Combined spinal-epidural anesthesia

Combined spinal-epidural (CSE) anesthesia is a neuraxial technique that offers benefits of both spinal and epidural anesthesia and analgesia. The CSE technique involves a subarachnoid injection followed by the placement of a catheter in the epidural space for administration of epidural medications. This permits rapid-onset spinal analgesia, with access for supplementing insufficient subarachnoid anesthesia or prolonging anesthesia and analgesia via the epidural catheter. Though an ongoing debate, many argue that CSE is associated with lower failure rates and fewer adverse events than spinal or epidural anesthesia.

Combined spinal-epidural anesthesia

Anesthesia type	Regional
Airway	None
Lines and access	PIV
Monitors	Standard, EKG
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Editor rating	Unrated
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Overview

Indications

• General, orthopedic, and trauma surgery of lower extremity
• Urologic and gynecologic surgery
• Labor analgesia - more rapid onset pain relief and lower failure rates than standard epidural
• Cesarean section - rapid onset with ability to prolong anesthesia via epidural catheter

Contraindications

Absolute contraindications

• Patient refusal
• Localized sepsis
• Allergy to drugs used in procedure
• Inability of patient to remain still for injection (risk of neurologic injury)
• Increased intracranial pressure (risk of brainstem herniation)

Relative contraindications

Relative contraindications

• Neurologic: myelopathy or peripheral neuropathy, spinal stenosis, spine surgery, multiple sclerosis, spina bifida
• Cardiac: aortic stenosis or fixed cardiac output, hypovolemia
• Hematologic: thromboprophylaxis, anticoagulants, inherited coagulopathy
• Infection: systemic infection, bacteremia, septic shock

Advantages of CSE

CSE vs. Epidural Anesthesia

The CSE technique provides more rapid onset analgesia and establishes surgical anesthesia 15-20 minutes faster than epidural anesthesia. CSE is also associated with lower failure rates and fewer adverse events. A lower incidence of accidental intravascular epidural catheters, inadequate epidural analgesia, and catheter replacements has been reported in patients who received CSE. Higher success rates may be due to confirmation of epidural space via CSF return with spinal needle. More complete sensory blockade with improved sacral spread has also been reported with CSE, though local anesthetic flux through the dural puncture site also varies with choice of spinal needle .