Spinal Subdural and Epidural Haematomas: Diagnostic and Therapeutic Aspects in Acute and Subacute Cases

Summary  Background. The diagnosis of spontaneous spinal haematomas mainly depends on magnetic resonance imaging. This study evaluates the MRI characteristics of spinal epidural and subdural haematomas. The results were correlated with medical history, coagulation abnormalities and therapeutic outcome to provide guidelines for early diagnosis and treatment of spinal epidural and subdural hematomas.  Summary of Background Data. Imaging signs of epidural and subdural haematomas have been reported before, however without special attention to the differential-diagnostic and therapeutic implications of haematoma localisation.  Method. Seven patients (3 women, 4 men, age range 55–86 years) with acute progressive neurological deficits and without a history of severe trauma were studied. In all cases neurological examinations were performed after admission followed by MRI studies with T2 and T1 weighted images, before and after administration of contrast agent. Spinal angiography was performed twice to exclude a vascular malformation. All patients underwent open surgery.  Findings. Acute and subacute hematomas were detected once in the cervical spine, in five cases in the thoracic region and once in the lumbar region. The hematomas had an epidural location in three cases and a subdural in four. In the thoracic region subdural haemorrhage was much more common than epidural hematomas. Subdural blood collections were mainly found ventral to the spinal cord. Epidural haemorrhage was always located dorsal to the spinal cord. The evaluation of the haematoma localisation may be difficult occasionally, but delineation of the dura is frequently possible in good quality MRI. The clue to the diagnosis of ventrally located subdural haemorrhage is the absence of the “curtain sign”, which is typical for epidural tumours.  Interpretation. Spontaneous spinal hematomas are frequently located in the thoracic spine. Subdural spinal haemorrhage is more frequent than epidural. Epidural haemorrhage is frequently located dorsal to the spinal cord because of the tight fixation of the dura to the vertebral bodies.     

Das epidurale Hämatom über dem Sinus sagittalis superior

Zusammenfassung Das epidurale Hämatom über dem Sinus sagittalis superior ist selten. Die Diagnose kann nur durch die Angiographie gestellt werden. Es besteht ein gefäßfreier Raum zwischen abgedrängtem Sinus sagittalis superior und Kalotte. Die Raumforderung ist oft gering, trotzdem die Symptomatik infolge venöser Abflußstauung meist ausgeprägt. In der Regel sollte das Hämatom über dem Sinus sagittalis superior operativ entfernt werden.

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Epidural haematoma overlaying the superior sagittal sinus

Summary An epidural haematoma overlaying the superior sagittal sinus is rare. The diagnosis can only be established by means of angiography. There is an avascular space between the calvarium and the displaced superior sagittal sinus. The space occupied by the lesion is often small in spite of the fact that the symptoms which develop from the obstructed venous outflow are usually pronounced. As a rule these haematomas should be evacuated at operation.

     

Lumbar epidural perineural injection: a new technique

Two controlled studies for a new epidural, perineural, singleshot, selective nerve root injection with a double-needle approach to the anterior epidural space of the lumbar spinal canal are presented. The results were analysed to determine the effectiveness of the new epidural perineural injection technique. The trial comprised two controlled studies on 182 patients. One study compared prospectively randomized results of patients with lumbar radicular syndromes who received epidural perineural injections (n = 47), conventional posterior epidural injections (n = 40) and, as a control group, paravertebral local anaesthetic (n = 46). A second, prospective, double-blind study compared the effect of epidural perineural injections with triamcinolone (n = 24) and pure saline (n = 25). Epidural perineural injections were more effective than conventional posterior epidural injections. Both epidural groups had better results than the paravertebral local injection group. Epidural perineural injections with steroids (10 mg triamcinolone) were more effective than saline alone. A systemic steroid effect was excluded by additional intramuscular steroid injections in the saline group. There were no severe complications or side effects in any of the three groups. The studies concluded that single-shot epidural perineural injection is effective in the treatment of lumbar radicular pain. It is a one drop only therapy to the source of pain.     

Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report

Summary Background. Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. Methods. Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine™ and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3–5 days. CT scans were performed daily from days 1 to 5. Results. In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8–12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. Conclusion. Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.     

