Despite concerns of masking pain that may be secondary to compartment syndrome, this case demonstrates that compartment syndrome can be diagnosed in the presence of effective regional anesthesia. Careful clinical evaluation coupled with a high index of suspicion is essential in the timely diagnosis and effective treatment of compartment syndrome.

Introduction Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache. Methods A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC). Results There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F (2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4–4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5–1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9–2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6–3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0–2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9–2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7–2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6–2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689). Discussion Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.

T he recent article by Epaud et al. 1 reinforces the need for anesthesiologists to be comfortable with the flexible fiberoptic intubation technique. I read with great concern that a neurologic injury occurred because of the choice of videolaryngoscopy as the intubation approach because the operator was more familiar with that technique. Was the decision to use videolaryngoscopy a result of our anesthesiology training programs shifting the focus of difficult airway training to videolaryngoscopy because this technique is readily available and relatively easy to use compared to flexible fiberoptic intubation? It has been demonstrated that videolaryngoscopy does not significantly reduce cervical spine movement compared to direct laryngoscopy 2 and, unfortunately, patient harm occurred in the authors' case presentation.The authors endorse that flexible fiberoptic intubation could have been used to avoid injury; the use of fiberoptic intubation mitigates cervical spine movement because it is flexible and can be manipulated in difficult anatomy presentations. A randomized clinical trial showed that there was no difference in intubation time and success rate 3 between videolaryngoscopy and flexible fiberoptic intubation in experienced hands. That is the key: experience! Anesthesiology residency programs should not compromise training in flexible fiberoptic intubation because of the relative ease of use and convenience of videolaryngoscopy, and American Board of Anesthesiology/Accreditation Council for Graduate Medical Education requirements should reflect this.

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Uterine and placental pathology can be a major cause of morbidity and mortality in the parturient and infant. When presenting alone, placental abruption, uterine rupture, or placenta accreta can result in significant peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality. We present the anesthetic management of a parturient who underwent an urgent cesarean delivery for non-reassuring fetal tracing in the setting of chronic hypertension, preterm premature rupture of membranes, and chorioamnionitis who was subsequently found to have placental abruption, uterine rupture, and placenta accreta.

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Placement of an epidural blood patch is the gold standard treatment for a postdural puncture headache when conservative measures have failed. If unsuccessful in relieving the symptoms, a second epidural blood patch may be warranted. However, when the accepted gold standard treatment has failed, alternative therapies may be pursued. A pterygopalatine ganglion block has been shown to be effective as an alternative to epidural blood patch placement. This case demonstrates the use of a suprazygomatic pterygopalatine ganglion block as a rescue technique for failed repeated epidural blood patch, with complete and permanent resolution of the headache.

Postdural puncture headache (PDPH) is a complication of dural puncture. An epidural blood patch (EBP) is the standard treatment; however, when EBP fails, alternative treatments and/or diagnoses must be considered. We present a case of orthostatic headache initially diagnosed as PDPH but likely due to spontaneous intracranial hypotension. It is imperative for anesthesiologists, as members of an interdisciplinary peripartum team, to be familiar with the evaluation and treatment of postpartum headache and recognize when further workup and consultation may be indicated.