Combined spinal and epidural anaesthesia (CSE) is a

regional anaesthetic Local anesthesia is any technique to induce the absence of sense, sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as we ...

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 or opioid into the subar ...

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 an ...

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 CSE 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 CSE 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 in England that publishes guidelines in four areas: * the use of health technologies withi ...

(September 2007) specifically recommends CSE 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 feeling in a specific area. In nerve blocks, it is injected around a nerve that supplies the area, or into the spinal canal's epidural space. I ...

and

fentanyl Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocain ...

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 A Tuohy (/tOO-ee/) needle is a hollow hypodermic needle A hypodermic needle (from Greek ὑπο- (''hypo-'' = under), and δέρμα (''derma'' = skin)), one of a category of medical tools which enter the skin, called sharps, is a very ...

(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 In neuroanatomy, dura mater is a thick membrane made of dense irregular connective tissue that surrounds the brain and spinal cord. It is the outermost of the three layers of membrane called the meninges that protect the central nervous system. ...

, 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 body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates. CSF is produced by specialised ependymal cells in the choroid plexus of the ventricles of the ...

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 pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general ...

(e.g.

) is then instilled. An

opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...

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 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 or opioid into the subara ...

. 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. 120mm) may be required.Alternatively, several manufacturers produce packs containing both a spinal and an epidural needle which are slightly modified to fit together.

Complications

CSE in labouring women is associated with more pruritus if fentanyl (25μg) is given intrathecally, than low-dose epidural analgesia. However, no difference has been found in the incidence of

post dural puncture headache Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes around the brain and spinal cord). The headache is severe and described as "searing and spreading like hot metal", involving the back and fro ...

, requirement for

epidural blood patch An epidural blood patch (EBP) is a surgical procedure that uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture or epidural. The procedure can be used to ...

or maternal hypotension. It is unknown if infections are more likely to happen during CSE when comparing with 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