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.     

Intrathecal catheter insertion during labour reduces the risk of postdural puncture headache

Purpose

To describe the anaesthetic management and report the incidence of PDPH in three parturients who had experienced accidental durai puncture during labour and the subsequent deliberate intrathecal insertion of an epidural catheter.

Clinical features

Inadvertent durai puncture with a 16-gauge Tuohy needle occurred during the first stage of labour at 3–4 cm cervical dilatation in all three women. The 20-gauge epidural catheter was immediately inserted into the subarachnoid space after accidental durai penetration. Intermittent intrathecal injections of lidocaine or bupivacaine with fentanyl were administered to provide analgesia during labour and delivery. Two of the women had spontaneous vaginal deliveries, whereas Caesarean section was performed in one case due to acute fetal distress during the second stage of labour. The intrathecal catheter was left in-situ for 13–19 hr after delivery and the women were questioned daily for symptoms of PDPH. None of the three women developed PDPH after dural puncture and intrathecal catheterisation with the epidural catheter.

Conclusion

Immediate intrathecal insertion of the epidural catheter after accidental durai puncture during labour proved to be an effective prophylactic technique to prevent PDPH in these three parturients.     

Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications

BackgroundThe aim of this study was to evaluate labor and delivery outcomes in parturients with inadvertent dural puncture managed by either insertion of an intrathecal catheter or a resited epidural catheter.MethodsThis was a retrospective cohort review of 235 parturients who had an inadvertent dural puncture during epidural placement over a six-year period. The primary outcome was the proportion of women with a delayed second stage of labor. Secondary outcomes were the proportion of cesarean deliveries, the proportion of cases resulting in post-dural puncture headache, and the incidence of failed labor analgesia.ResultsBaseline characteristics such as age, body mass index and parity were similar between the two groups. Among the 236 cases of inadvertent dural puncture, 173 women (73%) had an intrathecal catheter placed while 63 women (27%) had the epidural catheter resited. Comparing intrathecal with epidural catheters, there was no observed difference in the proportion of cases of prolonged second stage of labor (13% vs. 16%, P=0.57) and the overall rate of cesarean deliveries (17% vs. 16%, P=0.78). However, we observed a lower rate of post-dural puncture headache in women who had cesarean delivery compared to vaginal delivery (53% vs. 74%, P=0.007). A greater proportion of failed labor analgesia was observed in the intrathecal catheter group (14% vs. 2%, P=0.005).ConclusionThe choice of neuraxial technique following inadvertent dural puncture does not appear to alter the course of labor and delivery. Cesarean delivery decreased the incidence of post-dural puncture headache by 35%. Intrathecal catheters were associated with a higher rate of failed analgesia.     

Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases

Although epidural anaesthesia and analgesia are widely used in obstetrics, there are no large contemporary prospective series detailing associated complications. Prospective data was collected on all obstetric epidural blocks performed for labour and delivery in a single institution between July 1989 and August 1994. A data entry sheet was compiled and entered onto a computer database. Confidence intervals for proportions were calculated using standard methods. Information from 10 995 epidural blocks was analysed. Epidural analgesia in labour was the primary indication in 7648, and anaesthesia for caesarean section in 3311. Minor complications included failed or abandoned insertion (incidence 0.5%), reinsertion of the epidural catheter (5%), and inadequate anaesthesia (1.7%) or analgesia (0.9%). Three percent were associated with venous puncture and 0.6% with accidental dural puncture. Maternal mortality was zero. Unexpectedly high blocks occurred on eight occasions (0.07%), two requiring intubation and ventilation. Three women (0.06%) experienced mild respiratory depression after postoperative epidural opioid. There was no major local anaesthetic toxicity or neurological deficit. The incidence of potentially life-threatening morbidity was thus 0.02% although in both cases outcome was good. The only persisting complication was neurological, an apparent epidural catheter-induced traumatic mononeuropathy.     

Injecting saline through the epidural needle decreases theiv epidural catheter placement rate during combined spinal-epidural labour analgesia

PURPOSE: To determine if injecting 10 mL saline before epidural catheter threading (pre-cannulation epidural fluid injection) can decrease the incidence of iv epidural catheter placement during combined spinal-epidural (CSE) labour analgesia. METHODS: One hundred healthy women requesting CSE labour analgesia with either fentanyl 20 microg or sufentanil 10 microg were prospectively randomized to receive either no epidural injection (dry group, n = 50) or epidural 10 mL saline injection (saline group, n = 50) before epidural catheter placement. A nylon multiport catheter was then threaded 3-5 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, if the mother became tachycardic after injection of epinephrine 15 microg, or if intracardiac air was heard (using ultrasound) after injection of air 1.5 mL. RESULTS: Intravenous epidural catheter placement occurred in one saline and ten dry group patients (P < 0.01). No complications of excessive cephalad intrathecal opioid spread (i.e., difficulty swallowing, hypoxemia, or respiratory arrest) occurred. CONCLUSIONS: Injecting 10 mL or saline through the epidural needle after intrathecal opioid injection and before threading the catheter significantly decreased accidental venous catheter placement without any apparent increase in complications from excessive cephalad intrathecal opioid spread.     

