175

ANESTH ANALG
1 YXS.67.17i9

Inadvertent Subdural Injection:

A Complication of an Epidural Block
Timothy Lubenow, MD, Elisa Keh-Wong,
and Anthony D. Ivankovich, MD

MD,

LUBENOW T, KEH-WONG E, KRlSTOF K.

IVANKOVICH 0, IVANKOVICH AD. Inadvertent
subdural injection: a complication of an epidural block
Anesth Analg 1988;67:175-9.

Tzilenty-one h i d r e d eighty two consecutizle lzirribar epidural injections zcwe studied to determine the incidence of
iriaiiziertent subdural hlock retrcispectiuel!/. A sitbtliiral
block is defined as an estensiz1e neurd block in the absence
of S I ~ J U Y ~ C pzriicturc,
~ ~ J O ~ ~ that is out of proportion to the
amount of local anesthetic injected. Siibdural injection is a

It is generally accepted that the subdural space exists

in the cerebral meninges. The potential extension of
this subdural space, however, down into the spinal
segment of the meninges has not been well appreciated. This subdural space can have clinical significance when local anesthetics are inadvertently deposited there, causing unexpected sensory, sympathetic,
and motor blocks.
Clinically the extraarachnoid space has been demonstrated during myelograms with an incidence reported between 1 and 13%(1-3). This extraarachnoid
subdural space lies between the dura and arachnoid
membranes. It contains a small amount of serous
fluid to moisten the surfaces of the opposing membranes. While not communicating with the subarachnoid space, the extra-arachnoid subdural space does
continue for a short distance along the cranial and
spinal nerves (4). It is larger in the cervical than in
lumbar region, and is widest in its lateral and dorsal
aspects (5). Here, there is free communication with
the lymphatic vessels of the spinal nerves. Moreover,
there are isolated connective-tissue trabeculae, especially on the posterior aspect, which contact the
Presented at the 61st Congress of the International Anesthesia
Research Society, March 1418, 1987, Orlando, Florida.
Received from the Department of Anesthesiology, Rush Prysbyterian St. Lukes Medical Center, Chicago, Illinois. Accepted for
publication on Oct. 1, 1987.

Kathy Kristof,

BSN,

Olga Ivankovich,

MD,

conr;ilicntioii of epidural block that probabl!y occiirs t i l o w

frequently than previously recognized. An earlier report /ins
esfiinnted the incidence of siibdlird block to be 0 . 7 5%. This
study, liozuezlcr, reports a n incidence of 0.82% froni a
sample size of 2182 patients. Cndarwic dissection 700s also
~~erforiried,
fiirtlier clarifying tlic presence a n d ariiztcnnic
position of the siibdurnl spare.
Key Words: ANESTHETIC TECHNIQUESepidural.

inside surface of the dura and the outside surface of

the arachnoid.
Accidental subdural injections were first described
by de Saram (6) and Dawkins (7), but no large series
have examined its occurrence. There has been several
case reports of accidental subdural catheterizations
that have been radiographically confirmed (&lo).
Dawkins description of a massive epidural fits the
clinical presentation of an inadvertent subdural injection. He describes an unexpected widespread nerve
block occurring after a negative aspiration test associated with symptoms such as pupillary dilation,
consistent with a high sympathetic block. In addition,
the patients experienced a 20-minute delay in the
onset of symptoms. This is in contrast to an accidental subarachnoid injection in which symptoms characteristically develop in 1-2 minutes. The purpose of
this study is to retrospectively evaluate a large series
of epidural injections to determine the incidence of
inadvertent subdural block.

Methods
During the 30-month study period (March 1984September 1986), 2182 lumbar epidural steroid injections were performed at the Pain Center for various
forms of low back pathology. During this period any
patient whu exhibited any untoward or unpleasant

176

LUBENOW ET AL.

