References 1. Thomsen MN, Schneider U, Weber M, Johannisson R, Niethard FU. Scoliosis and congenital anomalies associated with KlippelFeil syndrome types I–III. Spine 1997;22:396–401. 2. Clarke RA, Catalan G, Diwan AD, Kearsley JH. Heterogeneity in Klippel-Feil syndrome: a new classification. Pediatr Radiol 1998;28:967–74. 3. Mayayo Sinue´s E, Soriano Guille´n AP, Larrosa Martı´nez R, Angulo Hervı´as E. Traumatic spinal injury in Klippel-Feil syndrome. Rev Clin Esp 2009;209:258–9. 4. Frova G. Do video laryngoscopes have a new role in the SIAARTI difficult airway management algorithm? Minerva Anestesiol 2010;76:637–40. 5. Shippey B, Ray D, McKeown D. Use of the McGrath videolaryngoscope in the management of difficult and failed tracheal intubation. Br J Anaesth 2008;100:116–9. 6. Jepsen CH, Ga¨tke MR, Thøgersen B, et al. Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios: a randomised controlled manikin study. Eur J Anaesthesiol 2014;31:131–6. 7. Kavanagh T, Jee R, Kilpatrick N, Douglas J. Elective cesarean delivery in a parturient with Klippel-Feil syndrome. Int J Obstet Anesth 2013;22:343–8. 0959-289X/$ - see front matter

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Spinal subdural haematoma after an epidural blood patch We describe a case of subdural haematoma following accidental dural puncture (ADP) and epidural blood patch (EBP). A 27-year-old patient with premature rupture of membranes requested neuraxial labour analgesia. During insertion of an 18-gauge Tuohy needle ADP occurred. According to institutional protocol, the epidural catheter (side-hole) was inserted intrathecally and labour analgesia provided by continuous spinal infusion. The catheter was left in-situ for 24 h and an infusion of 0.9% sodium chloride was started at 2 mL/h. The next morning the patient was discharged without symptoms of post-dural puncture headache (PDPH). She was advised to contact us if headache occurred. On the fourth postpartum day, she developed a severe frontal headache that worsened while standing and rapidly disappeared on lying flat. Following diagnosis of PDPH, a consultant obstetric anaesthesiologist performed an EBP. The epidural space was identified using loss-of-resistance to saline. Following negative aspiration, 20 mL of autologous blood was injected uneventfully in 5-mL increments. Mild lumbar pressure after the procedure was reported. After lying supine for 2 h she was discharged without headache or back pain. The next day she was contacted by telephone and reported no headache and only mild stiffness in her back. We advised her to contact us again if she developed headache, fever or other neurological symptoms.

International Journal of Obstetric Anesthesia The following day she contacted us complaining of increased back pain and was readmitted. A neurologist was consulted and concluded that the pain was from muscular origin and that imaging was not necessary, and she was sent home. Two days later she was urgently readmitted because of worsening back pain with lumbar muscle spasms radiating to both buttocks and legs. The pain was continuous with intermittent episodes of shooting pain. She had difficulties passing urine and developed a fever to 38°C. Neurological examination revealed full strength and normal sensation in both legs with normal reflexes but mild neck stiffness. She had no signs of urinary retention. Urgent magnetic resonance imaging (MRI) of her spine revealed a large subdural haematoma from levels T8 to L5 with compression of the spinal medulla. A neurosurgical opinion was sought and she was admitted for observation and pain relief. Her symptoms gradually improved over four days. The urinary problems also resolved spontaneously and were attributed to her vaginal delivery. Two weeks later, repeat MRI scan indicated almost complete resolution of the subdural haematoma. Her back pain fully recovered and there was no recurrence of headache. We agree with Rucklidge1 that performing an EBP for all patients with PDPH is non-evidence-based practice for which safety is not questioned enough. There are no randomized controlled trials adequately powered to describe the risks of EBP.1 Back pain, meningitis, arachnoiditis and spinal subdural haematoma have all been described as complications of EBP. The initial dural puncture and the EBP probably both contribute to these complications. Previously, Verduzco et al.2 described a postpartum patient who developed bilateral buttock and lateral thigh pain after an EBP for PDPH, caused by a spinal subdural haematoma extending from L1 to S3. An MRI scan showed no blood in the epidural space. The initial dural puncture had been during spinal anaesthesia for caesarean section using a 25-gauge needle; conservative treatment led to complete recovery. Piercing the dura with the epidural needle and direct injection of autologous blood into the subdural space was previously described by Reynolds et al.3 and is the most plausible hypothesis in our case and that described by Verduzco et al.2 This is supported by the lack of visualisation of blood in the epidural space in the MRI scan and because a relatively small volume of blood (20 mL) could distribute over 10 levels (T8–L5, Fig. 1). Riley et al.4 reported an obstetric patient with a spinal subdural haematoma after a high-volume EBP (58 mL) for PDPH caused by inadvertent dural puncture with a 17-gauge Tuohy needle. Her main complaint was persistent back and right leg pain and mild motor weakness, consistent with L4–L5 radiculopathy. An MRI scan showed two small spinal subdural haematomas. Two weeks after diagnosis, the patient made a full

