Dural puncture after spinal fusion, then postpartum seizure29-year-old woman, 66 kg, at 40 weeks in labour

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 29-year-old in labour with a T10–L3 fusion, asking for an epidural. Patient
   • At term a working epidural spares her the airway and aspiration risks of an emergency general.
   • Rods can make the epidural difficult or impossible at the fused levels. Disease
   • I review her imaging for the fused levels and the open space below.

2. Plan

   How will you site it, and what is your fallback?

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   • Below the fusion, L3/4 or L4/5, with ultrasound to find her midline. Disease
   • If it fails, remifentanil PCA, or a paravertebral block as rods block the epidural route.
   • Accidental dural puncture happens in 1–1.5%; 30–60% then get a headache.
   • If it happens: thread an intrathecal catheter, or resite at another space.
   • An intrathecal catheter is labelled and handed over; only spinal doses, given by an anaesthetist.
   • Daily review for headache after any dural puncture. After surgery

3. Crisis

   Day 2: severe headache on standing, eased lying flat, with neck ache and muffled hearing. BP 128/80, temperature 36.9 °C. What do you do?

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   • Postural headache after dural puncture: likely PDPH, but I exclude the dangerous causes first. (Crisis)
   • Red flags: BP for postpartum preeclampsia, fever and neck stiffness for meningitis, focal signs.
   • PDPH itself raises the risk of venous sinus thrombosis and subdural haematoma; atypical features need imaging.
   • Conservative first: fluids, paracetamol and NSAIDs; caffeine helps only briefly.
   • If it limits caring for her baby, a blood patch with consent: about 20 mL of her blood.
   • Diplopia would mean patching straight away.

4. Crisis

   While you review her, she has a generalised tonic-clonic seizure. BP 168/112, HR 120, SpO2 90%. What do you do?

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   • Postpartum eclampsia until proven otherwise; the blood patch is off the table. Crisis
   • Left lateral, airway opened, oxygen, and a call for the obstetrician and senior help.
   • Magnesium sulfate 4–6 g IV over 20–30 minutes, then 1–2 g/h.
   • BP over 160/110 treated within the hour: IV labetalol or hydralazine.
   • Persisting focal signs after the seizure: imaging for sinus thrombosis, haemorrhage or subdural.
   • HDU care with magnesium monitoring and clear documentation. After surgery