EPIDURAL ANATOMY AND

PHYSIOLOGY &
TECHNIQUE

CHAIR PERSON : DR. I.UPENDRANATH (professor)

MODERATOR : DR. PRAVEEN (asst professor)
PRESENTER : DR . BHARGAV
 TOPICS
1. Introduction
2. History
3. Epidural space
4. Boundaries
5. Contents
6. Thoracic epidural anatomy
7. Cervical epidural anatomy
8. Size of epidural space
9. Structures pierced
10. Physiologic considerations
11. Effect on systems
12. Technique
13. References
Neuraxial anesthesia refers to local anesthetic placed around the
nerves of the central nervous system
It includes:

1. Spinal anesthesia
2. Epidural anesthesia
3. Combined spinal and epidural anesthesia
4. Caudal anesthesia
• Epidural anesthesia is obtained by
blocking spinal nerves in the
epidural space as the nerve
emerges from the dura and then
pass into the intervertebral
foramina.

• A segmental block is produced

chiefly of spinal sensory and
sympathetic nerve fibres.
• Epidural anesthesia requires larger doses of local anesthetic and takes more time to
establish.

• However, when a catheter is in the epidural space, local anesthetic can be injected
repeatedly and anesthesia can be prolonged to match the duration of the surgery.

• Epidural injection can safely be performed in the lumbar, thoracic, and even cervical
regions.

• Thoracic epidural anesthesia is a useful adjunct to general anesthesia for upper abdominal
and thoracic surgeries.

• Cervical epidural injection is rarely used for surgery; however, it is commonly used to treat
pain associated with cervical disc disease.
History
• 1885 – Corning first performed peridural anesthesia with cocaine for pain relief . It was apparently
accidental.

• 1895 – Cathelin first used epidural anaesthesia in sacral region. This is now called caudal analgesia.

• 1910 – Lawen investigated the anatomy of spinal and epidural areas , he found that injections in
sacral canal did not reach the sabarachnoid space.

• 1921 – F. Pages performed extradural anesthesia in his surgical practice.

• 1949 – Curbelo first performed continuous peridural anesthesia by means of ureteral catheter.
• 1951 – Crawford used peridual anesthesia for thoracic surgery
Epidural space
• It is also known as peridural or extradural space.

• A potential space between spinal meninges (dura mater)

and the periosteum lining the vertebral canal.
 Boundaries
 Extends from foramen magnum to coccyx.

 Above : foramen magnum

 Below : sacrococcygeal membrane
 Anteriorly : posterior longitudinal ligament
 Posteriorly : ligamentum flavum
 Laterally : intervertebral foramina and peduncles of vertebrae
 At foramen magnum the periosteum fuses with the periosteal
of the skull.

 This periosteal layer is the extracranial extension of the

endosteal layer of the cranial dura mater.
 The space is more extensive and easily distensible
posteriorly , while anteriorly the dura adheres closely to the
periosteum of vertebral bodies .

 Lateral extensions of the space accompany the spinal nerves

through the intervertebral foramina into the paravertebral
tissue upto the angle of the ribs.
CONTENTS
1. Areolar tissue
2. Fat
3. Spinal nerve roots with their dural sleeves
4. Blood vessels – spinal arteries and venous plexsus (batson’s
plexsus)
5. Lymphatics
AREOLAR CONNECTIVE TISSUE
• It is present in significant amounts ventrally , forming strong connections
between the dura mater and anterior longitudinal ligaments in the vertebral
canal.

• A midline fold of connective tissue , extending in a longitudinal direction in the

midline , called the PLICA MEDIANA DORSALIS , connects the dura to the
ligamentum flavum in the midline.
 PLICA MEDIANA DORSALIS
• It is present in the form of strands connecting the flaval ligament to
the dura.
• It is present in the midline dividing the epidural space into right and
left sides and narrow the space.
• The connection appears to be well developed in the region of
vertebral arches.
• In some cases , it forms a complete membrane in a dorsomedian
saggital plane.
 Epidural fat
• It is principally present in the
posterior and lateral space.

• It has effects on pharmacology

of drugs injected intrathecally.
• There is a linear relationship between opioid's
lipid solubility and its terminal elimination
halftime in epidural space.

