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Epidural blockade is one of the most useful and versatile procedures in modern anesthesiology. It is unique in that it can be placed at virtually any level of the spinal spine, allowing more flexibility in its application to clinical practice. It is more versatile than spinal anesthesia, giving the clinician the opportunity to provide anesthesia and analgesia, as well as enabling diagnosis and treatment of chronic disease syndromes. It can be used to supplement general anesthesia, decreasing the need for deep levels of general anesthesia, therefore providing a more hemodynamically stable operative course and faster emergence from general anesthesia. It provides better postoperative pain control and more rapid recovery from surgery. When combined with spinal anesthesia in a technique called a CSE (combined spinal-epidural), benefits of both techniques can be combined and shortcomings of each avoided.

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Numerous studies have demonstrated the benefits of epidural blockade. Epidural anesthesia or analgesia can reduce the adverse physiologic responses to surgery such as autonomic hyperactivity, cardiovascular stress, tissue breakdown, increased metabolic rate, pulmonary dysfunction, and immune system dysfunction. Thoracic epidural analgesia has been shown to decrease the incidence of myocardial infarction1 postoperative pulmonary complications2,3 and to promote the return of gastrointestinal motility without compromising fresh suture lines in the GI tract.4–6 Epidural anesthesia and analgesia reduces the incidence of hypercoagulability.7,8 Well-conducted randomized trials have demonstrated the perioperative use of epidural anesthesia and analgesia may reduce overall mortality and morbidity by approximately 30% compared with general anesthesia using systemic opiods.9

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This chapter aims to provide the information necessary to provide safe and effective epidural blockade. The reader is encouraged to review specific chapters in this text for a more detailed discussion on specialized topics such as local anesthetics, combined spinal-epidural anesthesia, obstetric anesthesia, and serious complications such as epidural hematomas.

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Brief History

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Two French physicians, Jean-Anthanase Sicard, a radiologist, and Ferdinand Cathelin have been credited with the intentional administration of caudal epidural anesthesia over a century ago in 1901. They found that injecting a dilute solution of cocaine through the sacral hiatus can provide an effective treatment for severe sciatic pain and suggested the technique for surgical procedures.10 Nineteen years later, a Spanish military surgeon by the name of Fidel Pages Mirave, is credited with describing the lumbar approach to “peridural” anesthesia. Unfortunately he was killed in an accident at the early age of 37, and his work lay dormant for several years.11 Then in 1931, an Italian surgeon, Archile Dogliotti, performed abdominal surgery using single-shot lumbar epidural anesthesia, popularizing the method for producing “segmental peridural anesthesia.” He noted that a sufficient length of spinal nerves needed to be blocked with an anesthetic solution of sufficient quantity to provide adequate anesthesia. He correctly identified the epidural space by describing the sudden loss of resistance noted after the needle had crossed the ligamentum flavum.12

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Aburel, ...

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