epidural?? No.

[LouCRNA]

Heeyy! Don't shoot the messenger - I didn't make up the name!!!:chairshot:

All right, I won't shoot the messenger. I just hadn't heard this particularly colorful euphemism before. Took me by surprise :)

:ranger:

[athomas91]

in an elective spinal case - i would personally choose not to do one through a tat. however in an epidural case ... try to go around the tat is what i usually do - and although the needle is bigger - allowing more possibility for skin/ink to be transferred -you use the introducer to block the opening of the needle to prevent tissue pick-up....

i on a more personal note - have such a tat - not huge - but there.... and i asked the ologist to go around it - and if he couldn't i would go without.

[Catcolalex]

the articles ive seen are "theoretical", no evidence as of yet of any harm done... for the most part, they can be avoided, especially with epidurals, however, one of the articles suggests making a mini-incision to break the skin and then introduce the epidural needle throgh the incision thus avoiding ink.

[ethernaut]

the articles ive seen are "theoretical", no evidence as of yet of any harm done... for the most part, they can be avoided, especially with epidurals, however, one of the articles suggests making a mini-incision to break the skin and then introduce the epidural needle throgh the incision thus avoiding ink.

good thought here.. i guess the injury to the tat outweighs the possible outcomes of the ink-introduction to the cns..
very thought-provoking!!!

[dontquit]

Thought I'd stir up an old post just to keep this in mind. In my practice, I still do the epidural, but I advise my patients that the outcomes are unclear. There is worry that the dye may be introduced, and could pose a problem.

[armygas]

I just hadn't heard this particularly colorful euphemism before. Took me by surprise :)

:ranger:
You gotta be kidding me ;)

I knew this 20 years ago.....

http://en.wikipedia.org/wiki/Lower_back_tattoo

http://i208.photobucket.com/albums/bb276/DFBCT3/things/quatro/topgunwon-tramp_stamp-1.jpg

[armygas]

the articles ive seen are "theoretical", no evidence as of yet of any harm done... for the most part, they can be avoided, especially with epidurals, however, one of the articles suggests making a mini-incision to break the skin and then introduce the epidural needle throgh the incision thus avoiding ink.
Yah, if you are worried take an 18g needle and puncture the site first.

[Teillard]

I just go right through without a second thought.

[SuccsDrugs&Rocuron]

Dr. Turlington's Lower Back Tattoo Remover is the solution!

http://www.milkandcookies.com/link/21523/detail/

[SoonerFan]

I think a safe estimate is that 25% of my L&D patients have tramp stamps, usually right around where I'm gonna stick. The biggest annoyance I find is that they're usually not well-centered, as my initial inclination is to aim right between the "eyes" of the butterfly, which is usually a bit off midline.

I'm not sure aiming a mm away from the ink visible at skin level would insure that no ink was encountered deeper, visible to the naked eye or not.

So far, I haven't had patients develop any problems (other than the occasional PDPH) after an epidural or spinal.

Just let the malpractice attorneys get ahold of this idea ...