Combined spinal-epidural anesthesia

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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[1]. Though an ongoing debate, many argue that CSE is associated with lower failure rates and fewer adverse events than spinal or epidural anesthesia[2].

Combined spinal-epidural anesthesia
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Indications [2]

  • 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 [3]

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[1]. A lower incidence of accidental intravascular epidural catheters, inadequate epidural analgesia, and catheter replacements has been reported in patients who received CSE[4]. 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 [2].

CSE vs. Spinal Anesthesia

Epidural Volume Extension (EVE)

Use in High-Risk Patients


Needle-Through-Needle Technique

Separate Needle Technique

Drug Choices

Risks & Complications

Potential complications


  1. 1.0 1.1 Textbook of regional anesthesia and acute pain management. Admir Hadzic, New York School of Regional Anesthesia. New York: McGraw-Hill, Medical Pub. Division. 2007. ISBN 0-07-144906-X. OCLC 70051351.CS1 maint: others (link)
  2. 2.0 2.1 2.2 "Combined Spinal Epidural (CSE)". The American Society of Regional Anesthesia and Pain Medicine (ASRA). Retrieved 2022-09-26.
  3. Basics of anesthesia. Manuel, Jr. Pardo, Ronald D. Miller, Ronald D. Preceded by: Miller (Seventh edition ed.). Philadelphia, PA. 2018. ISBN 9780323401159. OCLC 989157369. |edition= has extra text (help)CS1 maint: others (link)
  4. "Combined Spinal-Epidural Anesthesia". NYSORA. 2018-09-20. Retrieved 2022-10-01.