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Year : 2020  |  Volume : 64  |  Issue : 3  |  Page : 248-249  

Inadvertent dural puncture: Is excess flexion of spine a possible cause?


1 Department of Trauma and Emergency, AIIMS, Patna, Bihar, India
2 Department of Anaesthesia, AIIMS, Patna, Bihar, India
3 Department of Radiology, AIIMS, Patna, Bihar, India

Date of Submission11-Nov-2019
Date of Decision14-Dec-2019
Date of Acceptance05-Jan-2020
Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. Ajeet Kumar
112, Block 2, Type 4, AIIMS Residential Complex, Khagaul - 801 105, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_830_19

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How to cite this article:
Kumar A, Kumar A, Sinha C, Kumar S. Inadvertent dural puncture: Is excess flexion of spine a possible cause?. Indian J Anaesth 2020;64:248-9

How to cite this URL:
Kumar A, Kumar A, Sinha C, Kumar S. Inadvertent dural puncture: Is excess flexion of spine a possible cause?. Indian J Anaesth [serial online] 2020 [cited 2020 Nov 24];64:248-9. Available from: https://www.ijaweb.org/text.asp?2020/64/3/248/280400



The rate of inadvertent dural puncture during epidural catheter placement varies from 0.19% to 3.6%.[1],[2] The performance of lumbar punctures and epidural catheterisations relies primarily on the palpation of anatomical landmarks, the angle of needle progression and the distance from the skin to the target space; hence, the skill of the operator is a major influencing factor. The 4 P's (position, preparation, projection, and puncture) continue to remain the very essence of these procedures.

Accidental dural puncture (ADP) during placement of an epidural catheter for anaesthesia is a well-known complication. Risk factors for this iatrogenic complication include patient movement and repeated epidural trials.[3] Kuroda K et al investigated retrospectively factors related to accidental dural puncture during epidural anaesthesia.[4] They concluded that the chances of ADP were more in lower thoracic and lumbar region, and in elderly patients.

In our clinical experience of inadvertent lumbar dural puncture, we feel that patient positioning could have (acute anterior flexion of lumbar spine) resulted in decreased posterior epidural space [Figure 1]. Anterior flexion of spine is required for proper insertion of Tuohy needle during epidural anaesthesia. This position of acute flexion can result in decreased posterior epidural space as dura comes closer to ligamentum flavum. This flexion that can help us pierce the dura in subarachnoid block, would also increase our chances of inadvertent dura puncture in case of epidural anaesthesia. [Figure 1] shows sketch diagram and MRI picture of epidural space in different positions of lumbar spine. There is a decrease in width of epidural space (5.3mm on acute anterior flexion, 5.9 in neutral position and 7.6 in dorsiflexion of lumbar spine).
Figure 1: MRI Lumbar Spine showing epidural space in various positions:(a) Flexion (b) Neutral (c) Extension

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There are no clear cut guidelines as to how much spine flexion is optimum for epidural catheterisation. Hence, we recommend further clinical/radiological studies to answer this question.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth1998;45:110-4.  Back to cited text no. 1
    
2.
Sprigge JS, Harper SJ. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: Presentation and management: A 23-year survey in a district general hospital. Anaesthesia2008;63:36-43.  Back to cited text no. 2
    
3.
Michaan N, Lotan M, Galiner M, Amzalag S, Many A. Risk factors for accidental dural puncture during epidural anesthesia for laboring women.J MaternFetal Neonatal Med 2016;29:2845-7.  Back to cited text no. 3
    
4.
Kuroda K, Miyoshi H, Kato T, Nakamura R, Yasuda T, Oshita K,et al. Factors related to accidental dural puncture in epidural anesthesia patients. J Clin Anesth2015;27:665-7.  Back to cited text no. 4
    


    Figures

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