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We describe a case of post lumbar puncture headache treated by extradural blood patch. Magnetic resonance imaging (MRI) demonstrated a large extradural haematoma extending over four spinal segments and extending out through the neural outlet foramina. There was significant compression of the thecal sac, supporting the theory that extradural blood patch causes tamponade at the site of dural puncture. The spread of clot was predominantly upwards from the injection site and subarachnoid extension of blood was also demonstrated.

SummaryTwo cases of unexpected high spinal anaesthesia following failed extradural anaesthesia for Caesarean section are described. In both cases rapid and unexpected advance of blockade, after the subarachnoid injection of moderate doses of local anaesthetic, required tracheal intubation. In one of the cases 15 ml of 0.9% saline, but no local anaesthetic. had been injected into the extradural space, suggesting that the mechanism involved is the cephalad displacement of the cerebrospinal fluid by extradural fluid, and not leakage of extradural anaesthetic solution into the subarachnoid space. Key wordsAnaesthetic techniques, regional; spinal, extradural. Complications.Extradural anaesthesia is a popular technique for Caesarean section in the United Kingdom. Inadequate analgesia occurs in about 50% of women undergoing Caesarean section under extradural block with 0.5% bupivacaine [ 1-31. Usually, supplementation with inhalational, systemic or local analgesia is adequate. However, in some cases of failed extradural blockade, further regional or general anaesthesia may be required.In the two patients described below, spinal anaesthesia was performed following failure to establish adequate extradural anaesthesia for Caesarean section. In both excessive spinal blockade required tracheal intubation. Case histories Case IA 19-year-old primigravida (weight 52.6 kg, height 150 cm) was admitted for induction of labour with poor weight gain (2.6 kg) and postdates (term + 7 days). Artifical rupture of membranes was performed and an intravenous infusion of oxytocin started.Three hours after induction of labour, the patient requested extradural analgesia. The extradural was sited at L213 interspace, with the patient in a sitting position, using the loss of resistance to air technique. The extradural space was identified at 4 cm, and 3 cm of catheter was introduced into the space. Following an uneventful test dose (4 ml of 2% lignocaine), 8 ml of 0.25% bupivacaine was given. This produced a bilateral sensory block to T,.Two hours after siting the extradural, vaginal examination revealed a hand presentation and, it was decided to proceed to Caesarean section. The patient requested to remain awake, so 10ml of 0.5% bupivacaine was given through the extradural catheter.After a further 10 min, the sensory block only extended to T,,, so a further dose of 10 ml of 0.5% bupivacaine was given. After a further 20 min the block had still not extended above T,,, and as the patient still wanted to stay awake, a spinal block was performed. The patient was positioned in the right lateral position, routine lumbar puncture at the L3,4 interspace was performed with a 26-gauge needle, and 2.0ml of 0.5% bupivacaine with 8% glucose was injected into the cerebrospinal fluid. The patient was returned to the supine position with a wedge under the right hip. Four litres per minute of oxygen was administered by face mask. Within 5 min the block extended to T,, and the Caesarean section was started. The patient's arterial pressure decreased to 70/40 mmH...

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Third branchial arch anomalies are rare. The authors present a case report of a neonate with a rapidly growing neck mass due to cystic dilation of a persistent thymopharyngeal duct, which is a derivative of the third branchial arch. The presence of thyroid and thymic tissue in the cyst wall, the communication of the cyst with the piriform sinus, and the relationship of the cyst to carotid vessels and the sternomastoid muscle were consistent with the features of a thymopharyngeal duct cyst embedded in the thyroid gland.