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      Failed dural puncture during needle-through-needle combined spinal–epidural anesthesia: a case series

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          Abstract

          Objective

          Combined spinal–epidural (CSE) anesthesia is a widely used neuraxial anesthetic technique. In clinical practice, failed dural puncture during needle-through-needle technique occasionally occurs, with incidence of 5%–29%. We radiologically evaluated four cases of failed dural puncture during needle-through-needle CSE anesthesia.

          Case series

          Four patients received CSE anesthesia for elective orthopedic surgery. CSE procedures were performed in the same manner using a CSE device for needle-through-needle technique. An epidural needle was inserted in midline at L4/5 interspaces using loss of resistance to air whilst patients lay in the lateral decubitus position. The spinal needle was then inserted through the epidural needle for subarachnoid block, however, negative cerebrospinal flow was identified. Subsequently, radiographic imaging using C-arm fluoroscopy was performed to evaluate the status of needles. We found that epidural needles were considerably deviated from the midline, while spinal needles exited epidural needles, not through back holes, but through the Tuohy curve in three patients. In one patient, when the spinal needle was inserted to 12 mm, the anesthesiologist felt the needle touching the bony structure. The spinal needle was in contact with the superior articular process of the fifth lumbar vertebra, which was confirmed by C-arm radiography.

          Conclusion

          Excessive paramedian deviation of the epidural needle may affect dural puncture during needle-through-needle CSE technique. Moreover, wrong passage of the spinal needle through Tuohy curve instead of the back hole, may contribute to failure of dural puncture.

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          Most cited references 13

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          Combined spinal-epidural techniques.

           Gregory Cook (1999)
          The combined spinal-epidural technique has been used increasingly over the last decade. Combined spinal-epidural may achieve rapid onset, profound regional blockade with the facility to modify or prolong the block. A variety of techniques and devices have been proposed. The technique cannot be considered simply as an isolated spinal block followed by an isolated epidural block as combining the techniques may alter each block. This review concentrates on technical and procedural aspects of combined spinal-epidural. Needle-through-needle, separate-needle and combined-needle techniques are described and modifications discussed. Failure rates and causes are reviewed. The problems of performing a spinal block before epidural blockade (potential for unrecognised placement of an epidural catheter, inability to detect paraesthesia during epidural placement, difficulty in testing the epidural, delay in positioning the patient) are described and evaluated. Problems of performing spinal block after epidural blockade (risk of catheter or spinal needle damage) are considered. Mechanisms of modification of spinal blockade by subsequent epidural drug administration are discussed. The review considers choice of technique, needle type, patient positioning and paramedian vs. midline approach. Finally, complications associated with combined spinal-epidural are reviewed.
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            A clinical comparison between needle-through-needle and double-segment techniques for combined spinal and epidural anesthesia.

            The goal of the present investigation was to compare the double-segment and the needle-through-needle techniques for combined spinal and epidural anesthesia (CSE) in a prospective, randomized, blinded study. With Ethical Committee approval and patient's consent, 120 patients were randomized to receive CSE by the needle-through-needle (SST; n=60) or the double-segment technique (DST; n=60). A blind observer measured the time required from skin disinfection to readiness for surgery (loss of pinprick sensation up to T10), failure of dural puncture, need for epidural top-up before surgery, patient acceptance, and occurrence of complications. No neurologic complications were observed in either group. Time to readiness for surgery was 22.7+/-8.2 minutes in the SST group and 29.8+/-8.31 minutes in the DST one (P < .001). Dural puncture was unsuccessful in three patients in the SST group (5%) and in one patient in the DST group (1.6%) (ns); inadequate spread of spinal anesthesia was observed in five patients in the SST group (8.3%) and in eight patients in the DST group (13.3%) (ns). No difference in the incidence of hypotension, postdural puncture headache, and back pain was observed between the two groups. Acceptance of anesthetic procedure was better in the SST (85%) than in the DST group (66.6%) (P < .05). The needle-through-needle technique for CSE requires less time, has no greater failure rate, and results in greater patient satisfaction than the double-segment technique. The use of a spinal needle with an adjustable locking mechanism and protruding up to 15 mm beyond the Tuohy needle improved successful spinal block in the needle-through-needle technique compared with previous reports.
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              Combined epidural/spinal anaesthesia: needle-through-needle or separate spaces?

              This prospective, randomized and blinded study compared the performance of a new needle-through-needle (NTN) kit (Epistar; Medimex, Germany) with the double-space technique for providing combined spinal epidural anaesthesia during Caesarean section. Following local Ethics Committee approval and patient consent, 200 females were randomized to receive combined spinal epidural anaesthesia by the double-space (n = 100) or NTN (n = 100) technique. The frequency with which the intrathecal component could achieve a T5 block to touch for Caesarean section without the need for epidural augmentation or an alternative technique was determined. The time from start of procedure to achieving a block height to T5 was recorded. Pain and backache at insertion, and at 24 h follow-up were recorded using a visual analogue scale. To remove any bias due to posture, 50% of each group were further randomized to receive their block in the sitting or in the left lateral position. To evaluate improvement of performance over time the success in the first 100 study patients were compared to the success in the second 100. A successful block to T5 with the double-space and NTN techniques were 80 vs. 54, odds ratio 0.29. Failure to enter the intrathecal space once the epidural space had been located occurred in 29 patients in the NTN group. Time to readiness for surgery was 15 min (95% confidence interval (CI): 12.7-17.4) and 12.9 min (95% CI: 11.5-14.3) for the double-space and NTN techniques, respectively. The median (interquartile range) visual analogue scores for discomfort at insertion were 30 (12.5-51.5) and 32 (12.75-60) and for postoperative backache 0 (0-10) and 0 (0-10.75) in the double-space and NTN groups, respectively. The number of epidural augmentations was similar in both the groups and posture made no difference. There was a tendency to increased success in the second half of the study. The double-space technique had a greater success rate than the NTN technique.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2019
                17 May 2019
                : 12
                : 1615-1619
                Affiliations
                [1 ]Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, South Korea
                [2 ]Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea, ball1210@ 123456hanmail.net
                [3 ]Department of Urology, Chonbuk National University Medical School, Jeonju, South Korea, ball1210@ 123456hanmail.net
                Author notes
                Correspondence: Yu Seob Shin, Department of Urology, Chonbuk National University Medical School, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Jeollabuk-do, South Korea, Tel +82 63 250 1565, Fax +82 63 250 1564, Email ball1210@ 123456hanmail.net
                Article
                jpr-12-1615
                10.2147/JPR.S178640
                6526918
                © 2019 Doo et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Case Series

                Anesthesiology & Pain management

                combined spinal–epidural anesthesia, dural puncture, fail

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