Combined spinal and epidural anaesthesia is a regional anaesthetic technique, which combines the benefits of both

spinal anaesthesia Spinal anaesthesia (or spinal anesthesia), also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic with or without an opi ...

and

epidural anaesthesia Epidural administration (from Ancient Greek ἐπί, "upon" + '' dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians ...

and analgesia. The spinal component gives a rapid onset of a predictable block. The indwelling epidural catheter gives the ability to provide long lasting analgesia and to titrate the dose given to the desired effect.

Indications

This technique also allows for better post operative pain relief. The epidural catheter may be left in place for up to 72 hours if required. In labouring women, the onset of analgesia is more rapid with combined spinal and epidural anaesthesia compared with epidural analgesia.Simmons SW, Cyna AM, Dennis AT et al. Combined spinal-epidural versus epidural analgesia in labour. pdate of Cochrane Database of Systematic Reviews 2003; 4. CD003401 Cochrane Database of Systematic Reviews 2007; 4. CD003401 Combined spinal and epidural anaesthesia in labour was formerly thought to enable women to mobilise for longer compared with epidural analgesia, but this is not supported by a recent Cochrane review. In the UK, the

National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care (United Kingdom), Department of Health and Social Care. As the national health technolog ...

(September 2007) recommends combined spinal and epidural anaesthesia for women who require rapid onset of analgesia in labour. It further recommends the use of

bupivacaine Bupivacaine, marketed under the brand name Marcaine among others, is a medication used to decrease sensation in a specific small area. In nerve blocks, it is injected around a nerve that supplies the area, or into the spinal canal's epidural ...

and

fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...

to establish the block.

Insertion technique

Combined spinal-epidural anaesthesia is a highly specialised technique which should only be administered by a properly trained anaesthetic practitioner working with full

aseptic technique Asepsis is the state of being free from disease-causing micro-organisms (such as pathogenic bacteria, viruses, pathogenic fungi, and parasites). There are two categories of asepsis: medical and surgical. The modern day notion of asepsis is deri ...

. The ''needle-through-needle'' technique involves the introduction of a Tuohy needle (epidural needle) into the

epidural space In anatomy, the epidural space is the potential space between the dura mater and vertebrae ( spine). The anatomy term "epidural space" has its origin in the Ancient Greek language; , "on, upon" + dura mater also known as "epidural cavity", "e ...

. The standard technique of loss of resistance to injection may be employed. A long fine spinal needle (25G) is then introduced via the lumen of the epidural needle and through the dura mater, into the subarachnoid space. A small ''pop'' is felt as the dura is punctured, and the correct position is confirmed when

cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless Extracellular fluid#Transcellular fluid, transcellular body fluid found within the meninges, meningeal tissue that surrounds the vertebrate brain and spinal cord, and in the ventricular system, ven ...

can be seen dripping from the spinal needle. A small dose of

local anaesthetic A local anesthetic (LA) is a medication that causes absence of all sense, sensation (including pain) in a specific body part without loss of consciousness, providing local anesthesia, as opposed to a general anesthetic, which eliminates all sen ...

(e.g.

) is then instilled. An

opioid Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...

such as

may also be given if desired. The spinal needle is then withdrawn and the epidural catheter inserted in the standard manner. Alternatively, a ''two-level'' approach may be undertaken. The epidural space is first located in the standard manner. Then, at another level, a standard spinal is performed. Finally, the epidural catheter is threaded through the Tuohy needle.

Maintenance technique

When the epidural catheter has been inserted, the techniques of maintenance of block are very similar to those of epidural anaesthesia. The intensity of the block may be adjusted as desired. Large doses of local anaesthetic can produce sufficient anaesthesia for surgery. Alternatively, smaller doses can provide analgesia, e.g. in the postoperative period.

Equipment

A standard epidural pack may be used with a standard spinal needle. However, the standard length of a spinal needle (90mm) may be insufficiently long to reach the subarachnoid space through the Tuohy needle. An extra-long needle (e.g., 120 mm) may be required. Alternatively, several manufacturers produce packs containing both a spinal and an epidural needle which are slightly modified to fit together.

Complications

Combined spinal and epidural anaesthesia in labouring women is associated with more pruritus if fentanyl (25 μg) is given intrathecally, than low-dose epidural analgesia. However, no difference has been found in the incidence of post dural puncture headache, requirement for

epidural blood patch An epidural blood patch (EBP) is a surgical procedure that uses autologous blood, meaning the patient's own blood, in order to close one or many holes in the dura mater of the spinal cord, which occurred as a complication of a lumbar puncture ...

or maternal hypotension. It is unknown if infections are more likely to happen during combined spinal and epidural anaesthesia compared to spinal or epidural techniques. Post-dural-puncture headache has a similar incidence rate (0.8 to 2.5%) to the conventional epidural.

References

{{DEFAULTSORT:Combined Spinal And Epidural Anaesthesia Regional anesthesia