Decrease in the incidence of post-dural puncture headache: maintaining CSF volume

The incidence of epidural needle-induced post-dural puncture headache (PDPH) in parturients following dural puncture with a large bore (18-gauge) needle has been reported to range 76-85%. We describe seven cases in which the performance of epidural anesthesia in parturients was complicated by an unintentional dural puncture with an 18-gauge epidural needle. In all seven cases, the unintentional dural puncture was followed by (i) injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, (ii) insertion of a epidural catheter into the subarachnoid space (now referred to as an intrathecal catheter), (iii) injection of a small amount of preservative free saline (3-5 ml) into the subarachnoid space through the intrathecal catheter, (iv) administration of bolus and then continuous intrathecal labor analgesia through the intrathecal catheter and then (v) leaving the intrathecal catheter in-situ for a total of 12-20 h. PDPH occurred in only one of these cases (14%).     

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery

Purpose

We investigated whether inserting an intrathecal catheter and leaving it in place for 24 h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH).

Methods

The study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004–March 2006

Results

In phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48 h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection.

Conclusion

Inserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24 h significantly reduces the incidence of PDPH.     

Accidental dural puncture,postdural puncture headache,intrathecal catheters,and epidural blood patch: revisiting the old nemesis

One of the controversial management options for accidental dural puncture in pregnant patients is the conversion of labor epidural analgesia to continuous spinal analgesia by threading the epidural catheter intrathecally. No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. To investigate whether the intrathecal placement of an epidural catheter following accidental dural puncture impacts the incidence of postdural puncture headache (PDPH) and the subsequent need for an epidural blood patch in parturients. A retrospective chart review of accidental dural puncture was performed at Hutzel Women’s Hospital in Detroit, MI, USA for the years 2002–2010. Documented cases of accidental dural punctures (N = 238) were distributed into two groups based on their management: an intrathecal catheter (ITC) group in which the epidural catheter was inserted intrathecally and a non-intrathecal catheter (non-ITC) group that received the epidural catheter inserted at different levels of lumbar interspaces. The incidence of PDPH as well as the necessity for epidural blood patch was analyzed using two-tailed Fisher’s exact test. In the non-ITC group, 99 (54 %) parturients developed PDPH in comparison to 20 (37 %) in the ITC [odds ratio (OR), 1.98; 95 % confidence interval (CI), 1.06–3.69; P = 0.03]. Fifty-seven (31 %) of 182 patients in the non-ITC group required an epidural blood patch (EBP) (data for 2 patients of 184 were missing). In contrast, 7 (13 %) of parturients in the ITC group required an EBP. The incidence of EBP was calculated in parturients who actually developed headache to be 57 of 99 (57 %) in the non-ITC group versus 7 of 20 (35 %) in the ITC group (OR, 2.52; 95 % CI, 0.92–6.68; P = 0.07). The insertion of an intrathecal catheter following accidental dural puncture decreases the incidence of PDPH but not the need for epidural blood patch in parturients.     

Hématome sous durai bilatéral après analgesie péridurale

Purpose

The authors report a case of bilateral subdural hematoma (SDH) which occurred following epidural analgesia for labour, complicated by post durai puncture headache (PDPH). Physiopathological mechanisms are discussed.

Clinical features

A 27-yr-old woman displayed typical PDPH following epidural anaesthesia. On the fifth day she was given a blood patch (BP) which proved immediately effective. Further developments were marked by late recurrence of PDPH and by administration of a second BP on the 24th day. With the aggravation of the headaches, the disapearance of their postural nature and with the appearance of transitory focal neurological signs on the 30th day, a CT-Scan was done and showed bilateral subdural haematoma. Following surgical drainage, the patient made an uneventful recovery.

Conclusion

The presence of PDPH complicated by a typical neurological deterioration should prompt the anaesthetist to seek an immediate clinical and x-ray diagnosis in order to look for the existence of intracranial complications.     

North American survey of the management of durai puncture occurring during labour epidural analgesia

Purpose

To document the range and the most common strategies for the management of the parturient with inadvertent durai puncture (DP) during labour epidural analgesia.

Methods

A confidential survey form was mailed to 46 academic units in Canada and USA. The responses were compiled into Canadian, US and joint North American databases.

Results

Thirty-six centres (78%) responded, representing 137,250 annual deliveries. The reported incidence of DP was 0.04–6%. The most common initial response to DP was re-siting the catheter at another level, Most centres made little change in routine practice regarding epidural top-ups and infusion rates after DP. Unrestricted mobilisation was advocated by 86% of centres following delivery; enhanced oral hydration was encouraged by 61%. Prophylactic epidural blood patch (PEBP) was recommended by 37% of centres, with twice as many US as Canadian centres doing so. In the presence of PDPH, EBP was offered most commonly at or within 24 hr of diagnosis. Complications were common after EBP: 86% of centres reported patch failures; 44% reported persistent headache after ≥2 EBP. Despite this, centres remained optimistic about EBP success, quoting cure rates >90% in 58% of centres.

