Inadvertent subarachnoid injection of a local anesthetic during the conduct of epidural anesthesia may have a devastating effect on the patient. The incidence of dural puncture with an epidural catheter has been reported to range from 0.5% to 0.9%. This case report demonstrates that, despite negative aspiration of cerebral spinal fluid from the catheter, subarachnoid injection of a local anesthetic can occur.
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