The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice

The management of accidental dural puncture and postdural puncture headache in obstetric practice continues to be of great interest. This survey aims to explore the current management of this complication in the United Kingdom and compares the findings to a similar survey undertaken in 1993. A postal questionnaire was sent to all maternity units (n = 248). The return rate was 71%. Of these, 144 units (85%) now have written guidelines for the management of accidental dural puncture compared to 58% in 1993. In 47 units (28%), the epidural catheter is now routinely placed intrathecally following accidental dural puncture; in 69 units (41%) the catheter is re-sited and in the remaining 53 units (31%) either option is allowed. This is in contrast to the previous survey, which found that catheters were re-sited in 99% of units. Only 31 units (18%) now limit the second stage of labour and 19 (11%) avoid pushing and deliver by ventouse or forceps, whilst 116 units (69%) allow labour to take place without any intervention. Only 44 units (26%) now treat postdural puncture headache with an epidural blood patch as soon as it is diagnosed, whereas in 120 units (71%) the blood patch is performed only after failure of conservative measures. Due to the large increase in the use of the intrathecal catheter following this complication, a follow-up questionnaire was posted 5 months later to those units (n = 99) that reported this practice in the initial survey, with a 94% response rate. The two most commonly cited reasons for intrathecal catheterisation were to avoid further dural puncture (76%) and to allow immediate analgesia for labour (75%).     

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.     

A comparison of epidural and cerebrospinal fluid glucose in parturients at term: an observational study

BackgroundDetecting inadvertent dural puncture during labour epidural insertion can be difficult when using a loss of resistance to saline technique. Testing fluid for glucose that leaks from a Tuohy needle may confirm the presence of cerebrospinal fluid and infer inadvertent dural puncture. This study compared the glucose content of intrathecal fluid obtained during spinal anaesthesia for elective caesarean delivery with that of fluid from a Tuohy needle or epidural catheter when establishing epidural analgesia for labour.MethodsWomen aged ?18 years undergoing elective caesarean delivery and labouring parturients who requested epidural analgesia were recruited prospectively in a tertiary referral centre over a three-month period. Fluid was collected into a sterile container either during spinal anaesthesia or from a labour epidural needle. Glucose content was evaluated using a bedside blood glucometer and laboratory colorimetric analyzer.ResultsOf the 118 women approached, 115 participated. All 40 women having spinal anaesthesia and 2/75 (2.7%) women having epidural analgesia, in whom inadvertent dural puncture was subsequently confirmed, had fluid samples testing positive for glucose. Median [range] laboratory glucose readings were 2.9 [1.3–5.1] mmol/L for cerebrospinal fluid and <0.3 mmol/L in fluid that leaked from a Tuohy needle (P = 0.0001).ConclusionWhen using a loss of resistance to saline technique for epidural catheter placement, bedside glucometer testing of fluid leaking from the epidural needle may be of value in the early detection of inadvertent dural puncture.     

New developments in epidural anesthesia and analgesia

Several recent advances in epidural anesthesia and analgesia have been reviewed. Perhaps the most exciting area of anticipated future developments relates to the continued development of novel analgesic agents and new epidural delivery systems. There appears to be some movement toward an increased use of intrathecal or peripheral neural blockade techniques for some clinical situations where epidural anesthesia and analgesia have been previously used; however, the ability to provide anesthesia and analgesia to relatively large areas of the body with a single injection or continuous catheter technique without the associated risks of dural puncture and intrathecal catheter placement will continue to assure epidural anesthesia and analgesia techniques a prominent role in anesthesia and pain management.     

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.     

Perispinal analgesia for labour followed by patient-controlled infusion with bupivacaine and sufentanil: combined spinal-epidural vs. epidural analgesia alone

BACKGROUND AND OBJECTIVE: Combined spinal-epidural is an alternative technique to epidural analgesia for labour, but its benefits are not clearly identified. METHODS: A prospective, blinded, randomized study was undertaken involving 113 women attending a university hospital obstetric department. Analgesia was initiated with intrathecal bupivacaine 0.25% 1 mL + sufentanil 5 microg in the combined spinal-epidural group (n = 54), and with bupivacaine 0.125% + epinephrine 2.5 microg mL(-1) + sufentanil 7.5 microg in the epidural group (n = 59). In both cases this was followed by patient-controlled epidural analgesia with bupivacaine 0.125% (+ sufentanil 0.25 microg mL(-1)). Duration of labour, quality of analgesia and side-effects were compared between groups. RESULTS: In the combined spinal-epidural group, the onset of analgesia was faster (5 vs. 15 min, P < 0.001), the consumption of bupivacaine was lower (7.5 vs. 11.3 mg h(-1), P = 0.003) and there was less unilateral analgesia (14.8% vs. 40.7%, P = 0.002) than in the epidural group. The characteristics of labour were similar in both groups. However, in the combined spinal-epidural group, there was a higher incidence of posterior presentation (25.9% vs. 10%, P = 0.03), pruritus (P < 0.001), hypotension (P = 0.002), somnolence (P = 0.01), nausea (P = 0.02) and one case of meningitis. CONCLUSIONS: The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.     