• Increased lipid solubility leads to sequestration of

drugs in fat , thereby reducing bioavailability of
drug.
 LYMPHATICS

• The lymphatics of epidural space are concentrated in the dural

roots where they remove foreign materials including micro
organisms from the subarachnoid and epidural spaces.
 BLOOD VESSELS
• The epidural arteries located in the lumbar region of
vertebral column are branches of ilio-lumbar arteries.

• These arteries are present in the lateral region of the space

and therefore not threatened by an advancing epidural
needle.
• The internal vertebral venous plexsus consists of four interconnecting
longitudinal vessels, two anterior and two posterior.

• The external vertebral plexsus (EVP) in contrast , lies peripheral to the

vertebrae and is made up of anterior and posterior external vertebral
plexsus.

• The EVP is situated anterior to the vertebral bodies and in relation to

laminae , spinous process , transverse process and articular process
respectively.
• The veins communicate with the segmental veins of the neck , intercoastal ,
azygos and lumbar veins. With the veins of bones of the vertebral column , the
internal and external vertebral plexsus forms the batson’s plexsus.

• These veins are predominantly present in the antero-lateral part of epidural space
, and ultimately drain into the azygos veins.
THORACIC EPIDURAL
ANATOMY
• Thoracic epidural block is achieved by
introducing a needle between thoracic spines in to
epidual space.

• Spinous process of T1-T4 and T10-T12 are more

horizontal

• In mid-thoracic region (T4-T7) , spinous process

are oblique and the tips of the spines overlie the
next lower vertebrae or interspace.
• Because of this anatomical difficulty it is difficult to attempt a midline entry in
the epidural space.

• Midline approach can be used for upper and lower thoracic region.

• In midthoracic region paramedian approach is preferred.

CERVICAL EPIDURAL
ANATOMY
• Cervical spinous process are not angulated and
horizontal approach is indicated as in lumbar region
.

• C7-T1 is widest and easiest to use . C7 is a

prominent landmark.

• Sitting position is used because of better palpation

of C7 process.
• Ligamentum flavum is quite thin in the cervical region and can be reached
superficially.

• A gentle click maybe appreciated while piercing ligamentum flavum.

• At C6-C7 or C7-T1 epidural space width is 3-4mm which becomes narrower

in higher segments where meningeal dura and endosteal dura fuses at
foramen magnum.
 SIZE OF EPIDURAL SPACE

• The distance across the semi or half moon

circular peridural space varies.

• In the anterior region , it is almost non-existent ,

while in the posterior region it is measured
readily especially in the midline.
 Epidural space (mm) Thickness of dura (mm)
Cervical 1.0 – 1.5 2.0 – 1.5
Upper thoracic 2.5 – 3.0 1.0
Lower thoracic 4.0 – 5.0 1.0
Lumbar 5.0 – 6.0 0.66 – 0.33
HOW TO REACH
EPIDURAL SPACE ??
• The following structures are
pierced :

1. Skin
2. Subcutaneous tissue
3. Supraspinous ligaments
4. Interspinous ligaments
5. Ligamentum flavum
PHYSIOLOGIC CONSIDERATIONS
• A negative extradural pressure was originally described by Heldt
and Moloney in 1928.

• This negative pressure in the peridural space is greatest at points of

firm attachments.

• It is greatest in the thoracic region , less in lumbar and least or

absent in the sacral area.
• Theories explaining negative pressure :

1. The CONE THEORY considers that the needle introduced into the peridural
space depresses the dura creating a larger epidural space.This is considered an
artifact caused by the indentation of the dura by advancing needle.

• Telford and Holloway demonstrated that epidural space pressure were always
positive , and negative pressure were only recorded when tenting of the dura
with a blunt needle was produced. Hence , the measurement of a negative
epidural pressure is an artifact.
2. The Transmission theory considers that the negative pressure in the epidural
space is caused by transmission of the intrapleural negative pressure through the
intervertebral foramina to peridural space.

• Anatomically , there is free communication of the extradural space with the

paravertebral space and in turn the tissue pressure in this area is influenced by
the intrapleural pressure.