The CT criteria for conservative treatment — but under close clinical observation — of posterior fossa epidural haematomas

Summary In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than 10 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30 ml in the latter. That means a PFEDH of 10 ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision     

Epidural and subdural haematomas as a complication of internal drainage of cerebrospinal fluid in hydrocephalus

Summary After mentioning the most important indications for the implantation of atrio-ventricular systems in increased intracranial pressure, the importance of epidural and/or subdural bleeding as one of the main postoperative complications is pointed out. In the literature, known to us, there are reports of 9 epidural and 25 subdural haematomas. Four more personal cases are reported. The cause of the bleeding is collapse of the cortex which leads to rupture of cortical veins or epidural vessels. Especially at risk are adult patients with high intracranial pressure or atrophy of the cortex in long standing hydrocephalus. Epidural haematoma always develops in the first few hours after the operation, whereas subdural haematomas may develop either in the first days or even after weeks and months. The incidence of this complication in our adult patients is 5.6%. Some possibilities for the prophylaxis of intracranial bleeding are mentioned.     

Serum S100B levels in patients with epidural haematomas

Protein S100B is today the most promising biomarker for cerebral injury. A welcomed area for the use of such a marker is in the early stages of head trauma and diagnosis of brain injury, in particular epidural haematomas. We report five consecutive cases of epidural haematoma where serum samples for S100B were drawn at admission. Three of the patients showed low levels of S100B (< or =0.2 microg/l). One patient with a large epidural haematoma with radiological signs of cerebral herniation displayed normal levels (0.14 microg/l) of S100B 3.5 h after the initial head trauma. Normal S100B levels in serum do not predict normal intracranial findings. S100B may be unreliable as a marker for epidural haematomas after closed head injury.     

Thromboembolism after total hip replacement: role of epidural and general anesthesia

The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.     

Traumatische intrakranielle Hämatome

Zusammenfassung In einem Bericht über 9000 cranio-cerebrale Traumen mit 1271 traumatischen intrakraniellen Hämatomen [Chirurgie Gießen (n = 291) 1942–1974 und Neurochirurgie Gießen (n = 980) 1953–1974] wird zur Verteilung, Diagnose, Therapie und Prognose der Hämatome Stellung genommen. Unter 26 % Hämatomen lagen 6,4 %. extradural, 17,2 % subdural und 2,4 % intracerebral. Die Mortalität ist von 84 % in den 40er Jahren auf ca. 40% im letzten Jahrzehnt zurückgegangen, am geringsten mit 64 % bei den intracerebralen Hämatomen. Die einzelnen Blutungsformen werden hinsichtlich Lokalisation, Klinik und Behandlung besprochen. Die Computer-Tomographie hat die Diagnose perfektioniert und gewährleistet Indikation, zeitgerechte Operation und Verlaufskontrolle. Ihr Fehlen in den meisten chirurgi-schen und traumatologischen Abteilungen, damit der weiterhin notwendige Einsatz der Angiographie und die mangelnde Ausbildung in der Neurotraumatologie sind die wesentlichen Gründe für die immer noch ungünstige Prognose.

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Traumatic intracranial haematomas

Summary Based on 9,000 craniocerebral traumas with 1,271 intracranial haematomas [Gießen General Surgery (n = 291) 1942–1974, Gießen Neurosurgery (n = 980) 1953–1974] distribution, diagnosis, therapy, and prognosis of traumatic haematoma has been discussed. Among 26 % of the haematomas, 6.4% were extradural, 17.2% were subdural, and 2.4% were intracerebral. Mortality has decreased from 84 % in the 1940's to 40 % in the last decades; the least decrease (64 %) being among the intracerebral haematomas. Distribution, site and size, symptomatology, and special diagnostic procedures were reported for the different types and forms of haematomas. Computertomography has proved to be the most decisive progress for the diagnosis, indication, timely and appropriate surgery, and follow up. The most important reasons for the still unfavourable results are lack of sufficient experience, among general surgeons and traumatologists, the lack of computer-tomographs, and the need for separate clinical and angiographic diagnosis.

