Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 187-192

Epidural injection at or around the level of accidental dural puncture: Does it make a difference?


Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission18-Nov-2013
Date of Acceptance19-Dec-2013
Date of Web Publication31-May-2014

Correspondence Address:
Hanaa A. El-Gendy
Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.133437

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  Abstract 

Background
When accidental dural puncture (ADP) occurs, options are either to cancel the technique and administer general anesthesia, perform spinal anesthesia, or reattempt epidural at a level above or below the site of dural puncture. The previous concept of avoiding the epidural technique at the same level as that of the ADP needs to be revised.
Patients and methods
The patients in this study were those scheduled for elective orthopedic procedures under epidural anesthesia, during which ADP occurred. Patients were divided randomly into three groups according to the level of epidural injection in relation to the site of ADP: group S included patients who received epidural anesthesia at the same site as that of the ADP. Groups A and B included patients administered epidural anesthesia at a level above or below the site of ADP, respectively. After identifying the epidural space, the test dose was administered. If spinal anesthesia was administered, the operation was started and epidural anesthesia was canceled. If no signs of intravenous injection or spinal anesthesia occurred, 20 ml bupivacaine 0.5% was injected into the epidural space. The primary outcome was the safety of epidural anesthesia at the same level as that of ADP. The secondary outcomes were simplicity and incidence of side effects.
Results
No cases of untoward subarachnoid injection were recorded. Identification of the epidural space was significantly easier and less time consuming in group S. No significant difference was observed between the groups studied in terms of side effects (nausea, vomiting, and headache). However, backache was significantly less in incidence and severity in group S.
Conclusion
Epidural anesthesia at the site of ADP was as safe as at a level above or below. Moreover, it was easier and less time consuming, with less incidence of backache.

Keywords: Accidental, dural puncture, epidural, level


How to cite this article:
Elewa GM, El-Gendy HA, Bondok RS. Epidural injection at or around the level of accidental dural puncture: Does it make a difference?. Ain-Shams J Anaesthesiol 2014;7:187-92

How to cite this URL:
Elewa GM, El-Gendy HA, Bondok RS. Epidural injection at or around the level of accidental dural puncture: Does it make a difference?. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Oct 27];7:187-92. Available from: http://www.asja.eg.net/text.asp?2014/7/2/187/133437


  Introduction Top


Epidural anesthesia is a versatile technique used widely in anesthetic practice. It has frequently been used for regional anesthesia and/or pain relief [1],[2],[3]. However, accidental dural puncture (ADP) is one of the complications that can occur even with experts [4]. Whenever ADP occurs, the options are either to reattempt the epidural technique, perform spinal anesthesia, or cancel the technique and administer general anesthesia [2],[4],[5]. A reattempt of the epidural technique is usually made at a level above or below the site of ADP [6]. This might be for the fear of spread of anesthetic and/or analgesic drug(s) through the dural puncture site, leading to all complications of injecting large doses of anesthetics in the subarachnoid space [7]. With the introduction of combined spinal epidural (CSE), where the epidural technique is safely performed at the same site of dural puncture (i.e without dangerous intrathecal spread of epiduraly injected drugs). So that the fear of total spinal anesthesia with CSE is to be evaluated.

Therefore, the aim of this study was to assess the safety (primary outcome), simplicity, and side effects (secondary outcome) of performing epidural anesthesia at the same level as that of ADP in comparison with performing it at a level above or below.


  Patients and methods Top


This prospective randomized comparative study was carried out after obtaining approval from the medical ethics committee. Informed written consents were obtained from patients included in this study. The study was carried out during the period from January 2004 to July 2011 in Ain Shams University Hospitals, Cairo, Egypt. Patients in this study were ASA I or II, scheduled for elective lower limb orthopedic procedures under epidural anesthesia, during which ADP occurred. All patients in this study were anesthetized by the same team of anesthesiologists. Midazolam 2-3 mg intravenously was administered, as premedication, 15 min before the technique. Epidural anesthesia was performed with the patients in the lateral decubitus position, using an 18-G Tuohy needle (Portex, USA), inserted into the midline with the bevel oriented parallel to the longitudinal axis of the dura using the 'loss of resistance to saline' technique to identify the epidural space.

