Dural puncture epidural for caesarean delivery in a parturient with multiple sclerosis

A 30‐year‐old woman with a history of multiple sclerosis (MS) presented for elective caesarean delivery. Her MS had relapsed during the first trimester with right upper and lower limb sensory deficit, lower limb weakness and difficulty walking necessitating treatment with natalizumab. Her symptoms had resolved by the third trimester. She was referred for anaesthesia assessment prior to her planned caesarean delivery, where she expressed a strong desire to be awake for childbirth.

A dural puncture epidural (DPE) was performed for this patient: Following insertion of a Touhy needle into the epidural space at the L4–L5 interspace, a dural puncture was undertaken by needle through needle passage of a 27G pencil‐point spinal needle. Clear cerebrospinal fluid was observed, but no medication was administered through the spinal needle. An epidural catheter was then inserted and test dose of 3 ml bupivacaine 0.5% was administered, followed by 8 ml lidocaine 2% and 8 ml bupivacaine 0.5%. Surgery proceeded after assessment of the block; the patient had no pain during the procedure with adequate sensory and motor blockade. She made an uneventful recovery with no recurrence of neurological symptoms.

Epidural anaesthesia has traditionally been favoured for obstetric procedures in patients with MS and is felt to be a potentially safer option than spinal anaesthesia due to the protection offered by the dural membrane and avoiding direct administration of intrathecal local anaesthetic. The efficacy of epidural anaesthesia for caesarean delivery is, however, reduced compared to spinal anaesthesia and conversion rate to general anaesthesia is higher. Although not directly contraindicated, spinal anaesthesia for this patient may have posed a theoretical higher risk given antenatal relapse of symptoms. We felt the DPE technique could enhance the efficacy of the epidural block in a patient with recently unstable multiple sclerosis presented for caesarean delivery while avoiding the potential concerns around the direct administration of local anaesthetic into the thecal sac.

A recently described technique for labour analgesia is the DPE, comprising puncture of the dural membrane with a spinal needle without intrathecal medication administration and then insertion of an epidural catheter which is used as normal. The DPE has been shown to provide more rapid onset and reliable analgesia than standard epidural analgesia when using a 25G pencil‐point needle [1]. One possible mechanism that may explain this effect is enhanced transfer of medication through the dural hole into the thecal sac. Furthermore, the presence of an epidural catheter or the introduction of air or saline into the negative pressure epidural space may alter the dynamics of intrathecal local anaesthetic. Goy and Sia reported faster onset and a higher sensory block versus single‐shot spinal anaesthesia when a combined spinal epidural without epidural medication administration was used [2]. The hypothesis is that the dynamics of the thecal sac may be altered by introducing atmospheric pressure to the epidural space. So with the DPE technique, enhanced anaesthetic and analgesic outcomes may be due to the combination of partial transfer of some intrathecal anaesthetic combined with an altered thecal sac volume or pressure that can enhance the block compared with epidural alone.

There are few indications for de novo epidural anaesthesia in the setting of planned caesarean delivery. We suggest that performing a DPE technique for planned caesarean delivery in patients with recently symptomatic multiple sclerosis may be an optimal compromise between the benefits of epidural and spinal anaesthesia.

Competing interests

No external funding and no competing interests declared. Published with written consent of the patient.