Combined Spinal-Epidural Technique

Background For the past 16 years the combined spinal-epidural (CSE) technique has been extensively researched and developed to the point where it is now in widespread use. Along with the use of low-dose mixtures of local anesthetics and opioids, and the introduction of fine-gauge pencil-point needles, CSE is being increasingly recognized as another important addition to the armamentarium of the anesthesiologist. Method One hundred and forty-two publications focusing on the CSE technique, or on questions concerning CSE-related issues, were reviewed. Out of 33 double-blind or controlled studies, 23 directly investigated the CSE technique. Fifty-four prospective studies and letters made directly relevant points on advantages or problems with CSE. Twenty-one book chapters, reviews and editorials were included, 11 of them concerning the use of CSE technique. Results All CSE techniques which may be used for surgical anesthesia, for analgesia in labor or for postoperative pain management are described. Indications, advantages, disadvantages, and the various methods for performing CSE procedures, including sequential CSE block, are described and reviewed, along with the equipment currently available for their administration. Conclusion The CSE technique offers many potential advantages over continuous epidural or subarachnoid methods alone, including a reduction in drug dosage, the ability to eliminate motor blockade and to achieve highly selective sensory blockade and optimize analgesia. These features hold great promise for minimizing the hazards and side effects of traditional epidural and subarachnoid techniques. Controversial fears, risks, and pitfalls of the CSE technique and of continuous epidural and subarachnoid methods are debated and discussed.

[1]  N. Rawal,et al.  Epidural and intrathecal opioids for postoperative pain management in Europe — a 17‐nation questionnaire study of selected hospitals , 1996, Acta anaesthesiologica Scandinavica.

[2]  A. Dahan,et al.  Mechanism of Action of an Epidural Top-Up in Combined Spinal Epidural Anesthesia , 1996, Anesthesia and analgesia.

[3]  M. Takasaki,et al.  Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia , 1996, Anesthesia and analgesia.

[4]  N. Herman,et al.  No additional metal particle formation using the needle‐through‐needle combined epidural/spinal technique , 1996, Acta anaesthesiologica Scandinavica.

[5]  G. Ostheimer,et al.  Pain relief and anesthesia in obstetrics , 1996 .

[6]  M. Peterson,et al.  Combined spinal-epidural anesthesia for outpatient surgery. Dose-response characteristics of intrathecal isobaric lidocaine using a 27-gauge Whitacre spinal needle. , 1995 .

[7]  P. Barry,et al.  Another complication of the combined extradural-subarachnoid technique. , 1995, British journal of anaesthesia.

[8]  R. Fernando,et al.  Accidental intrathecal insertion of an extradural catheter during combined spinal-extradural anaesthesia for caesarean section. , 1995, British journal of anaesthesia.

[9]  S. Datta,et al.  The Addition of Bupivacaine to Intrathecal Sufentanil for Labor Analgesia , 1995, Anesthesia and analgesia.

[10]  D. Davies,et al.  Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour , 1995, The Lancet.

[11]  P. Juelsgaard,et al.  Combined Spinal and Epidural Anesthesia , 1995, Anesthesia and analgesia.

[12]  N. Rawal,et al.  Risk of Catheter Migration During Combined Spinal Epidural Block: Percutaneous Epiduroscopy Study , 1995, Anesthesia and Analgesia.

[13]  N. Rawal.  European trends in the use of Combined Spinal Epidural technique - A 17-nation survey , 1995, Regional anesthesia and pain medicine.

[14]  G. Lyons.  Epidural is an outmoded form of regional anaesthesia for elective caesarean section. Proposer. , 1995, International journal of obstetric anesthesia.

[15]  R. Collis,et al.  Meningitis after combined spinal-extradural anaesthesia in obstetrics. , 1995, British journal of anaesthesia.

[16]  D. Buggy,et al.  Posterior column sensory impairment during ambulatory extradural analgesia in labour. , 1995, British journal of anaesthesia.

