Unanticipated Dural Tap in Caudal Anesthesia: A Case of Intrasacral Meningocele

Abstract

To the Editor: Dural puncture, although rare, is one of the complications of caudal anesthesia. Unrecognized dural puncture and subsequent injection of a large volume of anesthetic solution leads to respiratory arrest and total spinal anesthesia (1,2). We report an unanticipated dural tap while performing caudal anesthesia. Postoperative magnetic resonance imaging examination revealed the presence of intrasacral meningocele in the sacral canal. An otherwise healthy 2-yr-old boy had an undescended testis and was scheduled for orchidopexy. Preoperative physical examinations showed no other abnormal pathology. The caudal anesthesia was performed under general anesthesia. An IV disposable needle was inserted via the sacral hiatus and was advanced until it was judged to penetrate the sacrococcygeal membrane. Immediately, clear fluid dripped from the proximal end of the needle. Caudal anesthesia was abandoned because of potential dural puncture. Postoperative magnetic resonance imaging showed an intrasacral meningocele in the sacral canal (Fig. 1).Figure 1.: Magnetic resonance imaging in the median sagittal plane showed a T1-hypo-intensity signal in the epidural space from S2 to S4 (arrow). Tethered cord was not found and conus medullaris ends at L1 disk level.Caudal anesthesia is believed to be a reliable technique that is easy to perform, even by beginners (3). Although rare, consideration should always be given to the existence of an anatomical anomaly in pediatric patients. Therefore, the importance of gentle and careful aspiration before local anesthetic injections cannot be overemphasized. We strongly suggest that great care must be taken not only to detect intravascular injection but also to detect subarachnoidal injection. Gaku Inagawa, MD Takaaki Miwa, MD Koichi Hiroki, MD Department of Anesthesia Kanagawa Children’s Medical Center Yokohama, Japan [email protected]