Anesth Pain Med.  2017 Apr;12(2):137-139. 10.17085/apm.2017.12.2.137.

Failure after cerebrospinal fluid flow and success after no cerebrospinal fluid flow during spinal anesthesia induction for intrapartum cesarean section: A report of two cases

• Yoon HJ
• Do SH
• Kim KI

• KMID: 2379733
• DOI: http://doi.org/10.17085/apm.2017.12.2.137

Abstract

We report on failed spinal anesthesia (SA) after free flow of cerebrospinal fluid (CSF) and successful SA after no free flow of CSF in SA for laboring parturients undergoing emergency cesarean section (CS). We introduced a 25-gauge Sprotte type spinal needle for anesthesia for case 1 and confirmed backflow and aspiration of CSF. We injected 10 mg bupivacaine plus 15 µg fentanyl. However, sensory and motor block were not observed. During SA for case 2, a convincing dural "pop" was felt but without flow of CSF. Injection of 10 mg bupivacaine and 15 µg fentanyl produced successful sensory and motor block suitable for CS. The failure or success of SA in these intrapartum CS cases ran contrary to our expectations and could be related to the use of pencil-point needle and movement of the dura mater during labor.

Keyword

Cerebrospinal fluid; Cesarean section; Spinal anesthesia

MeSH Terms

Anesthesia
Anesthesia, Spinal*
Bupivacaine
Cerebrospinal Fluid*
Cesarean Section*
Dura Mater
Emergencies
Female
Fentanyl
Needles
Pregnancy
Bupivacaine
Fentanyl

Figure

• 

  Fig. 1 Possible position of the side hole of the pencil-point spinal needle. The hole is located in the subarachnoid space when the free flow of CSF is checked during induction of spinal anesthesia (A). Due to the epidural space pressure increase and ventral movement of the dura associated with increased labor pain (arrow), the side hole of the needle is located in the epidural or subdural space during injection of local anesthetics (B).

• 

  Fig. 2 Possible position of the tip and side hole of the pencil-point spinal needle. The tip of the needle is located in the subarachnoid space, but the side hole is outside of the subarachnoid space when the free flow of CSF is checked during spinal anesthesia induction with ventral movement of the dura due to the epidural space pressure increase (arrow) (A). Due to the epidural space pressure decrease and dorsal movement of the dura associated with reduced labor pain, the side hole of the needle is located in the subarachnoid space during injection of local anesthetics (B).

Reference

1. Jeon JY, Do SH, Lee IH, Jee YS, Park SI, Yoon HJ. Effectiveness of spinal anesthesia after epidural labor analgesia versus spinal anesthesia only for intrapartum cesarean section. Anesth Pain Med. 2015; 10:203–7. DOI: 10.17085/apm.2015.10.3.203.

2. Fettes PD, Jansson JR, Wildsmith JA. Failed spinal anaesthesia:mechanisms, management, and prevention. Br J Anaesth. 2009; 102:739–48. DOI: 10.1093/bja/aep096. PMID: 19420004.

3. Shah JL. Influence of cerebrospinal fluid on epidural pressure. Anaesthesia. 1981; 36:627–31. DOI: 10.1111/j.1365-2044.1981.tb10329.x. PMID: 7270833.

4. Messih MN. Epidural space pressures during pregnancy. Anaesthesia. 1981; 36:775–82. DOI: 10.1111/j.1365-2044.1981.tb08815.x. PMID: 7294338.

5. Corli O, Grossi E, Roma G, Battagliarin G. Correlation between subjective labour pain and uterine contractions:a clinical study. Pain. 1986; 26:53–60. DOI: 10.1016/0304-3959(86)90173-9.

6. Ramachandran K, Ponnusamy N. Dry tap and spinal anesthesia. Can J Anaesth. 2005; 52:1104–5. DOI: 10.1007/BF03021615. PMID: 16326686.

7. Stovring J, Saksanen SJ, Fernando LT, Roberson GH. Successful myelography after dry spinal puncture. Radiology. 1982; 143:265–6. DOI: 10.1148/radiology.143.1.7063738. PMID: 7063738.