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Epidural and combined spinal-epidural anesthesia: Techniques

Authors
Unyime Ituk, MBBS, FCARCSI
Cynthia A Wong, MD
Section Editor
Robert Maniker, MD
Deputy Editor
Marianna Crowley, MD

INTRODUCTION

Epidural anesthesia is a type of neuraxial anesthesia; local anesthetic (LA) is injected into the epidural space to anesthetize the spinal nerve roots that traverse the space. Epidural anesthesia is used for anesthesia of abdominal, pelvic, and lower extremity procedures and, less commonly, thoracic procedures. It may be used to supplement general anesthesia for thoracic, abdominal, and pelvic procedures and for postoperative analgesia following these procedures. The usual technique involves siting a catheter in the epidural space. LA solution and adjuvants are administered through the catheter, both to initiate and maintain anesthesia for the duration of the surgical procedure.

This topic will discuss the relevant anatomy, techniques, and management of epidural and combined spinal-epidural anesthesia. The technique for spinal anesthesia is discussed separately. (See "Spinal anesthesia: Technique" and "Overview of neuraxial anesthesia".)

SPINAL VERSUS EPIDURAL ANESTHESIA

Spinal, epidural, and combined spinal-epidural (CSE) anesthesia can be used for many of the same surgical procedures. Differences among them may affect the choice of technique for a specific procedure or patient. The advantages and disadvantages of the various neuraxial anesthesia techniques are shown in a table (table 1). Spinal anesthesia is usually administered as a single shot, whereas epidural anesthesia is usually administered via a catheter (thus it is a continuous technique), and CSE anesthesia combines the two.

Catheter-based neuraxial anesthesia (ie, epidural, CSE, and continuous spinal) allows prolonged anesthesia and titration of the onset of the anesthetic. Single-shot spinal or epidural anesthesia is limited to the duration of action of the injected drug.

ANATOMY

Epidural anesthesia is performed by introducing a needle between the lumbar, thoracic, or cervical vertebrae and injecting anesthetic medication into the epidural space, via the epidural needle and/or a catheter inserted through the needle into the epidural space (figure 1). Detailed anatomy of the bony spine and vertebrae are discussed separately (figure 2 and figure 3) (see "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Anatomy'). This topic will focus on lumbar and thoracic epidural anesthesia/analgesia. Cervical epidural injections are done mostly for pain procedures and are outside the scope of this topic.

