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The combined spinal epidural technique allows combining:


  • Rapid onset and dense block from the spinal anesthesia
  • Presence of an epidural catheter to prolong block (if surgery outlasts spinal anesthesia) and/or for postoperative analgesia


  • Epidural kit
  • Spinal needle long enough to exit epidural needle (24–27 gauge pencil-point needle: Whitacre, Sprotte, or Gertie Marx)

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Choice of Spinal Local Anesthetic for Inpatient Procedures
Duration (h)
DrugPreparationDose (mg)ProceduresPlainEpinephrine
Bupivacaine (isobaric)0.5%10THA, TKA, femur ORIF2
Bupivacaine (hyperbaric)0.75% in 8.25% dextrose4–10Perineum, lower limbs1.5–21.5–2.5
12–14Lower abdomen
12–18Upper abdomen
Ropivacaine0.5%, 0.75%15–17.5T10 level2–3Does not prolong block
18–22.5T8 level3–4
1% + 10% dextrose (equal volumes D10 and ropivacaine)18–22.5T4 level1.5–2
Tetracaine1% + 10% dextrose (0.5% hyperbaric)4–8Perineum/lower extremities1.5–23.5–4
10–12Lower abdomen
10–16Upper abdomen

  • Higher concentration to maintain dense block for surgical anesthesia
  • Lower concentration for postoperative analgesia


See chapters 122 and 162 for additional information.


  • After sterile prep, drape, and local infiltration of skin:
    • Advance epidural needle into epidural space using loss of resistance technique
    • Advance spinal needle through epidural needle into subarachnoid space
  • Verify free-flowing CSF and inject spinal medication
  • If persistent pain or paresthesia when needle “pops” into subarachnoid or on injecting local anesthetic, withdraw and redirect needle. Do not inject local anesthetic onto nerves or cord:
    • It is useful to ask patient which side the paresthesia was felt and redirect needle in the opposite direction (especially with spine deformities)
  • Remove spinal needle
  • Thread epidural catheter and secure 3–5 cm into epidural space


See Also Section “Pearls and Tips” in Chapters 122 and 123.


  • Use of saline to detect epidural space may lead to confusion of saline for CSF when spinal needle placed. Prefer LOR to air
  • The risk of threading the epidural catheter into dural hole created by spinal needle is minimal if 25 gauge or smaller spinal needle used
  • Epidural drugs should be administered and titrated slowly in small increments because of possible intrathecal injection. Dural hole may increase flux of drugs into CSF and enhance their effects
  • Incidence of dural puncture (“wet tap”) from epidural needle may be lower with CSE than with epidural technique alone
  • Incidence of failed epidural lower with CSE than with epidural alone

For references, please visit

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