F. Reynolds

Seven cases are described in which neurological damage followed spinal or combined spinal-epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2-3 interspace. In all cases, there was free flow of cerebrospinal fluid before spinal injection. There was one patchy block but, in the rest, anaesthesia was successful. Unilateral sensory loss at the levels of L4-S1 (and sometimes pain) persisted in all patients; there was foot drop in six and urinary symptoms in three. Magnetic resonance imaging showed a spinal cord of normal length with a syrinx in the conus (n = 6) on the same side as both the persisting clinical deficit and the symptoms that had occurred at insertion of the needle. The tip of the conus usually lies at L1-2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.

Spinal anaesthesia is generally preferred for Caesarean section. Its superiority for the baby is often assumed. Umbilical artery acid-base status provides a valid index of fetal welfare. Twenty-seven studies reporting neonatal acid-base data with different types of anaesthesia were used to compare umbilical artery or vein pH and base deficit, using random-effect meta-analysis. Cord pH was significantly lower with spinal than with both general (difference: -0.015; 95% CI -0.029 to -0.001; 13 studies, 1272 subjects) and epidural anaesthesia (difference -0.013; 95% CI -0.024 to -0.002; 11 studies, 828 subjects). Larger doses of ephedrine contributed to the latter effect (p = 0.023). Sixteen studies reported a base deficit, which was significantly higher for spinal than for general (difference 1.109; 95% CI 0.434-1.784 mEq.l(-1); seven studies, 695 subject) and epidural anaesthesia (difference 0.910; 95% CI 0.222-1.598 mEq.l(-1); seven studies, 497 subjects). Spinal anaesthesia cannot be considered safer than epidural or general anaesthesia for the fetus.

Dural puncture

Donald Caton Yale University Press, £20, pp 300 ISBN 0 300 07597 9 Rating: ![Graphic][1]</img> ![Graphic][2]</img> ![Graphic][3]</img> ![Graphic][4]</img> When her eldest daughter gave birth in 1859, Queen Victoria remarked, “What a blessing she had chloroform. Without it I think her strength would have suffered very much.” The Queen, an experienced mother, saw no controversy in the use of pain relief in labour. Yet the subject has continually been dogged by controversy (witches were burnt for it). Donald Caton, an eminent chronicler of the history of obstetric analgesia, has written a fascinating account of the social background to its evolution since the introduction of ether, then chloroform, to obstetrics by James … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif [4]: /embed/inline-graphic-4.gif