                                    
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Literature review current through: Sep 2017. | This topic last updated: Jul 25, 2017.
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References
Top
  1. Margarido CB, Mikhael R, Arzola C, et al. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Can J Anaesth 2011; 58:262.
  2. Broadbent CR, Maxwell WB, Ferrie R, et al. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia 2000; 55:1122.
  3. Lirk P, Messner H, Deibl M, et al. Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia. Acta Anaesthesiol Scand 2004; 48:347.
  4. Nishi M, Usukaura A, Kidani Y, et al. Which is a better position for insertion of a high thoracic epidural catheter: sitting or lateral decubitus? J Cardiothorac Vasc Anesth 2006; 20:656.
  5. Longbottom J, Clegg I, Bhatia K. Should ultrasound of the spine be mandatory before performing a lumbar central neuraxial block? Br J Hosp Med (Lond) 2014; 75:178.
  6. Perna P, Gioia A, Ragazzi R, et al. Can pre-procedure neuroaxial ultrasound improve the identification of the potential epidural space when compared with anatomical landmarks? A prospective randomized study. Minerva Anestesiol 2017; 83:41.
  7. Salman A, Arzola C, Tharmaratnam U, Balki M. Ultrasound imaging of the thoracic spine in paramedian sagittal oblique plane: the correlation between estimated and actual depth to the epidural space. Reg Anesth Pain Med 2011; 36:542.
  8. Antibas PL, do Nascimento Junior P, Braz LG, et al. Air versus saline in the loss of resistance technique for identification of the epidural space. Cochrane Database Syst Rev 2014; :CD008938.
  9. Mhyre JM, Greenfield ML, Tsen LC, Polley LS. A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement. Anesth Analg 2009; 108:1232.
  10. Banwell BR, Morley-Forster P, Krause R. Decreased incidence of complications in parturients with the arrow (FlexTip Plus) epidural catheter. Can J Anaesth 1998; 45:370.
  11. Segal S, Eappen S, Datta S. Superiority of multi-orifice over single-orifice epidural catheters for labor analgesia and cesarean delivery. J Clin Anesth 1997; 9:109.
  12. D'Angelo R, Foss ML, Livesay CH. A comparison of multiport and uniport epidural catheters in laboring patients. Anesth Analg 1997; 84:1276.
  13. Michael S, Richmond MN, Birks RJ. A comparison between open-end (single hole) and closed-end (three lateral holes) epidural catheters. Complications and quality of sensory blockade. Anaesthesia 1989; 44:578.
  14. Spiegel JE, Vasudevan A, Li Y, Hess PE. A randomized prospective study comparing two flexible epidural catheters for labour analgesia. Br J Anaesth 2009; 103:400.
  15. Norris MC, Fogel ST, Dalman H, et al. Labor epidural analgesia without an intravascular "test dose". Anesthesiology 1998; 88:1495.
  16. Norris MC, Ferrenbach D, Dalman H, et al. Does epinephrine improve the diagnostic accuracy of aspiration during labor epidural analgesia? Anesth Analg 1999; 88:1073.
  17. Beilin Y, Arnold I, Telfeyan C, et al. Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient. Reg Anesth Pain Med 2000; 25:596.
  18. Harrison GR, Clowes NW. The depth of the lumbar epidural space from the skin. Anaesthesia 1985; 40:685.
  19. Lai HC, Liu TJ, Peng SK, et al. Depth of the thoracic epidural space in paramedian approach. J Clin Anesth 2005; 17:339.
  20. Afshan G, Chohan U, Khan FA, et al. Appropriate length of epidural catheter in the epidural space for postoperative analgesia: evaluation by epidurography. Anaesthesia 2011; 66:913.
  21. Beilin Y, Bernstein HH, Zucker-Pinchoff B. The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space. Anesth Analg 1995; 81:301.
  22. Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology 1997; 86:778.
  23. Williams SR, Belliveau M, Brulotte V, Ruel MM. Impact of thoracic epidural catheter threading distance on analgesia during the first 24 hours following thoracotomy: a randomized controlled trial. Can J Anaesth 2016; 63:691.
  24. Igarashi T, Hirabayashi Y, Shimizu R, et al. The epidural structure changes during deep breathing. Can J Anaesth 1999; 46:850.
  25. Takeyama K, Yamazaki H, Maeda M, et al. Straight advancement of epidural catheter--comparative assessments by method and site of epidural needle puncture and angle of puncture. Tokai J Exp Clin Med 2004; 29:27.
  26. Guay J. The epidural test dose: a review. Anesth Analg 2006; 102:921.
  27. Mackie K, Lam A. Epinephrine-containing test dose during beta-blockade. J Clin Monit 1991; 7:213.
  28. Mulroy MF, Neal JM, Mackey DC, Harrington BE. 2-Chloroprocaine and bupivacaine are unreliable indicators of intravascular injection in the premedicated patient. Reg Anesth Pain Med 1998; 23:9.
  29. Browne IM, Birnbach DJ, Stein DJ, et al. A comparison of Espocan and Tuohy needles for the combined spinal-epidural technique for labor analgesia. Anesth Analg 2005; 101:535.
  30. McNaught AF, Stocks GM. Epidural volume extension and low-dose sequential combined spinal-epidural blockade: two ways to reduce spinal dose requirement for caesarean section. Int J Obstet Anesth 2007; 16:346.
  31. Thorén T, Holmström B, Rawal N, et al. Sequential combined spinal epidural block versus spinal block for cesarean section: effects on maternal hypotension and neurobehavioral function of the newborn. Anesth Analg 1994; 78:1087.
  32. Fan SZ, Susetio L, Wang YP, et al. Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section--a balance block technique. Anesth Analg 1994; 78:474.
  33. Choi DH, Ahn HJ, Kim JA. Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery. Int J Obstet Anesth 2006; 15:13.
  34. Dhir VB, Sharma AG, Kaur M, Gulabani M. Inadvertent high spinal anesthesia as sequelae to epidural injection of normal saline. Anesth Essays Res 2015; 9:109.
  35. Griffiths RB, Horton WA, Jones IG, Blake D. Speed of injection and spread of bupivacaine in the epidural space. Anaesthesia 1987; 42:160.
