Combined spinal–epidural techniques

Consultant Anaesthetist, Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
Anaesthesia (Impact Factor: 3.38). 02/2000; 55(1):42-64. DOI: 10.1046/j.1365-2044.2000.01157.x
Source: PubMed


The combined spinal-epidural technique has been used increasingly over the last decade. Combined spinal-epidural may achieve rapid onset, profound regional blockade with the facility to modify or prolong the block. A variety of techniques and devices have been proposed. The technique cannot be considered simply as an isolated spinal block followed by an isolated epidural block as combining the techniques may alter each block. This review concentrates on technical and procedural aspects of combined spinal-epidural. Needle-through-needle, separate-needle and combined-needle techniques are described and modifications discussed. Failure rates and causes are reviewed. The problems of performing a spinal block before epidural blockade (potential for unrecognised placement of an epidural catheter, inability to detect paraesthesia during epidural placement, difficulty in testing the epidural, delay in positioning the patient) are described and evaluated. Problems of performing spinal block after epidural blockade (risk of catheter or spinal needle damage) are considered. Mechanisms of modification of spinal blockade by subsequent epidural drug administration are discussed. The review considers choice of technique, needle type, patient positioning and paramedian vs. midline approach. Finally, complications associated with combined spinal-epidural are reviewed.

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    • "It combines the advantages of spinal as well as epidural blocks and avoids their disadvantages. Several CSE techniques are described, but needle-through-needle is the most widely reported technique in the literature and is likely to be the most frequently used.[1] Needle-through-needle CSE requires that subarachnoid blockade is initiated before placing and securing the epidural catheter. "
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    ABSTRACT: Needle-through-needle combined spinal-epidural (CSE) may cause significant delay in patient positioning resulting in settling down of spinal anaesthetic and unacceptably low block level. Bilateral hip flexion has been shown to extend the spinal block by flattening lumbar lordosis. However, patients with lower limb fractures cannot flex their injured limb. This study was conducted to find out if unilateral hip flexion could extend the level of spinal anaesthesia following a prolonged CSE technique. Fifty American Society of Anesthesiologists (ASA) I/II males with unilateral femur fracture were randomly allocated to Control or Flexion groups. Needle-through-needle CSE was performed in the sitting position at L2-3 interspace and 2.6 ml 0.5% hyperbaric bupivacaine injected intrathecally. Patients were made supine 4 min after the spinal injection or later if epidural placement took longer. The Control group patients (n=25) lay supine with legs straight, whereas the Flexion group patients (n=25) had their uninjured hip and knee flexed for 5 min. Levels of sensory and motor blocks and time to epidural drug requirement were recorded. There was no significant difference in sensory levels at different time-points; maximum sensory and motor blocks; times to achieve maximum blocks; and time to epidural drug requirement in two groups. However, four patients in the Control group in contrast to none in the Flexion group required epidural drug before start of surgery. Moreover, in the Control group four patients took longer than 30 min to achieve maximum sensory block. To conclude, unilateral hip flexion did not extend the spinal anaesthetic level; however, further studies are required to explore the potential benefits of this technique.
    Indian journal of anaesthesia 05/2011; 55(3):247-52. DOI:10.4103/0019-5049.82668
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    • "For diagnostic lumbar puncture, the left lateral recumbent position (for right-handed physicians) is preferred. Ill patients are generally unable to sit up and the sitting position increases the risk of headaches post-puncture, probably because the CSF pressure and flow is higher than in the lateral recumbent position (Norris et al., 1994; Cook, 2000). Furthermore, if any pressure measurements are done (Van Dellen and Bill, 1978; Adams et al., 1997), the patient must be in the lateral recumbent position. "
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    ABSTRACT: The safe and successful performance of a lumbar puncture demands a working and specific knowledge of anatomy. Misunderstanding of anatomy may result in failure or complications. This review attempts to aid understanding of the anatomical framework, pitfalls, and complications of lumbar puncture. It includes special reference to 3D relationships, functional and imaging anatomy, and normal variation. Lumbar puncture is carried out for diagnostic and therapeutic purposes. Epidural and spinal anesthesia, for example, are common in obstetric practice and involve the same technique as diagnostic lumbar puncture except that the needle tip is placed in the epidural space in the former. The procedure is by no means innocuous and anatomical pitfalls include inability to find the correct entry site and lack of awareness of structures in relation to the advancing needle. Headache is the most common complication and it is important to avoid traumatic and dry taps, herniation syndromes, and injury to the conus medullaris. With a thorough knowledge of the contraindications, regional anatomy and rationale of the technique, and adequate prior skills practice, a lumbar puncture can be carried out safely and successfully.
    Clinical Anatomy 01/2004; 17(7):544-53. DOI:10.1002/ca.10250 · 1.33 Impact Factor
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    • "While the needle-through-needle technique remains the most popular, commercial kits such as the ''back-eye'' Touhy and double-barrel needles are available. Because this technique's use has grown tenfold in the past decade [55], future studies may further define the optimal spinal drug and dose for use with the combined method [56]. "
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    ABSTRACT: In summary, regional techniques offer significant advantages in the outpatient setting. They can avoid the side effects of nausea, vomiting, and pain that frequently delay discharge or cause admission. They can also provide prolonged analgesia as well as offer, with the use of continuous catheters, the promise of a pain-free perioperative period. The choice of drugs must be carefully adjusted, especially with neuraxial techniques. Despite frequently requiring some additional time at the outset, regional techniques have consistently been shown to provide competitive discharge times and costs when compared with general anesthesia. They deserve a prominent place in outpatient surgery.
    Anesthesiology Clinics of North America 07/2003; 21(2):289-303. DOI:10.1016/S0889-8537(02)00071-8
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