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First documented in 1937, combined spinal–epidural anesthesia (CSE) is a technique in which both spinal and epidural anesthesia are administered simultaneously. The combination of the two approaches can present complications that are absent from each individual procedure.


Indications include patients in need of rapid anesthesia and analgesia with subsequent extended postprocedure analgesia. Labor analgesia, including emergent and elective cesarean sections, utilize CSE anesthesia because it offers timely, reliable anesthesia with adequate muscle relaxation and minimal drug toxicity to both mother and fetus. The CSE technique has been documented to be superior to sole individual and epidural anesthesia for abdominal procedures such as hysterectomies. Thoracic procedures have been performed with CSE anesthesia. However, the inhibition of cardioaccelerator fibers and respiratory depression may necessitate use of cardioactive drugs and general anesthesia with a secure airway. For certain lower extremity orthopedic procedures (eg, total hip arthroplasty, femur fractures, and total knee arthroplasty), implementation of CSE anesthesia provides benefits of decreased blood loss and decreased incidence of postoperative deep vein thrombosis.

Absolute contraindications include patient refusal, sepsis, hypovolemia, coagulopathy or therapeutic anticoagulation, elevated intracranial pressure, and infection at procedure site. Relative contraindications include current neurologic pathology, severe psychiatric disease, dementia, aortic stenosis, left ventricular outflow tract obstruction, and alteration of vertebral column secondary to prior surgery.


Ideally, CSE anesthesia incorporates the advantages of each procedure while avoiding the disadvantages. The spinal portion allows rapid onset of blockade and more reliable blockade, while the epidural portion provides ability for extended analgesia through redosing or continuous infusion of local anesthetic. Intensity of blockade may be altered by manipulating local anesthetic concentration. Although there is increased preparation time for surgery compared with general anesthesia, the technique of CSE anesthesia decreases recovery time in the postanesthesia care unit, time to postoperative patient fluid intake, narcotic requirements, and episodes of emesis.

Disadvantages potentially avoided include the single administration of local anesthetic and unpredictable level of blockade with spinal anesthesia and patchy blockade, poor sacral spread, and possible local anesthetic toxicity associated with epidural anesthesia.


  • Single pass—First performed in 1980 (Vitenbeck), using the same needle, local anesthetic is first injected into the epidural space, and then further inserted into the subarachnoid space for intrathecal local anesthetic administration.

  • Needle-through-needle—First described in 1982, this most commonly used technique involves locating the epidural space with a needle and subsequently inserting a small diameter spinal needle through the epidural needle lumen to administer local anesthetic intrathecally. Once the spinal needle is removed, the epidural catheter may be inserted into the lumen of the epidural needle and placed in the desired position. The epidural catheter may be placed before the spinal needle is introduced, but this may increase the risk of damage to the spinal ...

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