International Journal of Obstetric Anesthesia


Fig. 1 (A) Sagittal and axial (at level T12) T1 weighted spin-echo images show the subdural haematoma posteriorly in the spinal canal reaching from levels T6 to L5 (arrows). (B) Sagittal T1 weighted spin-echo image shows a significant decrease in the size of the subdural haematoma (arrow)

recovery with conservative therapy. A puncture with a large sized needle can create a communication between the dura and arachnoid that allows movement of blood from the epidural into the subdural space.4 Although EBP is frequently performed for PDPH, it can cause harm and therefore vigilance is required. This emphasizes once more the importance of follow-up of patients with PDPH and the responsibilities of the anaesthesiologist regarding post-EBP care. S. Devroe, M. Van de Velde Department of Anaesthesiology University Hospitals of the KU Leuven, Leuven, Belgium E-mail address: [email protected] P. Demaerel Department of Radiology University Hospitals of the KU Leuven, Leuven, Belgium K. Van Calsteren Department of Obstetrics University Hospitals of the KU Leuven, Leuven, Belgium

References 1. Rucklidge MW. All patients with a postdural puncture headache should receive an epidural blood patch. Int J Obstet Anesth 2014;23:171–4. 2. Verduzco LA, Atlas SW, Riley ET. Subdural hematoma after an epidural blood patch. Int J Obstet Anesth 2012;21:189–92. 3. Reynolds AF, Hameroff SR, Blitt CD, Roberts WL. Spinal subdural epiarachnoid hematoma: a complication of a novel epidural blood patch technique. Anesth Analg 1980;59:702–3. 4. Riley CA, Spiegel JE. Complications following large-volume epidural blood patches for postdural puncture headache. Lumbar subdural hematoma and arachnoiditis: initial cause or final effect? J Clin Anesth 2009;21:355–9. 0959-289X/$ - see front matter

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A novel obstetric table tilt indicator During caesarean section, it is recommended that, until delivery, the parturient is tilted 15° left lateral to reduce aortocaval compression.1 Cardiac output has been shown to decrease by over 20% when less than 15° tilt is used.2 The use of 15° left lateral tilt is common nowadays and evolved from the use of the Crawford Wedge over 40 years ago.3 We recently conducted a quality improvement project at our hospital looking into differences between left lateral tilt as both perceived and measured in a non-clinical environment using an obstetric mannequin. We showed that, in these circumstances at least, staff are poor at estimating tilt angles by eye, confirming findings from previous studies.4,5 In our study, 44 members of staff regularly involved in obstetric surgery were asked to tilt a table to the correct angle for a caesarean section. We found our colleagues achieved tilt angles between 3.3° and 17° with a mean of 8.9° and variance of 7.6°. Participants were asked to estimate the amount of table tilt applied; the mean estimated angle was 21.5°, demonstrating a large discrepancy between perceived and measured angles. This is an important finding as in cases of maternal cardiovascular compromise anaesthetists may discount inadequate table tilt as a cause.4 There seemed to be an unmet need for a means of reliably setting the correct tilt angle, so we developed a cheap and easily reproducible table tilt indicator. A laminated tilt guide with a tracheal tube stylet (outer plastic removed) acting as the pointer together make a cheap and accurate table tilt indicator which both acts as a reminder of the correct tilt angle and provides the means to achieve it easily (Fig. 1). Subsequent data using the indicator showed that the mean angle achieved increased to 14.5° and the variance reduced to 0.58°. Instructions for putting the device together may be found on our website.6

Spinal subdural haematoma after an epidural blood patch.

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