Background: Among the complications of the epidural technique there is the subdural blockade (SB) and cannulation of subdural space1, with a prevalence of 0.02% and low diagnostic rate. We present the case of a woman with SB who gave birth and had definitive radiological diagnosis after clinical suspicion.

Case Report: 32 years-old woman in labor requesting epidural analgesia. We performed a single atraumatic puncture with Tuohy 18G needle, administering test dose with 3 ml of 0.25% bupivacaine (7.5 mg) with vasoconstrictor; no hemodynamic or blockade response. Then a total dose of 10 ml, 9ml 0.125% Levobupivacaine (LVB 11.25 mg) + 1 ml fentanyl (50 mcg), is administered fractionally. After five minutes, physical examination shows paralysis of both legs (Bromage scale 3), without motor deficit in upper limbs, pain and temperature abolished to T3-T4 level, also hypotension; no respiratory distress. We delay continuous infusion of LVB and observe the regression of the clinical symptoms to avoid other complications (mainly neurological or cardiac). Painless childbirth after 110 minutes without more analgesic requirements. The patient recovers mobility in lower limbs 15 minutes after labor and no headache appears on successive days. NMR confirms the diagnosis with “railroad track”2 image.

Discussion:The handling of the case was correct; the patient was diagnosed soon and the appropriate safety measures were prepared to cope with possible complications in the delivery room (general anesthesia with intubation devices, lipid emulsion, etc.). Characteristics of sensitive blocking are: short duration, large, asymmetrical, patched, with cephalic progression. Motor blockade is variable, limited, with short duration. SB could produce sympathetic blockade with Horner syndrome or alterations of II and IV cranial nerves. The Hoftman and Ferrante criteria are used for diagnosis.

References: 1. Hoftman N.Anesthesiol Clin. 2011 Jun;29(2):279-90. doi: 10.1016/j.anclin.2011.04.002. Epub 2011 May 5. 2. Hoftman NN.Reg Anesth Pain Med. 2009 Jan-Feb;34(1):12-6. doi: 10.1097/AAP.0b013e31819339cf. 

Learning points: 1-SB is clinically heterogeneous. 2-Clinical suspicion with radiological definitive diagnosis2. 3-If suspected, we should dose volume,concentration and time lapses of the anesthetics administered. 4-Do not confuse SB with total spinal blockade. 5-Clinical follow-up is important after complications, always guided by the pain specialist.

05 / Accidental subdural catheterization after epidural technique for analgesia during labor. About a case.