Spinal anesthesia is perhaps one of the oldest and most studied modalities for providing pain relief in patients undergoing surgery. J. Leonard Corning(1) is credited with administering the first spinal anesthetic in 1885, and his experience was subsequently published in a medical journal. Although the use of intrathecal anesthesia administration in children was described in the early twentieth century,(2,3) this technique was seldom used in the pediatric population until Melman(4) reported a series of high-risk infants who underwent successful surgery under spinal anesthesia. Reports of apnea following general anesthesia in preterm infants appeared in the literature in the early 1980s,(5–9) and a series from Abajian et al.(10) offered practitioners an impetus to offer an alternative technique with reportedly fewer complications than general anesthesia. A number of series have since been reported in all age groups for a variety of surgical procedures attesting to the safety and efficacy of spinal anesthesia.(11–13)
Epidural analgesia is commonly used in addition to general anesthesia and to manage postoperative pain. Effective postoperative pain relief from epidural analgesia has numerous benefits including earlier ambulation, facilitating weaning from ventilators, reducing time spent in a catabolic state, and lowering circulating stress hormone levels.(1) Precise placement of epidural needles for single-injection techniques and catheters for continuous epidural anesthesia ensures that the dermatomes involved in the surgical procedure are selectively blocked, allowing for lower doses of local anesthetics to be used and sparing unnecessary blockade in nondesired regions. The approach to the epidural space can be at the caudal, lumbar, or thoracic level.
Postural headaches following interventions that disrupt meningeal integrity are most commonly labeled postdural puncture headaches (PDPHs). This terminology has been officially adopted in the International Classification of Headache Disorders and is used in this chapter. However, use of the word postdural has been criticized as confusing and probably inaccurate, resulting in the proposal of an alternate term, meningeal puncture headache (MPH), which readers may increasingly encounter. It is also important to acknowledge that references to “dural puncture” throughout the medical literature (including this chapter) actually describe puncture of the dura-arachnoid and are more correctly termed and thought of as “meningeal puncture.”
Regardless of terminology, the PDPH is well known to the many clinicians whose practice includes procedures that access the subarachnoid space. Yet, our understanding of this serious complication remains surprisingly incomplete. This chapter summarizes the current state of knowledge regarding this familiar iatrogenic problem as well as the closely related topics of accidental, or unintentional, dural puncture (ADP or UDP, respectively), and the epidural blood patch (EBP).