Inadvertent Dural Puncture during Caudal Approach by the Introducer Needle for Epidural Adhesiolysis Caused by Anatomical Variation

Abstract

There have been reports of abnormalities in the lumbosacral region involving a lower-than-normal termination of the dural sac, which is caused by disease or anatomical variation. Inadvertent dural puncture or other unexpected complications can occur during caudal epidural block or adhesiolysis in patients with these variations, but only a small number of case reports have described this issue. We report a case of dural puncture by the introducer needle before attempting caudal epidural adhesiolysis, which occurred even though the needle was not advanced upward after penetrating the sacrococcygeal ligament. Dural puncture was caused by a morphological abnormality in the lumbosacral region, with no pathological condition; the dural sac terminal was located more distally than normal. However, dural puncture could have been prevented if we had checked for such an abnormality in the magnetic resonance imaging (MRI) taken before the procedure.

Does the Use of Epiduroscopic Lysis of Adhesions Reduce the Need for Spinal Cord Stimulation in Failed Back Surgery Syndrome? A Short‐Term Pilot Study

“…Accidental dural punctures occurred in 5 of 35 cases (14%) in our study, which is a higher incidence that that observed after epidural anesthesia in laboring women, which varies between 0.2% and 6.6% . This may be attributed to abnormalities in the sacral vertebrae, caused by disease or anatomical variation, resulting in a lower‐than‐normal termination of the spinal cord and dural sac with ADP occurring due to the placement of the introducer needle via the caudal approach …”

“…11,12 This may be attributed to abnormalities in the sacral vertebrae, caused by disease or anatomical variation, resulting in a lower-than-normal termination of the spinal cord and dural sac with ADP occurring due to the placement of the introducer needle via the caudal approach. 13 This pilot study has weaknesses such as its retrospective nature, the small study sample, and the relatively short duration of follow-up. Five patients were lost to follow-up, mainly because our center was the only center in Belgium to perform epiduroscopic lysis of adhesions, and patients sometimes lived far away from the center.…”

The Termination Level of the Dural Sac Relevant to Caudal Epidural Block in Lumbosacral Transitional Vertebrae: A Comparison between Sacralization and Lumbarization Groups

“…During the caudal approach, it is also necessary to know the distance between the apex of the hiatus and the end of the DS for deterwww.painphysicianjournal.com mining the length of the needle to be introduced into the canal (5,7,8). Aggarwal et al (9) found the mean distance between the apex of the hiatus and the end of the DS to be 31.6 ± 12 mm (range 5.76 -60.0 mm).…”

“…Caudal epidural block (CEB) is a relatively safe procedure which is used in a wide range of clinical settings (5)(6)(7)(8). It is used for intra and postoperative analgesia in a variety of operations and has become one of the most commonly performed interventions in pain practice for those with low back pain and radiculopathy.…”

“…Although it is rare, the potential complication of dural puncture during CEB could occur. Therefore, determining the anatomical location of the sacral hiatus, the sacrococcygeal ligament, and the level of termination of the dural sac (DS) are essential before performing CEB, to prevent dural puncture (7)(8)(9). In this context, the questions could arise whether the termination level of the DS of LSTV patients would be significantly different from that of others with similar clinical symptoms and furthermore, within the LSTV group, the caudal level of the DS would be different based on the type of transitional segment-sacralization and lumbarization.…”