Doo A Ram, Shin Yu Seob, Choi Jin-Wook, Yoo Seonwoo, Kang Sehrin, Son Ji-Seon
Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, South Korea.
Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea,
J Pain Res. 2019 May 17;12:1615-1619. doi: 10.2147/JPR.S178640. eCollection 2019.
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.
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.
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.
腰麻-硬膜外联合（CSE）麻醉是一种广泛应用的神经轴索麻醉技术。在临床实践中，针内针法硬膜穿刺失败偶尔会发生，发生率为5%-29%。我们对4例针内针法CSE麻醉硬膜穿刺失败的病例进行了影像学评估。
4例患者接受CSE麻醉进行择期骨科手术。使用针内针法CSE装置以相同方式进行CSE操作。患者侧卧位时，在L4/5间隙中线处插入硬膜外针，采用空气阻力消失法。然后将腰麻针经硬膜外针插入以进行蛛网膜下腔阻滞，但未引出脑脊液。随后，使用C形臂荧光透视进行影像学检查以评估针的位置。我们发现硬膜外针明显偏离中线，在3例患者中，腰麻针穿出硬膜外针时，不是通过侧孔，而是通过Tuohy针的弧度穿出。在1例患者中，当腰麻针插入12 mm时，麻醉医生感觉到针碰到了骨质结构。C形臂X线检查证实腰麻针与第五腰椎的上关节突接触。
硬膜外针旁正中过度偏移可能会影响针内针法CSE技术中的硬膜穿刺。此外，腰麻针错误地通过Tuohy针的弧度而非侧孔穿出，可能导致硬膜穿刺失败。
