In recent years, regional anesthesia techniques for surgery,
obstetrics, and postoperative pain management have been used with increasing
frequency.1–3 The combined spinal–epidural (CSE)
technique, a comparatively new anesthetic technique, includes an initial
subarachnoid injection followed by epidural catheter placement and
administration of epidural medications. This allows for almost immediate
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
(SSS) block, and with advantages compared with the epidural block
alone.4–6 The introduction of 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 and
analgesia during labor.
The results of a recent survey demonstrate wide variation in CSE 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 CSE than with individual spinal or other anesthetic
In the literature, the technique has been described for use in general,
orthopedic, and trauma surgery of lower limb, as well as in urologic and
gynecologic surgery. Clinical studies have demonstrated that the CSE
technique provides excellent surgical conditions as quickly as with SSS
block—conditions that are better than with epidural block
alone.4,13 With the CSE technique, surgical anesthesia is
established rapidly, saving 15–20 min compared with epidural anesthesia.
Furthermore, epidural catheterization provides the possibility of
supplementing subarachnoid anesthesia, which may be insufficient when used
alone. In a recent article it was also observed that various needles can be
used in different combinations when performing CSE and may have different
advantages and disadvantages for different patients and
situations.14 This will be discussed later in the chapter.
The CSE technique is widely used in obstetric practice to provide
optimal analgesia for parturients. It offers effective, rapid-onset
analgesia with minimal risk of toxicity or motor block.15
In addition, this technique provides the ability to prolong the duration of
analgesia, as required, through the use of an epidural catheter.
Furthermore, should an operative delivery become necessary, that same
catheter can be used to provide operative anesthesia. The onset of spinal
analgesia is almost immediate, and the duration is between 2 and 3 h,
depending on which agent or agents are chosen. The duration of spinal
analgesia, however, ...