Encephalocele and myelomeningocele are congenital defects in the cranium and spine with herniation of contents into an extracranial and extraspinal sac, respectively. The occurrence of encephalocele and myelomeningocele in the same patient has rarely been described in the literature. The anesthetic management of such cases is associated with multiple challenges, which include difficulty in securing the airway, prone positioning, blood loss, electrolyte imbalance, hypothermia, cardiorespiratory disturbances, and perioperative care. The main aims are, to prevent hemodynamic fluctuations and excessive pressure on the sac to avoid premature rupture and manage a possible difficult airway due to the head and neck mass. We report such a rare case to highlight and share our experiences faced during perioperative management of a giant vascular occipital encephalocele with impending rupture and thoracic myelomeningocele requiring surgical excision and repair. Previous similar case reports were also reviewed, and potential perioperative complications were discussed.

Background and aim: There is an unmet need to prolong analgesia duration following regional anesthesia; dexmedetomidine as an adjuvant for the intrathecal block has gained popularity over the last few years. The present study compares the onset, duration of sensory and motor block, postoperative analgesia, hemodynamic changes, and adverse effect of dexmedetomidine or fentanyl as an adjuvant to hyperbaric bupivacaine administered intrathecally.Methods: With approvals, 60 American Society of Anesthesiologists (ASA) physical status I and II adult patients undergoing lower limb surgeries under subarachnoid block were randomized to receive either 5 µg dexmedetomidine (group BD, n=30) or 25 μg fentanyl (group BF, n=30) intrathecally along with 12.5 mg hyperbaric bupivacaine. The time to onset of sensory and motor blockade, time to peak block, intraoperative hemodynamic variations, duration of postoperative analgesia, and associated intraoperative and postoperative complications, if any, were recorded and compared statistically. SPSS v16 (IBM Corp., New York, United States) was used, and P<0.05 was considered significant.Results: The onset of sensory block in group BD was 1.54 ± 0.38 minutes and 3.4 ± 0.40 minutes (P<0.001) in group BF. Time taken for the sensory level to reach T10 in group BD was 3.11± 0.43 minutes and 5.55 ± 0.60 minutes (P<0.001) in group BF. Time taken for two-segment regression in group BD was 160.06 ± 6.85 minutes and 110.4 ± 6.03 minutes (P<0.001) in group BF. The onset of motor block was 2.58 ± 0.437 minutes in group BD and 4.43 ± 0.43 minutes (P<0.001) in group BF. The total duration of analgesia in group BD was 365.8 ± 24.76 minutes and 213.33 ± 20.19 minutes (P<0.001) in group BF. Minimum intraoperative hemodynamic variations were found in group BD, and two groups had comparable side effects. Conclusion: Dexmedetomidine 5 μg added to intrathecal bupivacaine produced early-onset and prolonged block compared with fentanyl 25 μg. No significant attributable adverse effects were noted for both the drugs except the fall in blood pressure, which was gradual in dexmedetomidine but a steep fall in fentanyl.