Background and Aims Continuous spinal anaesthesia (CSA) used in orthopedics has the advantage of immediate pain relief and anesthetic block achievement with minimum incremental anaesthetic doses. Nevertheless, in the elderly, insertion is often difficult, attributed to bone spur formation or other anatomical irregularities. We present a case with deliberate dural puncture and intrathecal epidural catheter insertion after unsuccessful attempts for CSA.

Methods A 90 y, 46kg BW, 1.58m HT woman was admitted for intramedullary nailing of a subtrochanteric right femoral fracture. Her medical history comprised serious senile dementia, three previous operations, a recent transient ischemic cerebral event and METs<4. Her labs were: Hgb 9.3g/dL, Hct 27.8%, PLTs 289000, PT 10.3sec, APTT 30.9sec and INR 0.96. CSA was attempted but after several attempts dural puncture was unfeasible due to spine deformities. A regular 18G Tuohy needle (Espocan®, B Braun) was inserted at L3–4 level and after CSF leakage at 6cm from skin, a conventional epidural 20G catheter (Perifix® Soft tip, B Braun, Meslungen, Germany) was inserted and secured at 10 cm from skin.1 ml 0.5% (5 mg) levobupivacaine was infused through an insulin syringe. An additional increment of 0.5 ml (2.5mg) was needed to achieve a T5 anesthetic level.

Results No further dose was needed, neither hypotension was noted. The catheter was removed at the end of the procedure; sensory block lasted 3 h. No post puncture headache was noted.

Conclusions Deliberate dural puncture and intrathecal epidural catheter placement is a safe and efficient alternative when high gauge spinal catheter is difficult to insert.