Chapter 26: Combined Spinal-Epidural Anesthesia

INTRODUCTION

In recent years, regional anesthesia techniques for surgery, obstetrics, and postoperative pain management have been used with increasing frequency.^1,2,3 The combined spinal-epidural (CSE) technique, a comparatively new anesthetic choice, includes an initial subarachnoid injection followed by epidural catheter placement and subsequent administration of epidural medications. This allows for rapid relief of pain or induction of regional anesthesia by the rapid onset of the spinal drugs and subsequent administration of medications for prolonged anesthesia. In addition, postoperative analgesia via the epidural catheter can be delivered for extended periods.

Clinical studies have demonstrated that the CSE technique provides excellent surgical conditions as quickly as the single-shot subarachnoid block and with advantages in comparison to the conventional epidural block.^4,5,6 The advantage lies in the fact that CSE anesthesia offers benefits of both spinal and epidural anesthesia.

Although the CSE technique has become increasingly popular over the past two decades, it is a more complex technique that requires comprehensive understanding of epidural and spinal physiology and pharmacology.

This chapter discusses the technical aspects, advantages, potential complications, and limitations of the CSE technique for surgery, postoperative pain management, and labor analgesia.

CLINICAL APPLICATIONS OF CSE

The results of a survey conducted by Blanshard and Cook demonstrated wide variation in CSE anesthesia use and practice among experienced anesthesiologists,⁷ reflecting concern over the frequency of CSE-related complications,^8,9 controversy over the technique,^10,11 and the potential for higher failure rates with the CSE technique compared with individual spinal or other anesthetic techniques.¹²

General Surgery

The CSE technique has been described in the medical literature for use in general surgery, orthopedics, trauma surgery of a lower limb, and urological and gynecological surgery. Clinical studies have demonstrated that the CSE technique provides excellent surgical conditions as quickly as with single-shot subarachnoid block—conditions that are better than with epidural block alone.^4,13 With the CSE technique, surgical anesthesia is established rapidly, saving 15–20 minutes compared with epidural anesthesia. Furthermore, epidural catheterization provides the possibility of supplementing the subarachnoid anesthesia, which may be insufficient when used alone.

This was recently illustrated by Mane et al,¹⁴ who presented a case series of laparoscopic appendectomy successfully performed under CSE anesthesia. CSE anesthesia in their series was performed using separate needles at two different interspaces. Spinal anesthesia was performed at the L2–L3 interspace using 2 mL 0.5% (10 mg) hyperbaric bupivacaine mixed with 25 μg fentanyl. The epidural catheter was inserted at the T10–T11 interspace to supplement spinal anesthesia and for postoperative pain relief. In an obstetrics-related article, it was also observed that various needles can be used in different combinations when performing the CSE technique and may have different advantages and disadvantages for different patients and situations.^...