• The transmission is dampened because of greater amounts of tissue as one

proceeds away from thoracic area.
• Marked flexion of the spinal column reduces the length of anterior wall and
elongates the posterior wall. Consequently , the capacity of vertebral canal
proper increases and results in a geater negative pressure.

• The negative pressure is greater in young people.

• In older patients with ligamentous changes and ankylosis of articulations ,

anterior flexion is limited.

• The negative pressure in lower lumbar region is about 0.5cm H2O , in upper
lumbar it is about 1cm H2O and in thoracic region varies from 1 to 3cm H2O .
 SITE OF ACTION
• Three sites of action of the local anesthetic agents have been identified :

1. On the nerves as they traverse the epidural space .

2. On the nerves as they pass out through the intervertebral foramina.
3. On the nerves in the subarachnoid space – the agent having reached this area by
diffusion through the dura.

• The initial and main action of local anesthetic agents injected epidurally is on the
spinal nerves outside the dural sac .

• The actual site of action is on the region of the intervertebral foramina where the
spinal nerves loose their protective dural sheaths.
 FATE OF EPIDURAL AGENTS
• Bromage has summarized the fate of epidurally introduced local anesthetic agents .

• Plasma venous levels of epidurally injected agents are reached quickly and much
sooner than after spinal anesthesia.

• The basis of rapid absorption from epidural space is the rich internal vertebral
venous plexsus .

• These veins are thin walled and without valves. Hence , the epidural drugs are
exposed to a large vascular surface.
 Epidural injection

Longitudinal spread in epidural space

leakage by vascular absorption

leakage through diffusion through diffusion through
intervertebral foramina dural root sleeves dura mater

paravertebral block of subdural spread

nerve trunks in young patients

centripetal subperineural spread spinal root block

subpial spread CSF

peripheral cord block

EFFECT ON SYSTEMS
 CENTRAL NERVOUS SYSTEM

• The exact site of action of epidural anesthesia remains unknown.

• Local anesthetic injected into the epidural space diffuses through the dura and
arachnoid and also can be identified in the nerve rootlets and spinal cord.

• Epidural local anesthetics decrease somatosensory evoked potential (SSEPs) in

areas of sensory block but not in dermatomes above or below, suggesting a
peripheral, but not spinal cord site of action.
•
CARDIOVASCULAR SYSTEM
Hypotension and bradycardia can also occur during epidural anesthesia.

• The major risk factors for hypotension are the extent and onset of sensory block.

• Faster onset and more extensive block increase the frequency of hypotension.

• Bradycardia is more common in males.

• Genetics also may alter the risk of hypotension after epidural anaesthesia. One study,
using phenylephrine requirement as a marker, found that β2-adrenoreceptor gene
variants altered vasopressor requirements during thoracic epidural anesthesia.
 RESPIRATORY SYSTEM
• Epidural anesthesia have little effect on pulmonary function.

• Although patients often note chest tightness and dyspnea with thoracic levels of
sensory block, respiratory function is usually unchanged.
 GASTROINTESTINAL SYSTEM
• Neuraxial anesthesia-induced sympathetic block leads to unopposed
vagal stimulation of the gastrointestinal system.
• Secretions increase, sphincters relax and the bowel constricts.
• Many patients experience nausea and vomiting.
• Risk factors for nausea and vomiting include: female gender, opioid
premedication and high level of block.
• At cesarean section, nausea and vomiting are strongly associated
with maternal hypotension.
 Indications
• Epidural anesthesia with or without sedation has been used as the sole
anaesthetic or as an adjunct to general anesthesia (reduces patient’s
requirement for opioid analgesics)
• Orthopaedic surgery : Major hip/knee surgery, pelvic fractures

• Obstetrics : Caesarean section, labour analgesia

• Gynaecologic surgery : Procedures involving female pelvic organs

• Urologic surgery : Prostate, bladder procedures

• General surgery : Upper and lower abdominal procedures
• Paediatric surgery : Penile procedures, inguinal hernia repair, anal
surgery, orthopaedic procedures on the feet; supplement to GA,
postoperative pain relief. 45
• Vascular surgery : Vascular reconstruction of the lower limb vessels,
amputations involving the lower extremities.
• Thoracic surgery : Postoperative analgesia, combination with GA to
reduce GA requirements.
• Diagnosis and management of chronic pain : Chronic benign pain-
Cervical & lumbar radiculopathy, vertebral compression fracture ,
degenerative disc disease, peripheral neuropathy, low back pain,
pelvic pain syndrome.
• Cancer related pain- pain secondary to face, neck, shoulder,
genital, pelvic, perineal etc .malignancy. & chemotherapy related
peripheral neuropathy.
46
 Epidural needle
Epidural needles have larger diameter than Spinal needle.