[17]  B. T. Sitzman,et al.  Comparison of the force required for dural puncture with different spinal needles and subsequent leakage of cerebrospinal fluid. , 1994, Anesthesia and analgesia.

[18]  B. Leighton,et al.  Complications of Labor Analgesia , 1994 .

[19]  D. G. Hughes,et al.  Combined spinal and epidural anaesthesia for inguinal hernia repair in babies , 1994 .

[20]  J. Eisenach,et al.  Intrathecal Sufentanil Compared to Epidural Bupivacaine for Labor Analgesia , 1994, Anesthesiology.

[21]  D. Kopacz,et al.  Effect of Needle Puncture on Morphine and Lidocaine Flux through the Spinal Meninges of the Monkey In Vitro: Implications for Combined Spinal-Epidural Anesthesia , 1994, Anesthesiology.

[22]  A. Santos,et al.  Current Controversies in Obstetric Anesthesia , 1994, Anesthesia and analgesia.

[23]  Ya-Jung Cheng,et al.  Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section--a balance block technique. , 1994, Anesthesia and analgesia.

[24]  S. Simmons,et al.  Patient‐controlled Analgesia in Pregnancy , 1994, International anesthesiology clinics.

[25]  E. Vandermeersch.  Combined spinal-epidural anaesthesia , 1996 .

[26]  James,et al.  Intrathecal sufentanil labor analgesia: the effects of adding morphine or epinephrine. , 1994, Anesthesia and analgesia.

[27]  B. Leighton,et al.  Spinal Anesthesia for Cesarean Delivery: A Comparison of Two Doses of Hyperbaric Bupivacaine , 1993, Regional Anesthesia & Pain Medicine.

[28]  Y. El‐Sayed,et al.  Intrathecal sufentanil for labor analgesia--sensory changes, side effects, and fetal heart rate changes. , 1993, Anesthesia and analgesia.

[29]  F. Carli,et al.  Effect of extradural diamorphine on analgesia after caesarean section under subarachnoid block. , 1993, British journal of anaesthesia.

[30]  M. Vercauteren,et al.  Combined continuous spinal‐epidural anaesthesia with a single interspace, double‐catheter technique , 1993, Anaesthesia.

[31]  R. Stacey,et al.  Single space combined spinal-extradural technique for analgesia in labour. , 1993, British journal of anaesthesia.

[32]  J. Thorp,et al.  The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. , 1993, American journal of obstetrics and gynecology.

[33]  P. W. Bailey,et al.  Cardiorespiratory arrest following combined spinal epidural anaesthesia for Caesarean section , 1993, Anaesthesia.

[34]  N. Rawal,et al.  Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery , 1993, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[35]  B. Duffy.  “Don't Turn the Needle!” , 1993, Anaesthesia and intensive care.

[36]  P. Armstrong,et al.  Continuous subarachnoid infusion of local anaesthetic , 1993, Anaesthesia.

[37]  M. Baxandall,et al.  Combined spinal epidural analgesia with ability to walk throughout labour , 1993, The Lancet.

[38]  S. Datta,et al.  Intrathecal Sufentanil for Labor Analgesia: Effects of Added Epinephrine , 1993, Regional Anesthesia & Pain Medicine.

[39]  S. Mccarroll,et al.  Evaluation of Combined Spinal-Epidural Anesthesia Using Two Different Techniques , 1993, Regional Anesthesia & Pain Medicine.

[40]  B. Leighton,et al.  Comparison among intrathecal fentanyl, meperidine, and sufentanil for labor analgesia. , 1992, Anesthesia and analgesia.

[41]  J. Westbrook,et al.  An evaluation of a combined spinal/epidural needle set utilising a 26‐gauge, pencil point spinal needle for Caesarean section , 1992, Anaesthesia.

[42]  S. Datta,et al.  A comparison of intrathecal, epidural, and intravenous sufentanil for labor analgesia. , 1992, Anesthesiology.

[43]  D. Ryall,et al.  Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. , 1992, British journal of anaesthesia.

