Journal of Anesthesia (2022) 36:441–443

https://doi.org/10.1007/s00540-022-03058-3

SHORT COMMUNICATION

Genesis of “negative pressure” during hanging drop; the answer

is positive pressure
Masayuki Miyabe1

Received: 5 February 2022 / Accepted: 13 March 2022 / Published online: 7 April 2022
© The Author(s) under exclusive licence to Japanese Society of Anesthesiologists 2022

Abstract
A drop of saline placed within the hub of an epidural needle is sucked in when the needle is advanced and penetrates through
a polyurethane foam cube. This phenomenon might be explained by the release of compressed air inside of the needle into
the air. The positive pressure inside of the needle may be generated by advancing of the needle. To prove this hypothesis,
the pressure inside of the needle was measured during needle advancement, and it increased gradually and then dropped to
zero suddenly when the needle fully penetrated the polyurethane foam block. We can speculate that the same phenomenon
occurs during hanging-drop method of epidural anesthesia, and this may occur regardless of whether epidural subatmospheric
pressure exists or not.

Keywords Epidural anesthesia · Hanging drop method · Negative pressure

In 1933, Guttierez 1 first described the hanging-drop method
whereby a drop of saline hanging in the hub of an epidural
needle was aspirated when the needle entered the epidural
space. The theory behind this maneuver has been attributed
to subatmospheric pressure in the epidural space. However,
Bryce-Smith 2 showed that epidural space pressure is not
negative. On the other hand, Zarzur 3 reported that the sub-
atmospheric pressure is related to expansion of the epidural
space as the needle pushes the dura away from the ligamen-
tum flavum.
The same phenomenon that is a drop of saline placed
within the hub of the epidural needle is “sucked in” when
the needle is advanced 1 cm and penetrates through a polyu-
rethane foam cube (Fig 1A, B). To confirm the principle
underlying this phenomenon, the pressure inside of the nee-
dle was measured during advancement through a polyure-
thane foam block.
A 17 DG, 80 mm epidural needle (Hakko Co., Ltd.,
Tuohy) was inserted into a cube of side 3 cm of polyurethane
foam. The insertion depth was measured, and the tip of the
needle placed 10 mm, 5 mm, or 2.5 mm from the opposite
wall. Before advancing, a pressure transducer with air-filled
tubing was connected to the epidural needle. The needle
was then advanced at a constant speed manually until fully
penetrating the cube. Pressure was measured using a biologi-
cal monitor (Nihon Koden Corp.) and recorded using digital
camera (Canon IXY 630, Canon Inc.).
During needle advancement, the pressure inside of the
needle increased gradually and then immediately dropped to
zero when the needle penetrated through the polyurethane
foam block (Fig. 2). The highest pressure measured was
about 5 mmHg after 10 mm advancement (Fig. 2A), about
2.5 mmHg after 5mm (Fig. 2B), and about 1.25 mmHg after
2.5 mm (Fig. 2C) respectively.
Polyurethane foam is not necessarily similar to ligamen-
tum flavum. However, it is highly airtight as ligamentum
flavum, inside of the pressure increased during advancing
needle. Furthermore, Suwa 4 reported that inside of the pres-
sure of epidural needle increased during advancing needle
through ligament of flavum in human. From these phenom-
ena, it is speculated polyurethane foam mimics ligament of
flavum.

* Masayuki Miyabe
miyabemyb@gmail.com
1
Department of Clinical Anesthesiology, Mie University
Hospital, Tsu, 2‑174 Edobashi, Mie 514‑8507, Japan

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Fig. 1  A Shows the hub of the needle filling with normal saline until
a drop of saline was observed hanging from the hub. B Shows the
drop of saline sucked into needle after fully penetrating the polyure-
thane cube.

Aspiration of the hanging drop of an epidural needle was

observed after penetration through a polyurethane cube. In
this study the pressure of inside of needle increased accord-
ing to the distance of needle movement and dropped to zero
after penetration through a polyurethane foam cube. Taking
together this phenomenon and the results of the study we
can speculate that “aspiration” of the hanging drop during
epidural anesthesia is caused by the release of compressed
air inside of the needle into the epidural space. Positive pres-
sure inside the needle may be generated by the advancing
of the needle. We can speculate this may occur regardless
of whether epidural subatmospheric pressure exists or not. Fig. 2.  Intra-epidural needle pressure trace. A shows trace when epi-
dural needle was advanced 10 mm and penetrated the polyurethane
cube. B shows trace of 5 mm advancing. C shows trace of 2.5 mm
advancing.

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References 4. Suwa T, Inomata S, Saito S, Toyooka H. Pressure-guided method

for identification of the epidural space in children. Anesthesiology.
1998;89:546–8.
1. Aldrete JA, Auad OA, Gutierrez VP, Wright AJ. Alberto
Gutierrez and the hanging drop. Region Anesth Pain Med.
Publisher's Note Springer Nature remains neutral with regard to
2005;30:397–404.
jurisdictional claims in published maps and institutional affiliations.
2. Bryce-Smith R. Pressures in the extra-dural space. Anaesthesia.
1950;5:213–6.
3. Zarzur E. Genesis of the “true” negative pressure in the lumbar
epidural space A new hypothesis. Anaesthesia. 1984;39:1101–4.

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