25 years of experience, thousands of caudal blocks, and no dural puncture. What happened today?

Abstract

25 years of experience, thousands of caudal blocks, and no dural puncture. What happened today? SIR-A single administration of local anesthetic via the caudal space is an easy, simple, and safe way to provide postoperative analgesia. We report a case of a caudal block, previously uneventful, now complicated by dural puncture. Case reportThe patient is a 7-year-old boy, 19.4 kg, body surface area 0.77, with a history of posterior urethral valves, status post vesicostomy, scheduled for re-ablation of valves and vesicostomy closure. In the past he underwent an uneventful caudal block for vesicostomy revision and a transversus abdominis plan block for repair of right inguinal hernia. There was no concern about any lumbosacral spinal dysraphism.After induction of general anesthesia with 8% sevoflurane, placement of an intravenous catheter, and endotracheal intubation, the patient was positioned with his left side up and his hips, knees, and neck flexed. After proper disinfection of the skin, a pediatric anesthesiologist with 25 years of experience attempted the caudal injection. After palpating both sacrum cornua and sacrum hiatus, a 20-gauge angiocath (Introcar Safety 20G x1-

Regional Anesthesia in Patients With Preexisting Neurologic Disease

“…127,128 Dural ectasia is also known to occur in patients with Patau syndrome (trisomy 13), 129 Ehlers-Danlos syndrome, neurofibromatosis type I, and ankylosing spondylitis. 130 Several case reports have described inadvertent dural puncture during caudal anesthesia 129,131,132 and incomplete spinal anesthesia 133 in patients with dural ectasia.…”

Anatomical Investigations for Appropriate Needle Positioning for Thoracic Paravertebral Blockade inChildren

“…17 The use of ultrasound in nerve blockade procedures can increase the success rate, shorten the duration of the block and reduce the use of local anaesthetics, so as to decrease the rate of anaesthesia-associated complications. 18 – 22 The use of ultrasound is strongly recommended for peripheral blockade in children and infants. 23 Even though it is expected to be beneficial, the justification for peripheral blockade is, however, limited in the case of neuroaxial block for which the target nerve is not directly visible.…”

Ultrasound determination of the dural sac to sacrococcygeal membrane distance in premature neonates

“…Ultrasound is used to image neuraxial anatomy in infants through unique acoustic windows generated by a lack of skeletal maturity. Ultrasound has been used to identify low lying dural sacs 6 7. Visualization of the neonatal sacral anatomy improves caudal success rates but no systematic studies have determined the feasibility of locating the dural sac using real-time imaging 8 9.…”