Typically sized of 16-19 gauge.

1 Tuohy & Hustead needle –with gently curve of 15-30°

degree.
2 Crawford needle- with straight tip.

47
• Available in different sizes 16G 18G 19G 20G
• Material : Nylon,polyurethane,polyethylene and Teflon

• Single lumen(open end)

• Multi orifice(blunt tip)
 Epidural needle
Epidural needles have larger diameter than Spinal
needle.
Typically sized of 16-19 gauge.

1 Tuohy & Hustead needle –with curved tip

2 Crawford needle- with straight tip

49
 Pre-op preparation

• PAC

• Informed consent
• Equipped for airway management & resuscitation
• INR & aPTT, Platelets counts should be with in normal range
• Monitor BP & HR

• IV access

50
Equipment 

• Solution of antiseptic.
• Syringe/needle for skin localization.
• Epidural needle.
• Glass syringe.
• Epidural catheter.
• Glass filter.
• Dosing syringe.
• Local anesthetic.
• Saline.
 Performing the procedure
 Position of patient- Careful attention to the patient’s position is
essential to successful placement of the epidural needle and
catheter.

Depending on the patient’s medical status, weight, and ability to

cooperate, the sitting or lateral decubitus position can be used.
Easier in sitting position.

52
 Sitting Position

If the sitting position is chosen, the patient should be

assisted to sit on the edge of the table or bed with feet
resting on a stool .

• The patient should lean forward with elbows resting

on a pillow or on the thighs. The back should be
maximally flexed to open up the lumbar vertebral
spaces. Flexing the neck will help the patient to flex the
lower spine.

• The assistant should help the patient to hold this

position during the entire procedure.
Lateral Decubitus Position 

• In the lateral decubitus position, the patient is placed on her side with the back at the edge of the
operating table that is closest to the anesthesiologist.

• The spinous processes should be oriented parallel to the floor to prevent rotation of the spine. • The
thighs should be flexed on the abdomen with the knees drawn to the chest and the neck flexed so that the
chin rests on the chest.

• Asking the patient to “assume the fetal position” or “touch your knees with your chin” may help with
positioning during lumbar epidural placement.
Site of injection • A spinal interspace is chosen one to two segments below the middle
of area to be anesthetized.
PREPARATION • Skin is cleaned ,an antiseptic applied, and the area draped ,a skin wheal is made and
deeper tissues infiltrated with 2% lidocaine
Approach - Four common approaches to the epidural space
are possible:
1. Midline,
2. Paramedian,
3. Taylor (modified paramedian),
4. Caudal
 Technique
• The most commonly performed Epidural is a Lumbar Epidural,
followed by a Caudal, then Thoracic and finally Cervical.
• Today most high thoracic and cervical epidurals are performed under
flouroscopic guidance by pain specialists as it takes a greater level of
skill to successfully perform those procedures.
 Technique
• The angles of approach for the various levels are
markedly different.
• The Lumbar region is at or greater than 90 degrees
to the skin.
• The Thoracic is at 40degree angle due to the
anatomical arrangement of the Thoracic Spinous
Processes.
• Finally the Cervical is at an angle in between the
previous two.
• Needle angulation required to accomplish epidural blockade
in the high thoracic/low thoracic/lumbar regions.
A: High thoracic region. B: Low thoracic region. C: Lumbar
region.  

61
Insertion of needle

• Insert epidural needle with stylet through same skin puncture. The dorsum
of the anesthesiologist’s non injecting hand rests on the patient’s back with
the thumb and index finger holding the hub of the epidural needle (Bromage
grip).

