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This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.

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Introduction: Postdural puncture headache (PDPH) is one of the iatrogenic complications of the neuraxial blockade. Its incidence has steadily declined with advances in anesthesia techniques, improved knowledge of pathophysiology, and the implementation of preventable measures. However, it has the potential to cause signifi cant morbidity in affected individuals. This article introduces a new non-invasive and cost-effective treatment for PDPH termed DISH10 (Deep Inspiration, Squeeze & Hold for 10 seconds) maneuver. It also describes the essential steps involved in the DISH10 maneuver and discusses various biomechanics associated with these steps. We hypothesize that the DISH10 maneuver hastens spontaneous recovery by increasing intrathoracic and intraabdominal pressure and provides quick relief.Methods: This comparative cohort study includes 100 PDPH patients in three years, from January 2018 to March 2021. This study is divided into two groups. Group 1 included a prospective case series of 50 patients of PDPH treated with DISH10 maneuver. Group 2 included a retrospective cohort of 50 patients of PDPH treated with conventional conservative management with or without sphenopalatine ganglion block (SPGB). The demographics, type of neuraxial anesthesia, size/type of spinal needle, time to develop headache, and time to outcome were noted.Results: The incidence of PDPH was higher with 25G spinal needles (Quincke) in both the groups (82% in DISH10 and 74% in group 2) than with 27G spinal needles (Whitacre). The median of time to outcome (time to make patients symptom-free) with DISH10 maneuver was signifi cantly lower (7 hours) than the conservative group (48 hours). All 50 patients in Group 1 (case series) became symptoms-free and ready to discharge within 24 hours of commencement of the DISH10 maneuver. Conclusion:The DISH10 maneuver has shown better results than conventional conservative management with or without SPGB in terms of treatment duration, time to discharge, and total hospital stays, making the DISH10 maneuver a cost-effective option.

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Intraoperative events are not uncommon to any anesthesiologist. For every case inside the operating room, some major or minor events always occur related to patient, surgery, or anesthesia. Managing such events depends on the skill and experience of the anesthesiologist. When it becomes unmanageable due to undiagnosed and unanticipated conditions, it creates a “tug of war” situation inside the operating room. So, screening of such unidentied undiagnosed conditions is an essential aspect of the pre-anesthesia checkup. Unfortunately, sometimes due to asymptomatic presentations in non-stress conditions, it becomes difcult to screen them before surgery.We describe such an event of an intraoperative hypertensive crisis that remained undiagnosed before and after surgery leading to continuing suspense.

Aims: The expanded horizon of the ultrasound-guided erector spinae plane block (ESPB) shows promising results in various surgeries involving the thoracic, abdominal, pelvic, joint, and spine regions. We aimed to administer ESPB in spine surgery of the early pediatric age group patient to reduce the overall requirement of the intraoperative general anesthetic drugs and postoperative opioids due to high analgesic demands. Presentation of Case: We report the application of ultrasound-guided bilateral ESPB as multimodal analgesia (MMA) component in the spine surgery of the youngest (2-year old) age group. Discussion: Spine surgeries, especially scoliosis surgeries, are associated with extensive surgical dissection, leading to significant postoperative nociception causing high analgesic demands and necessitating high opioid consumption. It further leads to opioid-related side effects, delay in discharge, late ambulation, and prolonged hospital stay. The ESPB potentially helps in controlling polypharmacy by providing wide multisegmented analgesic coverage due to its multidirectional drug spread pattern. There are upcoming concerns regarding anesthesia-induced developmental neurotoxicity and the detrimental effect of general anesthesia in developing children. Such concerns can be addressed by cutting down the requirement of general anesthetic agents to a minimum level with the help of modalities like MMA incorporating regional analgesia (RA) as an adjunct. Conclusion: The ESPB can be a safe and effective adjunct to the MMA in providing opioid-free optimal analgesia in spine surgery of the youngest population.

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