  36. Kanai A, Suzuki A, Hoka S. Rapid injection of epidural mepivacaine speeds the onset of nerve blockade. Can J Anaesth 2005; 52:281.
  37. Veering BT, Burm AG, van Kleef JW, et al. Epidural anesthesia with bupivacaine: effects of age on neural blockade and pharmacokinetics. Anesth Analg 1987; 66:589.
  38. Viscusi ER, Candiotti KA, Onel E, et al. The pharmacokinetics and pharmacodynamics of liposome bupivacaine administered via a single epidural injection to healthy volunteers. Reg Anesth Pain Med 2012; 37:616.
  39. Martin R, Lamarche Y, Tétreault L. Comparison of the clinical effectiveness of lidocaine hydrocarbonate and lidocaine hydrochloride with and without epinephrine in epidural anaesthesia. Can Anaesth Soc J 1981; 28:217.
  40. Capogna G, Celleno D, Fusco P, et al. Relative potencies of bupivacaine and ropivacaine for analgesia in labour. Br J Anaesth 1999; 82:371.
  41. Polley LS, Columb MO, Naughton NN, et al. Relative analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: implications for therapeutic indexes. Anesthesiology 1999; 90:944.
  42. Graf BM, Abraham I, Eberbach N, et al. Differences in cardiotoxicity of bupivacaine and ropivacaine are the result of physicochemical and stereoselective properties. Anesthesiology 2002; 96:1427.
  43. Dony P, Dewinde V, Vanderick B, et al. The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats. Anesth Analg 2000; 91:1489.
  44. Scott DB, Lee A, Fagan D, et al. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989; 69:563.
  45. Knudsen K, Beckman Suurküla M, Blomberg S, et al. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997; 78:507.
  46. Cox CR, Faccenda KA, Gilhooly C, et al. Extradural S(-)-bupivacaine: comparison with racemic RS-bupivacaine. Br J Anaesth 1998; 80:289.
  47. Hess PE, Snowman CE, Hahn CJ, et al. Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia. J Clin Anesth 2006; 18:29.
  48. Grice SC, Eisenach JC, Dewan DM. Labor analgesia with epidural bupivacaine plus fentanyl: enhancement with epinephrine and inhibition with 2-chloroprocaine. Anesthesiology 1990; 72:623.
  49. Palmer CM, Nogami WM, Van Maren G, Alves DM. Postcesarean epidural morphine: a dose-response study. Anesth Analg 2000; 90:887.
  50. Lanz E, Kehrberger E, Theiss D. Epidural morphine: a clinical double-blind study of dosage. Anesth Analg 1985; 64:786.
  51. Singh SI, Rehou S, Marmai KL, Jones PM. The efficacy of 2 doses of epidural morphine for postcesarean delivery analgesia: a randomized noninferiority trial. Anesth Analg 2013; 117:677.
  52. Grass JA, Sakima NT, Schmidt R, et al. A randomized, double-blind, dose-response comparison of epidural fentanyl versus sufentanil analgesia after cesarean section. Anesth Analg 1997; 85:365.
  53. Carvalho B, Roland LM, Chu LF, et al. Single-dose, extended-release epidural morphine (DepoDur) compared to conventional epidural morphine for post-cesarean pain. Anesth Analg 2007; 105:176.
  54. Gambling D, Hughes T, Martin G, et al. A comparison of Depodur, a novel, single-dose extended-release epidural morphine, with standard epidural morphine for pain relief after lower abdominal surgery. Anesth Analg 2005; 100:1065.
  55. Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002; 94:1598.
  56. Sakura S, Sumi M, Morimoto N, Saito Y. The addition of epinephrine increases intensity of sensory block during epidural anesthesia with lidocaine. Reg Anesth Pain Med 1999; 24:541.
  57. Abboud TK, DerSarkissian L, Terrasi J, et al. Comparative maternal, fetal, and neonatal effects of chloroprocaine with and without epinephrine for epidural anesthesia in obstetrics. Anesth Analg 1987; 66:71.
  58. Burm AG, van Kleef JW, Gladines MP, et al. Epidural anesthesia with lidocaine and bupivacaine: effects of epinephrine on the plasma concentration profiles. Anesth Analg 1986; 65:1281.
  59. Lee BB, Ngan Kee WD, Plummer JL, et al. The effect of the addition of epinephrine on early systemic absorption of epidural ropivacaine in humans. Anesth Analg 2002; 95:1402.
  60. Dobrydnjov I, Axelsson K, Gupta A, et al. Improved analgesia with clonidine when added to local anesthetic during combined spinal-epidural anesthesia for hip arthroplasty: a double-blind, randomized and placebo-controlled study. Acta Anaesthesiol Scand 2005; 49:538.
  61. Milligan KR, Convery PN, Weir P, et al. The efficacy and safety of epidural infusions of levobupivacaine with and without clonidine for postoperative pain relief in patients undergoing total hip replacement. Anesth Analg 2000; 91:393.
  62. DiFazio CA, Carron H, Grosslight KR, et al. Comparison of pH-adjusted lidocaine solutions for epidural anesthesia. Anesth Analg 1986; 65:760.
  63. Capogna G, Celleno D, Laudano D, Giunta F. Alkalinization of local anesthetics. Which block, which local anesthetic? Reg Anesth 1995; 20:369.
  64. Ackerman WE, Juneja MM, Denson DD, et al. The effect of pH and PCO2 on epidural analgesia with 2% 2-chloroprocaine. Anesth Analg 1989; 68:593.
  65. Berrada R, Chassard D, Bryssine S, et al. [In vitro effects of the alkalinization of 0.25% bupivacaine and 2% lidocaine]. Ann Fr Anesth Reanim 1994; 13:165.
  66. Ramos G, Pereira E, Simonetti MP. Does alkalinization of 0.75% ropivacaine promote a lumbar peridural block of higher quality? Reg Anesth Pain Med 2001; 26:357.
  67. Lam DT, Ngan Kee WD, Khaw KS. Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation. Anaesthesia 2001; 56:790.
  68. Bonhomme L, Benhamou D, Jebri M, et al. Chemical stability of bupivacaine in pH-adjusted solutions. Anesthesiology 1988; 69:754.
  69. Loubert C. Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development. Can J Anaesth 2012; 59:604.
  70. Beilin Y, Zahn J, Bernstein HH, et al. Treatment of incomplete analgesia after placement of an epidural catheter and administration of local anesthetic for women in labor. Anesthesiology 1998; 88:1502.
  71. Furst SR, Reisner LS. Risk of high spinal anesthesia following failed epidural block for cesarean delivery. J Clin Anesth 1995; 7:71.
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