     

A clinical comparison of non-traumatic acute subdural haematomas either related to coagulopathy or of arterial origin without coagulopathy

Summary ¶Background. Non-traumatic acute subdural haematomas enable study of the morbidity and mortality due to the haematoma without the effect of trauma. Whereas it is known that coagulation disorders worsen the outcome of spontaneous intracerebral haematomas, this has not been studied in non-traumatic acute subdural haematomas. Methods. In a series of 13 non-traumatic acute subdural haematomas admitted to our department between January 1995 and March 2002, we had 9 coagulopathy associated haematomas and 3 haematomas corresponding to the syndrome of spontaneous acute subdural haematoma of arterial origin. Both groups were compared. Findings. Age and gender distribution were comparable. The bleeding source was a cortical artery in 2 of the 2 non-coagulopathy related haematomas operated on, but also in 2 of the 4 coagulopathy associated haematomas that underwent surgery. The average haematoma thickness was higher in the coagulopathy related haematomas. The mean Glasgow Coma Score on admission was 7,7 and the mortality rate was 55,6% in the coagulopathy related group. In the non-coagulopathy related haematomas the mean Glasgow Coma Score was 12,0 and the mortality rate 33,3%. The latter mortality rate corresponds well to that of a historical group of spontaneous acute subdural haematomas of arterial origin collected from the literature. Interpretation. The outcome was worse in the non-traumatic acute subdural haematomas that were associated with a coagulation deficiency. While in all non-traumatic acute subdural haematomas the interval to surgery should be minimized, early recognition and urgent correction of coagulation deficiencies is certainly indicated.Published online May 19, 2003     

Haematoma and abscess after neuraxial anaesthesia: a review of 647 cases

Although rare, spinal haematoma and abscess after central neuraxial blocks may cause severe permanent neurological injury. Optimal treatment and outcome remain unclear. In order to identify possible predisposing patient characteristics and describe the ensuing clinical course, we searched Medline, Embase, and the Cochrane Library for reports of spinal haematomas and abscesses associated with central neuraxial blocks. Extracted data included patient characteristics, symptoms, treatment, and outcome. We analysed 409 reports, including 647 patients (387 patients with spinal haematoma and 260 patients with spinal abscess). Spinal haematoma and abscess occurred predominantly after epidural anaesthesia (58% and 83%, respectively). Neurological recovery was correlated with the severity of initial neurological deficit. When decompression of spinal haematoma was delayed for >12 h after clinical diagnosis, neurological outcome was worse compared with earlier decompression (odds ratio 4.5, 95% confidence interval 2.1–9.9, P<0.001, n=163). After spinal haematoma, 47% of published patients had full recovery, 28% had partial recovery, and in 25% no recovery was observed. Good outcome after conservative management was observed in patients with mild symptoms or with spontaneous recovery during the diagnostic and therapeutic workup. After spinal abscess, 68% of reported patients recovered fully, 21% showed partial recovery, and no recovery was reported in 11%. Persistent neurological symptoms after spinal haematoma and abscess are common and correlate with the severity of initial neurological deficit. Neurological outcome seems worse when decompressive surgery of haematoma is delayed. Notwithstanding the considerable risk of selection bias and publication bias, conservative management may be feasible in patients with mild symptoms or spontaneous recovery.     

Favorable effects of epidural analgesia on hemodynamics,oxygenation and metabolic variables in the immediate post-anesthetic period

Fourteen adult patients undergoing elective major abdominal surgery were divided into two groups. One group received epidural and general anesthesia (epidural group), and 20 ml of 0.125% bupivacaine and 2 mg of morphine were administered epidurally about 30 min before the end of the operation for post-anesthetic analgesia. The other group (control group) received general anesthesia alone with nitrous oxide, oxygen and enfiurane. Flow-directed pulmonary arterial and radial arterial catheters were inserted preoperatively, and hemodynamic, respiratory, neuroendocrine and metabolic variables were measured serially. The data were compared during anesthesia and the immediate post-anesthetic recovery period. In the control group, the plasma epinephrine level in the post-anesthetic recovery period increased about four times over the anesthetic period. Oxygen consumption was increased and mixed venous oxygen saturation was decreased significantly. There was a close linear correlation between oxygen consumption (Y) and plasma epinephrine (X) level: Y = 285.7X + 90.5 (P < 0.01, r = 0.72). On the other hand, plasma epinephrine, oxygen consumption and mixed venous oxygen saturation did not change significantly in the epidural group in the post-anesthetic recovery period. There was also a close linear correlation between oxygen consumption (Y) and oxygen delivery (X): Y = 0.22X -32.0 (P < 0.01, r = 0.89). We conclude that the surgical stress and anesthetic reversal may seriously influence neuroendocrine responses and subsequently increase plasma epinephrine. Tissue oxygenation and metabolic imbalance may occur due to the rapid increase of epinephrine in the postanesthetic recovery period. Epidural analgesia at this period may play a more important role and have a more favorable effect on the tissue metabolism.     

Factors affecting the spread and duration of epidural anesthesia with ropivacaine

BACKGROUND: Epidural anesthesia has an unpredictable extent and duration. Differences in the surface area of the lumbosacral dura, epidural fat volume, and epidural venous plexus velocity might explain the variability in the extent and duration of epidural anesthesia with ropivacaine. METHODS: Twenty-six healthy patients, aged 18-45 y, undergoing peripheral orthopedic surgery were enrolled. Dural surface area and posterior epidural fat volume were calculated from low thoracic, lumbar, and sacral axial magnetic resonance images obtained at 8-mm increments. Epidural venous plexus velocity at the L3-L4 disk level was derived from phase-contrast magnetic resonance images. The patients received 100 mg ropivacaine (1.0%) epidurally. The spread and duration of sensory anesthesia was assessed by pinprick, and that of motor block was assessed using a modified Bromage scale. Statistical correlation coefficients (rho) between magnetic resonance imaging and epidural anesthesia measurements were assessed by Spearman rank correlation. Stepwise multiple linear regression models were used to select important predictors of measures of epidural anesthesia. RESULTS: Dural surface area correlated with peak sensory block level (rho= -0.73, P = 0.0003) and onset time of caudal and cephalad block (rho = 0.62, P = 0.002; rho = -0.63, P = 0.002). Fat volume correlated with the regression to L5-S3 (rho = -0.44.44 to -0.54, P = 0.029 to 0.007). Epidural venous plexus velocity was significantly correlated with the regression to L3 (rho = -0.42, P = 0.038) and L4 (rho = -0.48, P = 0.017). Multiple regression analysis revealed that dural surface area was a significant predictive variable for the peak sensory block level (R = 0.61, P < 0.0001). CONCLUSIONS: These findings indicate that dural surface area influences the spread of epidural anesthesia with ropivacaine and posterior fat volume influences the duration of epidural anesthesia in healthy patients within a narrow age range. Epidural venous plexus velocity might also influence the duration of epidural anesthesia with ropivacaine.     

Factors Affecting the Spread and Duration of Epidural Anesthesia with Ropivacaine

Background: Epidural anesthesia has an unpredictable extent and duration. Differences in the surface area of the lumbosacral dura, epidural fat volume, and epidural venous plexus velocity might explain the variability in the extent and duration of epidural anesthesia with ropivacaine.

Methods: Twenty-six healthy patients, aged 18-45 y, undergoing peripheral orthopedic surgery were enrolled. Dural surface area and posterior epidural fat volume were calculated from low thoracic, lumbar, and sacral axial magnetic resonance images obtained at 8-mm increments. Epidural venous plexus velocity at the L3-L4 disk level was derived from phase-contrast magnetic resonance images. The patients received 100 mg ropivacaine (1.0%) epidurally. The spread and duration of sensory anesthesia was assessed by pinprick, and that of motor block was assessed using a modified Bromage scale. Statistical correlation coefficients ([rho]) between magnetic resonance imaging and epidural anesthesia measurements were assessed by Spearman rank correlation. Stepwise multiple linear regression models were used to select important predictors of measures of epidural anesthesia.

Results: Dural surface area correlated with peak sensory block level ([rho] = -0.73, P = 0.0003) and onset time of caudal and cephalad block ([rho] = 0.62, P = 0.002; [rho] = -0.63, P = 0.002). Fat volume correlated with the regression to L5-S3 ([rho] = -0.44 to -0.54, P = 0.029 to 0.007). Epidural venous plexus velocity was significantly correlated with the regression to L3 ([rho] = -0.42, P = 0.038) and L4 ([rho] = -0.48, P = 0.017). Multiple regression analysis revealed that dural surface area was a significant predictive variable for the peak sensory block level (R2 = 0.61, P < 0.0001).     

Comparison between general,spinal, epidural,and combined spinal-epidural anesthesia for cesarean delivery: a network meta-analysis

BackgroundThis study is a network meta-analysis to compare maternal and fetal outcomes associated with four different anesthetic techniques for cesarean delivery.MethodsAn arm-based, random-effects frequentist network meta-analysis was performed. A random effect model was selected considering deviance information criteria. Randomized trials reporting the following outcomes were included: Apgar score at 1- or 5-min; umbilical arterial and venous pH; umbilical arterial pH <7.2; and neonatal score at 2–4 hours. Loop-specific heterogeneity was evaluated by risk of odds ratio and τ². Quality of evidence was assessed using the GRADE approach.ResultsData from 46 randomized trials including 3689 women contributed to the study. There were significant differences in Apgar score ≤6 at 1 min between spinal versus general anesthesia (odds ratio 0.27, 95% confidence interval [CI] 0.13 to 0.55: moderate quality evidence) and Apgar scores at 1- and 5-min, favoring spinal anesthesia. Umbilical venous pH associated with epidural anesthesia was significantly higher than that with general anesthesia (mean difference 0.010, 95% CI 0.001 to 0.020: moderate quality evidence) or spinal anesthesia. Spinal anesthesia was ranked best for Apgar score ≤6 at 1-min (SUCRA=89.8), Apgar score at 1-min (SUCRA=80.4) and 5-min (SUCRA=90.5). Epidural anesthesia was ranked highest for umbilical venous pH (SUCRA=87.4) and neonatal score (SUCRA=79.3).ConclusionsSpinal and epidural anesthesia were ranked high regarding Apgar scores and epidural anesthesia was ranked high regarding umbilical venous pH, but the results were based on small heterogeneous studies with high or unclear risks of bias.     

Huge epidural hematoma after surgery for spinal cord stimulation

Summary Objective and importance. Spinal epidural haematoma (SEH) following implantation of an epidural spinal cord electrode is a very rare complication but one that must not be overlooked. This case is unusual because of the almost holocord extension of the haematoma and the excellent recovery obtained by prompt surgical treatment.Clinical presentation. A 69 years old man with normal serum coagulation parameters was submitted to spinal cord stimulation (SCS) for chronic pain syndrome. After a minimal L1 laminotomy the patient developed paraplegia due to a large haematoma at D4-L2.Intervention. Surgical removal of the entire clot by a D4-L2 laminectomy was performed immediately.Conclusion. Large epidural haematoma can result from SCS and this complication may be cured by appropriate and prompt surgery.     

Comparison of CT characteristics of extravertebral cement leakages after vertebroplasty performed by different navigation and injection techniques

Summary   Objective. This study was intended to assess the results of post-operative CT scans in three groups of patients following percutaneous vertebroplasty (VP) using different navigation and injection methods, in an attempt to explain the radiological characteristics of extravertebral cement leakage with relation to needle placement and focused on the ventral epidural accumulation of bone cement. Furthermore, we have suggested a morphological (and functional) classification of the types of cement leakage. Methods. Between July 2001 and February 2005, 123 percutaneous VP procedures were performed during 75 sessions in 65 patients for treatment of painful osteoporotic vertebral body compression fractures. These included:- Group I: 28 patients, 33 sessions; 50 right sided unilateral VP under fluoroscopic control with central position of the tip of the needle within the bone marrow. Group II: 27 patients, 28 sessions; 50 bilateral VP under fluoroscopic control with separate cement injections into both “hemivertebrae”. Group III: 14 patients, 14 sessions; 23 bilateral VP navigated by frameless stereotaxy (neuronavigation). Needles were positioned strictly into the lateral thirds of the vertebral bodies. Leakages were classified as epidural, foraminal, intradiscal, venous paravertebral, compact extravertebral on the post-operative CT scans, and their frequency was compared in relation to the navigation method and the position of the tip of the needle. Results. Group I: extravertebral cement was detected in 23 patients (82%), and in 35 (70%) of the 50 vertebrae treated (ventral epidural: 23 vertebrae = 46%; intradiscal: 12 vertebrae = 24%; venous paravertebral: 8 vertebrae = 16%; intraforaminal: 7 vertebrae = 14%; and compact extravertebral: 3 vertebrae = 6%). Group II: extravertebral cement was detected in 20 patients (74%), and in 38 (76%) of the 50 vertebrae treated (ventral epidural: 12 vertebrae = 24%; intradiscal: 12 vertebrae = 24%; venous paravertebral: 9 vertebrae = 18%; and foraminal: 1 vertebra = 2%). Group III: extravertebral cement could be detected in 10 patients (71%), and in 10 (43%) of the 23 vertebrae treated (ventral epidural: 3 vertebrae = 13%; intradiscal: 8 vertebrae = 34%; venous paravertebral: 4 vertebrae = 17%). Conclusion. The incidence of epidural accumulation of bone cement may be concluded to be closely correlated with the position of the tip of the needle. Centrally injected bone cement may easily invade into the basivertebral system, and the material can then be transferred via these veins toward the ventral epidural space, and result in canal compromise and/or compression of the neural elements. The results of statistical analysis (Chi-square test) revealed that injection of bone cement into the lateral third of the vertebral body significantly decreases the extent of ventral epidural leakage. Therefore, a strictly lateral injection is advised, when the tip of the needle is placed into the lateral third of the vertebral body. Frameless stereotaxy navigation improves achievement of accurate needle placement and decreases the frequency of ventral epidural leakage. It is a safe and very accurate method for positioning of the injecting needles. Correspondence: Prof. Dr. Tamás Dóczi, Department of Neurosurgery, University of Pécs, 7623 Pécs, Rét u. 2., Hungary.     

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.     

Epidural haematoma at the vertex

Summary We report 14 cases of vertex epidural haematomas among 478 cases of epidural haematomas that were hospitalized in the Neurosurgical Department of the University Hospital of Padova during the period 1953–1980.We discuss the clinical, diagnostic, and prognostic features. The mortality rate was 50%. In this type of traumatic haematoma prompt surgical treatment is not always followed by good recovery.     

Aktuelle Praxis der Analgesie in der Geburtshilfe an den deutschen Universitätsklinika Ergebnisse einer Umfrage 1996. Teil 2

Obviously there is a world-wide trend towards regional analgesia for pain relief during delivery. Data on the current practice in Germany are lacking. Methods: In 1996 questionnaires on obstetric anaesthesia and analgesia were mailed to all university departments of anaesthesia. Results: All 38 university hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156. Epidural analgesia (EA) (n=22), intramuscular injection of opioids (n=18), and non-opioids as a suppository (n=17) were often used for pain relief during labour. Intravenous injections (n=12) or pudendus anaesthesia (n=7) were practised as well. Entonox (N₂O/O₂), paracervical blocks or transcutaneous electrical stimulation (TENS) was rarely used. EA for relief of labour pain was offered in all university hospitals. Twelve of them had an epidural rate of less than 10%, in nine the rate was 10–19%, in eight hospitals 20–29% and 30% or more in nine. Indication for EA was a demand by the parturient (n=34), by the obstetrician (n=26) or the midwife (n=18), predominantly because of prolonged labour (n=32) or significant pain (n=21). Half of the university departments used an epidural combination of local anaesthetics (bupivacaine) and opioids (sufentanil (n=12) and/or fentanyl (n=9)). In all but one department the application of an epidural catheter was performed by anaesthesiologists exclusively. In some hospitals obstetricians (n=10) or midwives (n=4) were allowed to give epidural top-up injections. Of the 38 university departments 11 had an anaesthesiologists on duty 24 h a day responsible for the obstetric unit exclusively. Conclusion: In 1977, 14 of 18 university departments of anaesthesiology offered epidural analgesia for parturients. This option was available in all university departments in 1996. A mean rate of 10–20% epidurals for vaginal delivery is well within the limits reported from other countries, whereas the rate of regional anaesthesia for scheduled caesarean section (40%) still is rather low in Germany, as reported in part 1 of this survey (Anaesthesist 1998; 47:59–63).