Patients were (by a simple randomization procedure: computerized random numbers) divided randomly into three groups according to the level of epidural drug injection in relation to the site of ADP. Group A included patients who were administered epidural anesthesia at a level above the site of ADP, whereas group B included patients who were administered epidural anesthesia at a level below the site of ADP. Group S included patients who were administered epidural anesthesia at the same site as that of ADP. In group S, when the dura was accidentally punctured and cerebrospinal fluid (CSF) emerged, the epidural Tuohy needle was withdrawn gradually until about one cm after no CSF emerged so that the needle did not come out of the skin. Then, the needle was readvanced, at the same level as the dural puncture, with the needle bevel parallel to dural fibers, and the epidural space was reidentified using the technique of loss of resistance to saline. If identification of the epidural space failed or dural puncture occurred during three successive trials, the technique was canceled and the patient was administered general or spinal anesthesia, respectively. In other groups, when the dura was accidentally punctured and CSF emerged, the epidural Tuohy needle was withdrawn completely outside the skin. Then, it was reintroduced - after local skin infiltration with 2 ml lidocaine 2% - at another level, which was one space above (group A) or below (group B) the level of ADP. The epidural space was reidentified by the same method as that used in group S. If identification of the epidural space failed with three successive trials or dural puncture occurred, the technique was canceled and the patient was administered general or spinal anesthesia.

In all groups, after identifying the epidural space, 45 mg lidocaine 2% with epinephrine 15 μg was administered slowly as a test dose. The patient was monitored for signs of intravascular injection (an increase in systolic blood pressure ≥15 mmHg and/ or an increase in heart rate ≥10 bpm) or signs of spinal anesthesia. If signs of spinal anesthesia were observed, the operation was started and epidural anesthesia was canceled. If no signs of intravascular injection or spinal anesthesia were observed, 20 ml bupivacaine 0.5% was injected slowly into the epidural space. The anesthetist who performed the epidural technique left the operating room, and another one - blinded to the group - was responsible for monitoring and collecting the patient's vital data. Patients were monitored as is done routinely in cases of epidural anesthesia. When the level was fixed, surgery was started. If bradycardia occurred (heart rate < 50 bpm), 0.3 mg intravenous atropine was administered and was repeated if required. If hypotension occurred (systolic blood pressure < 90 mmHg), 10 mg intravenous ephedrine was administered and could be repeated. The end point for atropine and ephedrine administration was to maintain the heart rate and blood pressure within normal basal preoperative values ± 20%.

The three groups were compared in terms of patients' characteristics, incidence of inadvertent intravascular injection and spinal anesthesia after the test dose, and incidence of total spinal after an epidural injection of 20 ml bupivacaine. Groups were also compared in terms of the number of retrials and duration to identify the epidural space (calculated from the time of ADP until the start of injection of the test dose). The number of patients who required atropine or ephedrine and the total doses of atropine and ephedrine administered per patient in each group were compared. The studied groups were also compared in terms of the incidence of headache, backache, nausea, and vomiting.

Statistical analysis

Data were recorded, coded, tabulated, and then statistically analyzed using the SPSS computer soft ware, version 16 (SPSS Inc., Chicago, Illinois, USA). Numerical variables were presented as mean ± SD or median and range as appropriate. Categorical variables were presented as number and percentage. The analysis of variance test was used for comparison of parametric data between the studied groups and the Kruskal - Wallis test for nonparametric data. A P value less than 0.05 was considered statistically significant. The post-hoc Tukey test was applied to determine significant differences between groups.


  Results Top


The study included 186 patients, 62 in each group. In one case in group A, the epidural space could not be identified after three attempts. Thus, the technique was canceled and the patient was administered general anesthesia. Accidental dural repuncture occurred in one patient in group B on the first retrial and in two patients in group S with three retrials. Therefore, the operation was performed under spinal anesthesia in these patients. Thus, 61, 61, and 60 patients were studied in groups A, B, and S, respectively.

