Background:
Accidental dural puncture during epidural insertion is a known complication. The incidence of accidental dural puncture can be up to 0.73% [1]. It is not uncommon for patients to present for emergency lower segment caesarean section (LSCS) following an accidental dural puncture, hence it is important to be prepared for a situation like this.
Case Report:
A 32-year-old, ASA1, primigravida had labour induced at 39 weeks gestation. An intrathecal catheter was inserted post accidental dural puncture during epidural insertion with an 18G Tuohy needle. 14 hours later, it was discovered that the catheter had dislodged. Coincidentally, she had to undergo LSCS for failure to
progress in labour. A single shot spinal was performed. Following a change in resistance felt when the dura was breeched with a 27G Whitacre needle and clear cerebrospinal fluid (CSF) seen, 2.3ml of 0.5% heavy bupivacaine, 15mcg of fentanyl and 100mcg of morphine was given. Subsequently, the patient was only unable to move her hips. There was also a loss of sensation to cold till T4, but she could feel sharp sensation when the incision site was tested with forceps 10 minutes later. The spinal was deemed inadequate for surgery and she was placed under general anesthesia for the surgery. Post operatively, she had no motor weakness and no sensory level.
Discussion
A regional technique is preferred for LSCS, thus it is important to report this case as it may impact the anesthetic technique chosen. Literature search on Pubmed did not review any similar cases. Some reasons postulated for the failure of spinal anaesthesia in our patient includes misleading tactile feel of the change in resistance when piercing the dura. The back flow and positive aspiration from the spinal needle may have been the ropivacaine infused. Another possibility is leakage of local anaesthetic out of the previous dural puncture site. Lastly, the CSF volume could be larger due to intrathecal infusion of ropivacaine, hence our patient received a more diluted spinal dose.
References
1. S.Singh, et al. (2009). Sci. World J. 9, 715-722
Learning points
Awareness of possibility of failed spinal post dural puncture with large bore needles is important. Strategies such as attempting spinal at a different level and insertion of intrathecal or epidural catheter can be used to improve success. General anaesthesia may also be a good first choice.

02 / Is spinal anaesthesia a good plan post dural puncture with a large bore needle? A case report of a failed spinal.