SummaryThe records .from 34 819 obstetric epidurals performed at Birmingham Maternity Hospital over the period 1969-1988 were examined. During that time there were 460 dural taps (overall incidence 1.3%). Of the methods used to detect the epidural space, loss of resistance to injection of saline was associated with the lowest incidence of dural tap (0.6%). The incidence of typical postdural puncture headache when managed conservatively was 86%. Provision of an epidural drip after delivery reduced the incidence of headache to 70%. Elective .forceps delivery conferred no additional benefit. and tended to delay the onset of headache. Blood patches were perjormed on 135 patients and provided complete relief of headache in 93 (68%). A .further 23 patients (16%) obtained partial relief: Key wordsAnaesthetic techniques, regional; epidural. Complications; dural puncture. Anaesthesia; obstetric.The epidural service at Birmingham Maternity Hospital (BMH) was started in 1968. During the 20-year period 1969-1988, full records of 34 819 epidurals were collected in a standardised way and were available for scrutiny; 460 inadvertent dural punctures (dural taps) were documented.The size of this database offered an unparalleled opportunity to investigate factors affecting the incidence of dural tap in the obstetric patient, and the prevention and management of its sequelae. Although very low dural tap rates have been reported, this problem can never be totally eliminated wherever an epidural service is offered. Subsequent postdural puncture headache (PDPH) can be a particularly distressing condition in this group of patients. It is important that the anaesthetist be well-informed of the implications of dural tap and the management options available. so that this distress can be minimised.
Recent studies have identified a subpopulation of craniosynostotic individuals who exhibit progressive or delayed-onset synostosis and mild craniofacial growth abnormalities. These individuals may be good candidates for nonextirpation, distraction osteogenesis therapy. The present study was designed to test this hypothesis by using internal calvarial bone distraction in a rabbit model with familial delayed-onset craniosynostosis. Data were collected from 159 rabbits: 71 normal controls, 72 with delayed-onset coronal suture synostosis, 8 with delayed-onset coronal suture synostosis and coronal suturectomy, and 8 with delayed-onset coronal suture synostosis and distraction. At 10 days of age, all rabbits had amalgam markers placed on both sides of the frontonasal, coronal, and anterior lambdoidal sutures. At 25 days of age, correction was accomplished through either a 5-mm-wide suturectomy or distraction osteogenesis. An internal distraction appliance was fixed to the frontal and parietal bones and percutaneously and intermittently activated at an average of 0.10 mm/day for 42 days (4.11 mm total). Serial radiographs were taken at 10, 25, 42, and 84 days of age. Results revealed that rabbits with delayed-onset synostosis had significantly (p < 0.01) reduced coronal suture growth rates (0.04 mm/day) compared with the other three groups (0.07 mm/day). Rabbits with suturectomy and rabbits with distraction showed similar coronal suture responses. However, from 42 to 84 days of age, rabbits with distraction showed reduced growth at the vault sutures and abnormal growth patterns in cranial vault width, cranial vault shape, and cranial base angulation compared with the other three groups. Results demonstrated that, although the normal coronal suture growth rate was maintained in rabbits with delayed-onset synostosis using intermittent distraction osteogenesis, normal adult craniofacial structure was not achieved. Such anomalous growth was probably a result of altered growth vectors and compressive forces at adjacent sutures during distraction. These findings suggest that distraction osteogenesis without corticotomy may be a treatment alternative in individuals with progressive, delayed-onset synostosis, but that internal appliances that generate low-level, continuous distractive forces should be investigated and developed.
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