There were no statistically significant differences between groups in patients' characteristics, types and durations of surgery, and level of sensory and motor blockade [Table 1]. No case of inadvertent intravascular injection or spinal anesthesia occurred after the injection of the test dose, and there was also no case of total spinal anesthesia after epidural injection of 20 ml of the local anesthetic in the three groups. In addition, epidural anesthesia at the same level as that of ADP was easier and less time consuming than at another level. This was evident on comparing the number of patients in whom the epidural space was identified from the first retrial. This was more in group S than in the other groups. Also, the duration for identification of the epidural space was significantly less (P < 0.05) in group S (1.8 ± 0.8 min) than in groups A (3.4 ± 1.7 min) and B (3.5 ± 1.8 min), respectively [Table 2].
Table 1: Patients' characteristics, surgical data, and level of sensory and motor blockade in the groups studied

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Table 2: Comparison between groups in the number of patients in relation to the number of trials to identify the epidural space and duration to reidentify the epidural space

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In terms of hemodynamic data, there was no statistically significant difference between groups. The number of patients who required atropine or ephedrine, and the total doses of such drugs were comparable in the three groups [Table 3]. Also, incidences of headache, nausea, and vomiting were also comparable in all groups (P > 0.05). However, backache was significantly (P < 0.05) less in incidence and severity in group S [10 patients, 16.7%, visual analogue scale (VAS) = 2.3 ± 0.8] than in group A (15 patients, 24.6%, VAS = 3.2 ± 0.7) and group B (16 patients, 26.2%, VAS = 3.3 ± 0.8) [Table 4].
Table 3: Number of patients who required atropine or ephedrine and their total doses

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Table 4: Comparison between groups in the incidence of headache, backache, nausea, and vomiting

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  Discussion Top


Epidural anesthesia is used widely in lower abdominal and lower limb surgery, especially orthopedic, because of its advantages and to avoid the complications associated with general anesthesia and endotracheal intubation [6]. However, inadvertent dural puncture can occur even in experienced hands [1],[8],[9],[10],[11].

In terms of the primary outcome, our study showed that epidural anesthesia at the site of ADP was as safe as that at a level above or below this site; there was no case of spinal anesthesia by the test dose and no case of total spinal anesthesia after epidural injection of the anesthetic. This indicates that there was no, at least clinically serious, leakage of the injected anesthetic through the site of the previously punctured dura. This might be because the direction of the needle bevel was parallel to the direction of dural fibers, so that, after withdrawal of the needle from the site of ADP, the opening closed again because there was only separation - and not cutting - of the fibers [12],[13],[14],[15]. Another explanation might be related to the design of the Tuohy needle; it is curved at its end and its opening is directed to one side. Therefore, even at the site of the previous dural puncture, the injection is directed away from the breached dura. A third explanation is that the subarachnoid pressure is higher than the epidural space pressure, even after a slow epidural injection of the test dose and anesthetic dose of the drug [16],[17]. This is because the meninges are compressed by the volume of drug(s) injected into the epidural space, increasing both epidural and subarachnoid pressures, so that the subarachnoid space pressure tends to be greater than the epidural space pressure. Therefore, there would be no leakage of the anesthetic drug into the CSF to cause spinal or total spinal anesthesia. Fourth, Angle et al. [14], under scanning electron microscopy, found that there was complete or partial plugging of the dural puncture sites with what seemed to be dural tissue fragments. This phenomenon might contribute toward a reduction in the size of the dural hole.

The theoretical risk that solutions introduced into the epidural space during a CSE technique may enter the subarachnoid space has been studied previously. Many studies showed no evidence of intrathecal leakage [10,18]. Revising the reported cases of leakage from the epidural into the subarachnoid space through the dural puncture site [7, 19, 20], they were CSE with the use of epidural catheter; either the catheter was accidentally placed into the subarachnoid space [20] or leakage occurred during injection through the epidural catheter, and it was postulated that the side-way opening of the catheter was in direct contact with the site of dural puncture so that the injection pressure was higher than the intrathecal pressure [7]. Thus, it was recommended to use a single tip hole epidural catheter than a multiholed one in such cases [19],[21]. Moreover, most of the patients reported were pregnant and the CSE technique was used for labor analgesia or cesarean section [7],[19],[20]. Epidural space pressure is known to be higher in pregnant than nonpregnant women, so that the pressure difference between the subarachnoid space and the epidural space is less, and consequently, the chance of leakage from the epidural to the subarachnoid space is more than in other cases.