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%).     

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.     

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey

Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post‐dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. Results: The overall response rate was 93%. About 32% (22–47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n≈900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24–48 h. The success rate for EBP was >75% in 67% (62–79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non‐obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non‐obstetric population.     

Improved epidural analgesia in the parturient in the 30° tilt position

PURPOSE: To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30 degree leftward tilt or in the left lateral decubitus position. METHODS: After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30 degree leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted. RESULTS: In the lateral group, 38% required additional medication compared with 24% in the tilt group (P = 0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%), P = 0.035. CONCLUSIONS: Placing the parturient supine with a 30 degree leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.     

Comparison of continuous spinal and epidural analgesia for pain relief in labour

We have compared continuous spinal analgesia with continuous epidural analgesia for pain relief in labour. Twenty-six women were randomly allocated to receive either epidural 0.25% bupivacaine 5-10 ml via a 20 gauge catheter inserted through a 16 gauge Tuohy needle or intrathecal 0.25% bupivacaine 0.5-1.0 ml via a 32 gauge catheter inserted through a 24 gauge Sprotte needle. This was supplemented with fentanyl 5-10 mcg (spinal) or 1 mcg per kg (epidural) if analgesia was unsatisfactory. Outcome was measured by the success and timing of the procedure, time to analgesia, amount of drug given, visual analogue scoring of pain relief by the patient and an observer and degree of motor block. Onset time and dosage were significantly reduced in the continuous spinal group. Two catheters failed to feed in the spinal group. One catheter became displaced in each group. Pain relief was satisfactory in all patients and none had post-dural puncture headache. Continuous spinal analgesia may offer significant advantages over epidural analgesia but technical difficulties remain with the present equipment. The reasons for the withdrawal of the spinal catheters in the United States of America are discussed.     

Comparison of midwife top-ups, continuous infusion and patient- controlled epidural analgesia for maintaining mobility after a low-dose combined spinal--epidural

We studied 133 women given a combined spinal-epidural for analgesia in labour. The initial intrathecal dose contained bupivacaine 2.5 mg with fentanyl 25 micrograms. When the mothers were comfortable, they were allocated randomly to one of three groups: continuous infusion (group Cl, n = 46), midwife top-ups (group MW, n = 43) or patient-controlled epidural analgesia (group PCEA, n = 44), to maintain analgesia throughout labour. All epidural solutions contained 0.1% bupivacaine and fentanyl 2 micrograms ml-1. Motor block was assessed by the mother's ability to straight leg raise (SLR). Four hours after combined spinal-epidural analgesia, 88.1% of women could SLR in group MW, 83.7% in group PCEA and 57.8% in group Cl (P = 0.002). Total use of bupivacaine was highest in group Cl (mean 11.3 (SD 3.3) mg h-1) compared with group MW (7.5 (3.1) mg h-1) and group PCEA (9.1 (2.1) mg h-1) (P < 0.001). Analgesia was similar between groups and overall satisfaction was equally high.      

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.     

Prophylactic blood patch performed prior to continuous epidural analgesia

Two cases of inadvertent dural puncture in patients at high risk for dural puncture headache are presented. These patients were managed with an immediate epidural blood patch through a catheter placed at another level with placement of this catheter occurring immediately following the dural puncture. Following the blood patch, the patients were anesthetized with the epidural catheter being used for supplementation of the general anesthetic and for postoperative pain management. Neither patient required further management of a dural puncture headache nor did it appear that the blood interfered with the patients receiving adequate postoperative analgesia through the use of this epidural catheter.     

A comparison of Espocan and Tuohy needles for the combined spinal-epidural technique for labor analgesia

When using the needle-through-needle combined spinal-epidural (CSE) technique for labor analgesia, failure to obtain cerebrospinal fluid (CSF), paresthesias, and intrathecal or intravascular migration of the catheter are of concern. Epidural needles with spinal needle apertures, such as the back-hole Espocan (ES) needles, are available and may reduce these risks. We describe the efficacy and adverse events associated with a modified epidural needle (ES) versus a conventional Tuohy needle for CSE. One-hundred parturients requesting labor analgesia (CSE) were randomized into 2 groups: 50-ES 18-gauge modified epidural needle with 27-gauge Pencan atraumatic spinal needle, 50-conventional 18-gauge Tuohy needle with 27-gauge Gertie Marx atraumatic spinal needle. Information on intrathecal or intravascular catheter placement, paresthesia on introduction of spinal needle, failure to obtain CSF through the spinal needle after placement of epidural needle, unintentional dural puncture, and epidural catheter function was obtained. No intrathecal catheter placement occurred in either group. Rates of intravascular catheter placement and unintentional dural puncture were similar between the groups. Significant differences were noted regarding spinal needle-induced paresthesia (14% ES versus 42% Tuohy needles, P = 0.009) and failure to obtain CSF on first attempt (8% ES versus 28% Tuohy needles, P < 0.02). Use of ES needles for CSE significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt. IMPLICATIONS: The use of modified epidural needles with a back hole for combined spinal-epidural technique significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt.