A simple technique to reduce the incidence of accidental dural puncture

We would like to respond to recent comments (Reynolds. Anaesthesia 2001: 56 : 1129) on our epidural technique. In our practice we apply loss of resistance to air technique, which helps identify a nick in the dura with a small leak of CSF. On many occasions, only a few drops of CSF and not a constant leak helped identify dural puncture, which could have been missed with the use of saline. Upon inserting the epidural needle, we remove the stylet when the needle is engaged in the interspinous ligament or the ligamentum flavum. Very often, it is difficult for our residents to advance the epidural needle with one hand and apply constant pressure on the plunger with the other hand. Excessive pressure with one hand, by a resident, had caused dural puncture when the needle was pushed in too far. By reinserting the stylet with each advancement of the needle, we remove tissues that may enter and occlude the epidural needle. It is quite possible that constant plunger pressure with saline may also avert this problem.