Cappiello et al. [17] aimed to perform dural puncture before the epidural technique for labor analgesia, suggesting that it would make the block more rapid and more intense than the classic epidural technique. This study and the CSE technique, together with our study, confirm the conclusion that it is safe to perform the epidural technique at the same level as that of the ADP, taking into consideration the precautions taken with classic spinal, epidural, and CSE techniques.

There are reported cases of total spinal anesthesia with epidural test doses, with epidural anesthesia, and with the CSE technique [19],[20],[22], but these reported cases were very few. Continuous monitoring is important to identify and detect such complications and react well in the proper time. This practice should be extended to the technique of epidural anesthesia at the same level as that of ADP.

Moreover, the epidural technique at the site of ADP might be preferred than at another level. This might be evident in this research by the fewer retrials and less time required to identify the epidural space at the site of ADP (P < 0.05; [Table 2]). The average time required to identify the epidural space was significantly shorter (P < 0.05) in group S (1.8 ± 0.8 min) than in groups A and B (3.4 ± 1.7 and 3.5 ± 1.8 min, respectively). This might be explained by the fact that when dural puncture occurred, the needle certainly passed through the epidural space into the subarachnoid space; that is, the needle was in the same plane as the epidural space. Thus, the epidural space could be reidentified easily. However, on entering another space, the needle might be away from the proper plane to reach the epidural space. Thus, more time might be required to reach and reidentify the epidural space. Of course, this was in addition to the time spent to infiltrate local anesthesia at the new site of skin puncture by an epidural needle.

Backache was significantly less in group S than in the other groups. This might be because of puncture of the skin by the epidural needle in more than one site with more trials to identify the epidural space in the other groups [Table 4]. Incidences of headache, nausea, and vomiting were comparable in all the groups studied. Although we used the large-bored epidural Tuohy needle, the incidence of headache was not greater than that reported with spinal, epidural, and CSE techniques [6],[11],[23],[24],[25]. Sadashivaiah and McLure [26] reported that an 18-G Tuohy needle can reduce the incidence of severe post dural puncture headache. Cappiello et al. [17], in their study of the 'dural puncture epidural' technique, recorded no case of postdural puncture headache in 80 patients. The relatively lower incidence of headache in our study might be attributed to several mechanisms. Injection of the anesthetic drug into the subarachnoid space increases the pressure difference between epidural and subarachnoid spaces in favor of leakage into the epidural space, whereas injection of the anesthetic drug into the negative epidural space reduces the pressure difference and thus minimizes CSF leakage [27]. This might be the principle behind the use of epidural saline and/or local anesthetics to reduce the rate of CSF loss and consequently treat postdural puncture headache [3],[28],[29],[30]. Another explanation is that the saline may induce an inflammatory reaction within the epidural space, promoting closure of the dural perforation. Also, damage to adjacent tissues by the blunt 18-G Tuohy needle tip might induce an inflammatory response facilitating closure of the dural defect and preventing persistent CSF leakage [14],[27],[31]. Consequently, CSF leakage would be expected to be more in case of spinal anesthesia than in case of epidural anesthesia with dural puncture. However, further studies are needed to confirm this finding and this explanation.

The limitations of our study were the relatively small number of cases studied (because of limited cases available) and that this was a was a single-center study. Thus, further multicenter studies need to be carried out.

It is our recommendation that a local anesthetic test dose should be administered before the injection of a larger bolus of epidural anesthetic solution. This and constant monitoring by the anesthesiologist are the most effective recommended safety measures when reattempting epidural anesthesia at the same level as that of ADP.


  Conclusion Top


Epidural injection of local anesthetics at the level of ADP was as safe as injection at a level above or below. Moreover, it was easier and required less time, with less frequency and severity of backache.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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