Conclusion

There is little difference between the practices reported by Canadian or US centres. The expressed optimism regarding the efficacy of EBP is not supported by the evidence available and may be unwarranted. More research is needed to define the issue better.     

The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.     

Injection of intrathecal normal saline in decreasing postdural puncture headache

Purpose

Postdural puncture headache (PDPH) is the most common and still unresolved postoperative complication of spinal anesthesia. Although there are several positive results of intrathecal saline injection for the treatment of PDPH and prophylaxis after accidental dural puncture, the effect of deliberate intrathecal saline injection before spinal anesthesia has not been examined. The objective of our study was to evaluate the effect of prophylactic administration of intrathecal normal saline in decreasing PDPH.

Methods

One hundred healthy women (ASA physical status I) of age between 18 and 35 years scheduled for elective term cesarean delivery under spinal anesthesia were included. Patients were randomly divided into two equal groups. Group C received 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 % as a control, and group S received intrathecal normal saline 5 ml before intrathecal injection of 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 %. The incidence and severity of PDPH were assessed after 48 h and again 3–7 days after operation.

Results

Basal characteristics were statistically similar in both groups (P > 0.05). The incidences of moderate and severe PDPH during first postoperative 48 h were not different between the groups (P = 0.24). However, the frequency of PDPH after 3–7 days was statistically higher in group C in compared with group S (16 vs. 2 %, P = 0.03). Totally the frequency of PDPH was higher in group C (24 vs. 2 %, P = 0.002).

Conclusion

Administration of normal saline (5 ml) before intrathecal administration of hyperbaric bupivacaine as a preventive approach is an effective and simple way to minimize PDPH in patients undergoing cesarean section.     

PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies

PURPOSE: Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency, onset, and duration of PDPH. METHODS: Citations on PDPH in the obstetrical population were identified by computerized searches, citation review, and hand searches of abstracts and conference proceedings. Citations were included if they contained extractable data on frequency, onset, or duration of PDPH. Using meta-analysis, we calculated pooled estimates of the frequency of accidental dural puncture for epidural needles and pooled estimates of the frequencies of PDPH for epidural and spinal needles. RESULTS: Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to 1.5%) risk of accidental dural puncture with epidural insertion. Of these, approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk of PDPH from spinal needles diminishes with small diameter, atraumatic needles, but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%). PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days. CONCLUSION: PDPH is a common complication for parturients undergoing neuraxial blockade.     

Unilateral trigeminal and facial nerve palsies associated with epidural analgesia in labour

Purpose To report a rare complication related to epidural analgesia for obstetrics: the association of unilateral trigeminal and facial nerve palsies in a patient with the clinical syndrome of intracranial hypotension.

Clinical features

A 38-yr-old woman was admitted in pre-term labour (at 35 wk gestation). She was receiving 40 mg methadonepo daily for opioid addiction. Epidural analgesia for labour was established with 9 ml bupivacaine 0.25%. The patient underwent normal vaginal delivery of a 2500 g female infant. She developed post-dural puncture headache (PDPH) on the third postpartum day which was managed by palliative measures: bed rest (patient’s position of choice), increased hydration (water: 3 litrespo per day), lysine acetyl salicylate (5.4 gpo per day) and caffeine (600 mgpo per day). She developed paraesthesiae and numbness of the right side of the face one day after the onset of PDPH and unilateral facial nerve palsy two days later. There was no evidence of durai puncture and no cause was found. Treatment of the nerve palsies with epidural blood patch or epidural dextran 40 was not considered to be indicated. Headache disappeared on the 10th postpartum day and trigeminal palsy regressed. At the time of discharge, on the 17^th postpartum day, neurological examination showed minimal facial assimetry. The patient refused further exploration and follow-up.

Conclusion

Post delivery trigeminal and facial nerve palsy in a 38 yr old woman recovered spontaneously with conservative therapy.     

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

Purpose  To investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36–72 h affected the incidence of post-dural puncture headache (PDPH). Methods  The records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle. Results  The study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively). Conclusion  Subsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36–72 h may reduce the incidence of PDPH.     

The management of accidental dural puncture and postdural puncture headache: a North American survey

Study Objective

To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America.

Design

Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP).

Setting

University hospital.

Measurements

In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up.

Main Results

Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset.

Conclusions

Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.     

Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post–dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n=17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n= 13) patients had an immediate conversion to spinal anaesthesia and received post–caesarean section continuous intrathecal patient–controlled analgesia consisting of fentanyl 5 (ig'ml^-1 with bupivacaine 0.25 mg·ml^-1 and epinephrine 2 μg·ml^-1 with catheterization lasting >24 h. No parturient in group III developed a PDPH. This was substantially lower ( P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.     

The injection of intrathecal normal saline reduces the severity of postdural puncture headache

BACKGROUND AND OBJECTIVES: We investigated whether the injection of 10 mL of normal saline into the subarachnoid space following accidental dural puncture reduced the incidence of postdural puncture headache (PDPH) and the need for epidural blood patch (EBP). METHODS: Twenty-eight patients who experienced accidental dural puncture with an epidural needle had 10 mL of normal saline injected into the subarachnoid space. In 22 patients, the injection was performed immediately through the epidural needle. In 6 patients who had intrathecal catheters placed through the epidural needle, the saline was injected through the catheter before removal. All other patients who experienced wet taps during the same period that the study was in progress but did not receive the saline injection served as a control group, 26 in number. Patients with severe or persistent PDPHs were treated with EBP. RESULTS: Of those patients who received intrathecal normal saline immediately through the epidural needle, 32% developed a headache compared with 62% of controls. Of these, 1 patient who received saline required EBP compared with nine in the control group (P =.004). Of those patients who had intrathecal catheters placed, there were no headaches in the saline group of 6 compared with 3 in the control group of 5, 1 of whom was treated with EBP (P >.05). CONCLUSIONS: The immediate injection of 10 mL intrathecal normal saline after a wet tap significantly reduced the incidence of PDPH and the need for EBP. When an intrathecal catheter had been placed following a wet tap, injection of 10 mL of normal saline before its removal effectively prevented PDPH.     

Management of postdural puncture headache

Postdural puncture headache (PDPH), a complication of regional anesthesia, is not infrequently seen in parturients because of their inherent risk from young age and female gender. With spinal anesthesia, the risk of PDPH is mainly dependent on the size and type of needle and can be reduced with the use of small-gauge, pencilpoint spinal needles. For unintentional dural puncture with epidural needles, a prophylactic epidural blood patch can reduce the risk of PDPH. Other potentially efficacious maneuvers include insertion of an intrathecal catheter and avoidance of second- stage pushing. Treatment of PDPH includes the use of caffeine or an epidural blood patch. Other pharmacologic interventions (eg, theophylline, sumatriptan, adrenocorticotropic hormone) and epidural administration of saline or dextran 40 await further investigation. The evidence for these interventions is discussed in this review. Copyright © 2001 by W.B. Saunders Company     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after inadvertent dural puncture during epidural insertion. PDPH typically develops 24–48 hours post-puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. At the time of inadvertent dural puncture (IDP) one may insert an intrathecal catheter, re-site the epidural or use alternative analgesia. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Epidural blood patch (EBP) remains the gold standard treatment of PDPH.     

Accidental dural puncture: Combination of prophylactic methods to avoid post-dural puncture headache

Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effective treatment of PDPH. Prophylactic BP has shown its efficacy to prevent PDPH; nevertheless, this method may be insufficient. We report an ADP case before induction of labor in a 28-year-old parturient. To avoid PDPH, an intrathecal catheter was immediately inserted after ADP and an epidural catheter was also inserted at the interspace above. Catheters were kept in place for more than 24 hours. A prophylactic BP was performed immediately after removal of the intrathecal catheter. The patient did not experience any headache. This combination of treatments (intrathecal catheter insertion + prophylactic BP) may be a good alternative approach to prevent PDPH, even if it has to be warranted by other clinical studies.     

Combined spinal-epidural analgesia in advanced labour

The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid — low-dose local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often difficult to achieve. The technique was evaluated in an open-label, non-randomized trial using parturients in advanced, active labour for the provision of pain relief during the late first stage and second stage of labour. Thirty-eight term parturients in active, advanced labour received a spinal injection of bu-pivacaine 2.5 mg and sufentanil, 10 μg, via a 25- or 27-gauge Whitacre needle placed into the subarachnoid space through a 17- or 18- gauge Weiss epidural needle which had been placed into the epidural space. This was followed by placement of an epidural catheter for supplemental analgesia if required. Onset of analgesia was noted by asking patients if their contractions were comfortable. Motor blockade was assessed using the Bromage criteria. Patients were asked if they experienced either pruritus or nausea on a four-point scale (none, mild, moderate, severe). The mean cervical dilatation at placement of the spinal medication was 6.1 ± 2.2 cm. Thirty-two patients had spontaneous vaginal delivery, two were delivered by outlet forceps, and four by Caesarean section. Onset of analgesia was rapid (< five minutes) in all cases. Twenty-three patients (60%) delivered vaginally with no additional anaesthetic. The remaining 15 had supplemental local anaesthetic given via the epidural catheter, a mean of 123 ± 33 min after the original spinal dose. Side effects were limited to pruritus in eight (21%) patients, and mild lower extremity motor weakness in one patient. One patient experienced transient hypotension. No patient developed postdural puncture headache. This technique allows for profound analgesia with a rapid onset and few bothersome side effects. In particular, the absence of motor blockade may facilitate maternal expulsive efforts or positioning during the second stage of labour.     

Treatment of accidental dural puncture during obstetric epidural analgesia

OBJECTIVE: To assess the effectiveness of continuous intrathecal analgesia as prophylaxis for postdural puncture headache (PDPH) and for analgesia during labor in 12 patients who suffered accidental dural puncture. PATIENTS AND METHODS: A total of 920 patients who received spinal analgesia during labor were enrolled. Group A (no accidental dural puncture) received a single dose of 10 mL of 0.2% ropivacaine, and 5 minutes later continuous epidural infusion of 0.125% ropivacaine and 3 micromg mL(-1) was started at a rate of a 5 mL h(-1); a 5 mL bolus dose was allowed every 20 minutes if needed. In patients who suffered accidental dural puncture (Group B) we inserted an intrathecal catheter to administer an initial dose of 3 mL of 0.2% ropivacaine and the same analgesic mixture at the same dose as was administered in Group A. Patient characteristics, analgesic efficacy, duration of labor and delivery, motor blockade, analgesic volume, and incidence of PDPH were recorded. The Student t test was used for statistical comparisons. RESULTS: No significant differences in duration of labor and delivery, analgesic efficacy, or motor blockade were observed. The incidence of PDPH was 16.6% in Group B and 0.33% in Group A. The patients in Group B required more additional bolus doses: 10 (SD, 2) in Group B and 3 (1.25) in Group A (P<0.01). CONCLUSIONS: Continuous intrathecal analgesia after accidental dural puncture was a safe way to provide analgesia during labor and to reduce the expected incidence of PDPH.     

Reversal of high spinal anesthesia with cerebrospinal lavage after inadvertent intrathecal injection of local anesthetic in an obstetric patient

Purpose

High or total spinal anesthesia commonly results from accidental placement of an epidural catheter in the intrathecal space with subsequent injection of excessive volumes of local anesthetic. Cerebrospinal lavage has been shown to be effective at reversing the effects of high/total spinal anesthesia but is rarely considered in obstetric cases. Here, we describe the use of cerebrospinal lavage to prevent potential complications from high/total spinal anesthesia after unintentional placement of an intrathecal catheter in a labouring obstetric patient.

Clinical features

A 34-yr-old female presented to the labour and delivery unit in active labour. Epidural anesthesia was initiated, and after the first bolus dose, the patient experienced lower extremity motor block and shortness of breath. A high spinal was confirmed, and cerebrospinal lavage was performed. In total, 40 mL of cerebrospinal fluid (CSF) were exchanged for an equal volume of normal saline. The patient’s breathing difficulties and motor block resolved quickly, and a new epidural catheter was placed after removal of the spinal catheter. Pain control was effective, and the patient delivered a healthy baby.

Conclusion

We show that exchange of CSF for normal saline can be used successfully to manage a high spinal in an obstetric patient. Our results suggest that CSF lavage could potentially be an important and helpful adjunct to the conventional supportive management of obstetric patients in the event of inadvertent high or total spinal anesthesia.     

High quality labour analgesia using small gauge epidural needles and catheters

PURPOSE: Inadvertent epidural needle punctures represent the leading cause of severe postdural puncture headache (PDPH) in parturients. Use of small gauge (G) epidural needles for continuous analgesia has received little attention despite possible important reductions in PDPH. We report the first study to examine the feasibility of using small G Tuohy needles and 23 G catheters for labour analgesia. METHODS: Healthy parturients 30 min), recognized dural puncture, PDPH, patient assessment of analgesia within 24 hr of delivery, complications and anesthesiologist satisfaction. RESULTS: Twenty-seven parturients were recruited. Successful blocks were initiated and maintained in 24/27 who rated overall analgesia from good to excellent (19/24 very good to excellent). Three block failures occurred at the initiation phase only (two unilateral, one absent). There was no evidence of catheter kinking after placement. One patient developed PDPH after unrecognized dural puncture which was self-treated with acetaminophen for four days, followed by complete symptom resolution. CONCLUSION: It is feasible to provide high quality labour analgesia using small G epidural needles and catheters. The effect of small G epidural needles on PDPH warrants future study.