ANESlH ANALG
1988:67 1 7 5 9

side effects from the injection (e.g., headache, hypotension, nausea, motor or extensive sensory block)
was identified for follow-up. The patients ranged in
age from 17 to 86 years and each received a single
epidural injection via a lumbar interspace, between
L1 and L5. The blocks were performed by an attending anesthesiologist or a supervised resident using
bupivacaine, 4-6 cc of 0.25% or 6-8 cc of 0.125%, in
combination with methylprednisolone acetate 80-120
mg (Depo Medrol, Upjohn Company, Kalamazoo,
Michigan). The epidural space was identified by the
loss-of-resistance technique. After a careful negative
aspiration test, injections were performed with disposable 17- or 18-gauge Touhy point needles. Aspiration was routinely done before, during, and after
each injection. After the injections, the patients were
observed for approximately 1 hour before discharge
from the center.
Records were evaluated in the following manner
for the presence or absence of clinical findings consistent with subdural injection. I n any patient exhibiting a complication as mentioned above, a detailed
description of the complication and clinical findings
was obtained and recorded in the patients chart at
the time of occurrence. Clinical findings were classified into two levels of criteria, major and minor.
Findings considered major criteria were: 1)a negative
aspiration test, or 2) an unexpected widespread sensory block after epidural injection. The three minor
criteria were: 1)a delayed onset of 10 minutes or more
of a sensory or motor nerve block, 2) a variable motor
blockade occurring, despite use of low doses of
bupivacaine, or 3 ) sympatholysis out of proportion to
the administered dose of local anesthetic. A positive
subdural injection was judged to have occurred in
both of the major criteria and at least one minor
criteria were present. With the criterion of negative
aspiration test we excluded any patient who had a
wet tap before the apparent successful epidural injection. All of these records of morbid events were then
retrospectively evaluated by one reviewer (TL) to
determine if criteria for a subdural block were
present. From 38 potential subdural injections, 18
were judged by an additional investigator (ADI) as
having met the criteria for a subdural injection.

Results
Eighteen patients met the criteria for a subdural
block, establishing an incidence of 0.82%. One patient exhibited all three minor criteria, while an
additional seven patients displayed two of the minor
criteria (Table 1).

All 18 patients developed sensory levels much

higher than would be expected from the amount of
local anesthetic administered. One patient had a
sensory level of C4 after injection of 6 cc of 0.25%
bupivacaine. In none of the 18 patients was CSF
aspirated. Ten of the 18 patients developed motor
block. Delayed onset times of greater than 10 minutes
were noted in 11 patients (61%)with the longest time
to onset of symptoms being 30 minutes. Hypotension, defined as a drop in systolic pressure of at least
30% from baseline, occurred in 11 patients. Eight of
the 11 patients had moderate to severe hypotension
with a drop in pressure greater than 40% of the
baseline. Six of these patients had severe decreases in
blood pressures. In all cases, hypotension responded
to fluids or ephedrine ( 5 1 5 mg).
Five of the 18 patients (2870) had had previous
back surgery. These five patients represent a higher
percentage of patients than what is seen in our
overall patient population (12%)).Six of the 18 received 0.25% bupivacaine, while 12 received 0.125%
bupivacaine.
Further studies were also performed on cadavers
to provide additional information on the subdural
space. The existence of the subdural space was confirmed by cadaveric dissection. A lumbar laminectomy was performed and the spinal cord and meninges were exposed from the S1 to the L1 levels.
Dissected dura mater was found to have two layers:
an outer, thicker, opaque layer and an inner, more
translucent layer. Deep to these layers there existed a
potential space easily identified after reflecting the
dura mater. The arachnoid mater was noted to be a
translucent membrane separating the subdural space
from the subarachnoid space. Deep to the arachnoid
mater the spinal nerves and subarachnoid space were
identified. Our depiction of the anatomy is similar to
the description made 23 years ago by Sechzer (11).

Discussion
Epidural nerve blocks occasionally exhibit an atypical
pattern of spread. This may be caused by relative
overdose or accidental injection into the subdural or
subarachnoid spaces. Several investigators have
demonstrated radiological confirmation of catheters
present in the subdural space, especially in cases of
massive epidurals (8,12). A recent report describes
the ease of intentional subdural puncture and further
suggests that accidental subdural puncture may occur
in attempted epidural block even in experienced
hands (13). Consequently, it appears that accidental
subdural injection probably occurs more frequently
than previouslv recognized.