[44]  M. Popat,et al.  Epidural needle rotation and inadvertent dural puncture with catheter , 1992, Anaesthesia.

[45]  S. Morley,et al.  Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study , 1992, Pain.

[46]  J. Eldor,et al.  Combined spinal-epidural anesthesia using the CSEN. , 1992, Anesthesia and analgesia.

[47]  S. Datta,et al.  Anesthesia for cesarean delivery. Part I: general considerations and spinal anesthesia. , 1992, International journal of obstetric anesthesia.

[48]  S. Datta,et al.  Anesthesia for cesarean delivery. Part II: epidural anesthesia intrathecal and epidural opioids venous air embolism. , 1992, International journal of obstetric anesthesia.

[49]  C. Rodeck,et al.  Maternal and fetal haemodynamic effects of spinal and extradural anaesthesia for elective caesarean section. , 1992, British journal of anaesthesia.

[50]  M. Ramsay,et al.  Epidural injection does cause an increase in CSF pressure. , 1991, Anesthesia and analgesia.

[51]  J. Rosenfeld,et al.  Epidural Abscess Associated with Postoperative Epidural Analgesia , 1991, Anaesthesia and intensive care.

[52]  J. Hughes,et al.  A technique to avoid dural puncture by the epidural catheter , 1991, Anaesthesia.

[53]  R. Telford,et al.  Observations on deliberate dural puncture with a Tuohy needle: pressure measurements , 1991, Anaesthesia.

[54]  M. Tunstall.  Incremental spinal anaesthesia and caesarean section--relevance to the test dose for extradural analgesia. , 1991, British journal of anaesthesia.

[55]  Finucane Bt.  Danger of metallic particles in the spinal-epidural spaces using the needle-through-needle approach. , 1991 .

[56]  T. Abboud,et al.  Effect of Subarachnoid Morphine on the Incidence of Spinal Headache , 1991, Regional Anesthesia & Pain Medicine.

[57]  N. Rawal,et al.  Intrathecal morphine 0.2 mg versus epidural bupivacaine 0.125% or their combination: effects on parturients. , 1991, Anesthesiology.

[58]  H. Aken,et al.  KSE - die Kombination aus spinaler und epiduraler Anaesthesie , 1991 .

[59]  P. Raj.  Clinical practice of regional anesthesia , 1991 .

[60]  J. Egmond,et al.  A Double-Needle Technique for Spinal Anesthesia to Prevent Post-Spinal Headache , 1991 .

[61]  S. Cotev,et al.  Epidural morphine injections for the treatment of postspinal headache , 1990, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[62]  M. Césarini,et al.  Sprotte needle for intrathecal anaesthesia for Caesarean section: incidence of postdural puncture headache , 1990, Anaesthesia.

[63]  J. Šimša.  Device to maintain the position of a 29‐gauge spinal needle , 1990, Anaesthesia.

[64]  Torben Æ. Mogensen,et al.  Prevention of postoperative pain by balanced analgesia. , 1990, British journal of anaesthesia.

[65]  B. Morgan.  Unexpectedly extensive conduction blocks in obstetric epidural analgesia , 1990, Anaesthesia.

[66]  F. Reynolds,et al.  The subdural space: the third place to go astray , 1990, Anaesthesia.

[67]  S. Datta,et al.  Influence of local anesthetic solution on postdural puncture headache. , 1985, Anesthesiology.

[68]  L. Carrie.  Epidural versus combined spinal epidural block for caesarean section , 1988, Acta anaesthesiologica Scandinavica.

[69]  S. Datta,et al.  Epidural versus combined spinal epidural block for cesarean section , 1988, Acta anaesthesiologica Scandinavica.

[70]  B. Meiklejohn.  The effect of rotation of an epidural needle , 1987, Anaesthesia.

[71]  Kumaran Cm.  Combined subarachnoid and epidural block for caesar ean section , 1987 .

[72]  I. Russell.  EFFECT OF POSTURE DURING THE INDUCTION OF SUBARACHNOID ANALGESIA FOR CAESAREAN SECTION Right v. Left Lateral , 1987 .

[73]  B. Dennison.  Combined subarachnoid and epidural block for Caesarean section , 1987, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[74]  E. Abouleish.  Postpartum Tubal Ligation Requires More Bupivacaine for Spinal Anesthesia Than Does Cesarean Section , 1986, Anesthesia and analgesia.

[75]  R. Macdonald,et al.  Possible subarachnoid migration of an epidural catheter , 1986, Anaesthesia.

[76]  A. G. Van der Donck,et al.  Motor Blockade During Epidural Anesthesia , 1986, Anesthesia and analgesia.

[77]  J. S. Crawford.  Some maternal complications of epidural analgesia for labour , 1985, Anaesthesia.

[78]  G. O'Sullivan,et al.  Subarachnoid bupivacaine 0.5% for caesarean section. , 1984, European journal of anaesthesiology.

[79]  J. Thorburn,et al.  Bupivacaine toxicity in association with extradural analgesia for caesarean section. , 1984, British journal of anaesthesia.

[80]  R. Nickalls,et al.  A modification of the combined spinal and epidural technique , 1983, Anaesthesia.

[81]  F. M. James,et al.  Neonatal Neurobehavioral Responses after Epidural Anesthesia for Cesarean Section Using Lidocaine and Bupivacaine , 1982, Anesthesia and analgesia.

[82]  J. Aulakh,et al.  Anaesthesia for caesarean section. A medical audit of junior anaesthetic staff practice. , 1983, British journal of anaesthesia.

[83]  I. Russell.  Spinal anaesthesia for caesarean section. The use of 0.5% bupivacaine. , 1983, British journal of anaesthesia.

[84]  R. Wilkes,et al.  Hypotension during epidural analgesia for Caesarean section , 1983 .

[85]  R. Riegler,et al.  [Unremovable epidural catheter due to a sling and a knot. A rare complication of epidural anesthesia in obstetrics]. , 1983, Regional-Anaesthesie.

[86]  A. Lewiński,et al.  Epidural morphine for the prevention of headache following dural puncture , 1982, Anaesthesia.

[87]  M. Coates,et al.  Combined subarachnoid and epidural techniques , 1982 .

[88]  R. Hodgkinson,et al.  Total Spinal Block After Epidural Injection into an Interspace Adjacent to an Inadvertent Dural Perforation , 1981, Anesthesiology.

[89]  P. Brownridge.  Epidural and subarachnoid analgesia for elective Caesarean section , 1981, Anaesthesia.

[90]  S. Datta,et al.  Anesthesia for cesarean section. , 1980, Anesthesiology.

[91]  P. Slattery,et al.  An aid to identification of the subarachnoid space with a twenty‐five gauge needle , 1980, Anaesthesia.

[92]  R. Husemeyer,et al.  Topography of the lumbar epidural space , 1980, Anaesthesia.

[93]  R. Ravindran,et al.  Apparent intravascular migration of epidural catheter. , 1979, Anesthesia and analgesia.

[94]  I. Curelaru.  Long duration subarachnoid anaesthesia with continuous epidural block. , 1979, Praktische Anasthesie, Wiederbelebung und Intensivtherapie.

[95]  J. Robson,et al.  Latent dural puncture after lumbar epidural block. , 1977, Anesthesia and analgesia.

[96]  D. Thompson,et al.  Prevention of spinal hypotension associated with Cesarean section. , 1976, Anesthesiology.

[97]  J. Philip,et al.  Total spinal anesthesia late in the course of obstetric bupivacaine epidural block. , 1976, Anesthesiology.

[98]  M. Frumin.  Spinal Anesthesia Using a 32-gauge Needle , 1969, Anesthesiology.

[99]  D. Barclay,et al.  The influence of inferior vena cava compression on the level of spinal anesthesia. , 1968, American journal of obstetrics and gynecology.