INADVERTENT SUBDURAL INlECTlON OF EPIDURAL BLOCK

ANESTH ANALG

177

1988,67 175-9

Table 1. Summary of Patient Data

Bupivacaine
Patient concentration
Aspiration Level Sensory
(%)
Vol.
test
injected
level
no.
1

0.25

T12-Ll

T4

0.25

L4-5

L2

0.25

L34

T4

0.125

L34

T2

5
6

0.125
0.125

8
8

L34
L34

T10
TI2

0.125

L34

T6

8
9

0.125
0.125

8
8

L34
L45

TI2
T8

10

0.125

L2-3

T10

11

14

0.125
0.25
0.125
0.125

8
6
8
8

L M
L34
L1-2
L4-5

L10
T10
T6
T10

15

0.125

L2-3

T4

16

0.125

L34

T9

17

0.25
0.25

6
6

L45
L3-4

c4
T2

12
13

18

Onset
time Recovery
(min) time (hr)

Motor
block

Degree of
hypotension

Dense, LE
bilateral
Dense, LE
bilateral
Moderate,
LE bilateral
Moderate,
LE bilateral
None
Mild LE
bilateral
Dense, LE
bilateral
None
None

40%)

10

3.5

None

10

50%

Mild, LE
bilateral
None
None
None
Dense, Le
bilateral
Moderate,
LE bilateral
Dense, LE
bilateral
None
None

Previous
back
surgery

Major Minor
criteria criteria
met
met
2

4.0

Yes, fusion
L 4 5 , 5-s1
No

-7

10

3.0

NO

50%

20

6.0

No

-7

None
None

5
5

3.0
2.0

No
No

None

3.0

No

30%
50%

30
30

2.0
2.0

None

10

4.0

No
Yes, LAM
x 2
Yes, LAM

None
30%
404
None

10
5
20
5

2.0
1.5
3.0
3.0

Yes, LAM
No
Yes, LAM
No

2
2
2

1
1
2
I

50%

3.0

No

None

2.0

N0

50%
50%

10
15

3.0
3.5

No
No

1
1

2
2

1
2

LAM, laminectorny, LE, lower extrcmity

Intentional neurolytic subdural puncture has been

previously described (14). This technique involves
identification of the epidural space using the loss-ofresistance technique. The needle is then rotated
through an arc of 180" with applied gentle pressure.
In order to avoid accidental subdural puncture, the
authors believe that a properly placed epidural needle should never be rotated to point the bevel in a
superior or inferior position. If one rotates the needle
to produce an intentional subdural puncture, this
same practice, if repeated for an epidural block, may
produce an accidental subdural puncture.
The three most common features noted in this
study were: 1) an unexpectedly high sensory block, 2)
exaggerated hypotension, and 3) unexpected motor
block. An interesting characteristic of subdural blocks
in the study is the variability in onset time. The
fastest onset time was between 5 and 10 minutes,
while other patients did not notice symptoms or
exhibit signs until 30 minutes after injection. These
findings do not differ significantly from other studies.
Case reports have documented the onset of symptoms to be as long as 30 minutes. Other descriptions

of accidental subdural injections have reported onsets

to be as short as 7 minutes (15). We believe that
subdural blocks do exhibit a variability in onset time.
This is dependent, perhaps, upon the relative
amount of local anesthetic deposited in the subdural
space, and may also be responsible for the widespread sensory block and exaggerated hypotension.
Another explanation for the unexpected high sensory
and sympathetic blocks may be that previous back
surgery produced scarring and cicatrization, thereby
partly obliterating the epidural space in the lower
lumbar area. This partial obliteration of the epidural
space may cause marked cephalad spread. There are,
however, many exceptions to this hypothesis. Only 5
of the 19 patients had had previous back surgery. The
patients who had the most dramatic symptoms (patients 3, 4, and 17) had had no back surgery. Three of
the six patients who had previous back surgery
(Patients 10, 11, and 13) were among those who
exhibited the mildest symptoms. The presence of
previous back surgery with deformity of the epidural
space does not explain all of the observed events.
However, it appears that patients who have had back

178

ANESTH ANALG
1988.67:17'59

LUBENOW ET A1

Figure 1. This illustration depicts relative position of intrathecal, epidural,

and subdural needle placement. Note
that if the needle is in the subdural
space, with the dura straddling the
bevel, some of the local anesthetic
may be deposited in the subdural
space while some will be placed in the
epidural space.

surgery are more prone to accidental subdural injection. This is likely because the anatomy may be
altered secondary to scarring and retraction, producing a thin epidural and wide subdural space.
Epidural blocks seem more likely to produce accidental subdural injection than do spinal blocks. This
may be due to differences in technique and the type
of needle used. Epidural injections use a large, blunttipped, long-bevel needle that is introduced very
slowly, sometimes a millimeter at a time. In contrast,
for a subarachnoid puncture, a thinner, sharper needle is introduced, usually at a much faster rate. It is
more likely that the blunt needle tip will pierce the
dura without piercing the arachnoid. The large opening of the epidural needle may straddle the subdural
and epidural, allowing part of the local anesthetic to be
injected into the subdural space while some of it could
be deposited in the epidural space (Fig. 1). This
partitioning of anesthetic may explain the difference in
degree of symptoms. Patients experiencing profound
sensory and motor block obviously would have had
more anesthetic deposited in the subdural space.
Another explanation regarding the difference in
symptomatology may relate in part to the anatomic
distribution of sensory, sympathetic, and motor
nerve fibers. The anterior nerve roots carry motor and
sympatlietic nerve fibers, while sensory fibers are
within posterior nerve roots. Because the subdural
space has more potential capacity posteriorly and
laterally, one should expect a sensory block. Meanwhile, a motor or sympathetic block would be present
only if local anesthetic traveled anteriorly within this

subdural space (Fig. 2). Therefore, positioning of the

patient after the block would influence the type of
block to a large extent. Moreover, a motor and
sympathetic block would occur more readily if a
patient were in the lateral position, whereas sensory
block would predominate if the patient were supine
after the injection.
The absence of significant hypotension, in conjunction with a profound motor block as demonstrated by some of our patients, may reflect hydration
status more than anything else. The hypotension
seen in our patients was dramatic in certain cases, but
was easily treated in all cases with relatively small
amounts of fluid (250-500 cc) and small doses of
ephedrine. Only one patient required 15 mg ephedrine. All others with hypotension responded to 5 or
10 mg ephedrine. Hypotension, which is easily
treated, has been a feature of all previously confirmed
subdural injections (16). This contrasts accidental
subarachnoid injection where hypotension is characteristically more profound and difficult to correct.
The cadaveric dissection was perforined to further
exemplify the presence and anatomic proportion of
the subdural space. It is well accepted that the subdural space exists in the cerebral meninges, and that
certain clinical entities are seen when pathology is
present in the subdural space (e.g., subdural hematoma). However, the extension of the subdural space
down into the spinal segment of the meninges has
been previously regarded by some authors as having
questionable clinical significance (4). Our dissection
supports the presence of the subdural space within

INADVERTENT SUBDURAL INJECTION OF EPIDURAL BLOCK

ANESTH ANALG
19SS;h7 175-9

179

Figure 2. This illustration shows the

anatomic relationship of dura and
arachnoid. The subdural space exists
as a potential space encircling the
arachnoid membrane and contained
within the dura.

the spinal cord segment of the meninges. A previous

study on autopsy subjects has also portrayed the
subdural space as a readily identifiable potential
space. In our dissection, the potential subdural space
and its relationship to the dura and arachnoid membranes was found to be similar to its portrayal by
other authors (4,11,13). As depicted in Figure 1, a
needle may pierce the dura but not the arachnoid and
be contained within the subdural space. Local anesthetics, if deposited here, can travel cephalad and
caudad in this narrow potential space, producing the
unexpected extensive sensory, sympathetic, and motor blocks encountered in this series of therapeutic
epidural drug depositions.
In conclusion, after subdural deposition of a local
anesthetic, the development of an extensive sensory
and motor block, with or without hypotension, may
occur up to 30 minutes after the injection. The differential diagnosis of a possible subdural injection
should be entertained as readily as one would suspect a subarachnoid injection. A subdural block
should be considered when there has been extensive
sensory or motor blockade after a negative CSF
aspiration test when small volumes and dilute concentrations of local anesthetics are utilized. We recommend that outpatients receiving epidural injections of any amount of local anesthetics be observed
for at least 1 hour before discharge because of potential for a subdural injection.

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