• Advance the needle through the supraspinous ligament and into the
interspinous ligament at which point the needle should sit firmly in the
midline

• After the ligaments are penetrated, it is no longer possible to change the

direction of the needle tip
 Locating the Epidural space
• 3 methods are used to identify Epidural space-

 Loss of resistance (to with air or saline):-As needle

reaches Epidural space Loss of Resistance is felt
LORS Vs LORA:
• LORA is associated with nerve root compression, pneumocephalus and
greater incidence of incomplete analgesia, paresthesia and venous air
embolism.
• LORS is associate with reduces incidence of dural puncture in adult, while
in pediatric patients, dural puncture incidence are more.

• LORA is safer than LORS in children less than 2 yrs old.

63
A glass syringe or a low resistance plastic syringe
is filled with 2-3 ml saline /air and attached to hub of
epidural needle ,after removing the stylet.

• Maintain constant pressure on the syringe with the

dominant hand.

• Controlled needle advancement is made with the non

dominant hand.

• As the needle enters the epidural space there is

sudden loss of resistance as the saline or air is rapidly
injected.
 Hanging drop method:-As needle reaches Epidural space
Hanging drop is sucked in d/t negative pressure.
 In cervical region, negative pressure poorly reliable and
only useful in sitting position.
 The negative intra-thoracic pressure may influence the
pressure in epidural spaces in thoracic region and should
be maximal during inspiration.
 Ultrasonography / Fluoroscopy
Hanging Drop Technique

66
Capillary tube method:
Odom devised a small capillary tube filled with sterile saline in which one or two bubbles of air were placed. as soon
as needle enters epidural space, saline will be sucked in, and air bubbles could be seen to advance into the space

Manometer technique
• a small U shaped tube about 3-4 inches high is used as a water manometer after needle has been introduced into
the interspinous ligaments ,manometer is attached to needle. as it is advanced through lig flavum and enters the
epidural space ,there is an immediate movement of the liquid ,signifying a negative pressure
Others technique are

 • Spring loaded syringe

• Saline drip technique
• Balloon technique
• Brooks device (odoms indicator)
• Vertical Tube of Dawkins
 Confirmatory Test for Epidural Puncture

 1. Aspiration Test:­

Gentle suction is done with 2ml syringe. CSF or blood can be easily detected. 1-2 ml of air is injected
through needle and aspiration is again performed. Air should go easily, but nothing should return
on aspiration.

2. Sterile water injection:­

Fluids which differ from normal tonicity are painful in epidural space — (Lund’s concept).

Rapid injection of NS ( or) LA:- • Rapid injections when given epidurally in conscious patients cause an
increase in CSF pressure leading to feelings of discomfort and anxiety. In unconscious patient, the rate
and depth of respiration is increased.
Once a loss of resistance to air or saline has
occurred, the glass syringe is removed, and depth
at which the epidural space was entered is noted.
The noninjecting hand should continue to hold the
needle in place. • Note the depth of the needle at
the skin. The marking on the needle at the skin is
the depth from the skin to the epidural space.

Thread the catheter gently through the needle

into the epidural space to approximately the 15-
17-cm mark, then remove the needle without
dislodging the catheter

• Add the skin-to-epidural depth plus 3–5 cm.

Withdraw the catheter to that point and secure.

.No more than 5 cm of catheter should be left in

the epidural space to prevent displacement of the
catheter laterally or into extradural structures.
 Catheter placement
• The catheter is made of a flexible, calibrated, durable,
radiopaque plastic .
• Typically, 19-or 20- gauge catheter is introduced through 17-or
18- gauge epidural needle.
• Catheter is threaded through needle after placing in space.

• Needle is withdrawn over the catheter.

• 4-6 cms catheter remain in epidural space. Threading more
catheter may increase the likelihood of catheter malposition.
• Catheter is firmly secured to skin with surgical tape.
71
Problems encountered during epidural placement
 Types of epidural catheter

Single –end hole catheter Closed tip, multiple-side Spring wire-reinforced

hole catheter catheter
Bromage ideal characteristics of an epidural catheter:

• Biochemical inertness
• Low coefficient of friction
• High tensile strength
• Maneuverable rigidity
• Kink resistant
• Atraumatic tip
• Depth indicators
• Radio opacity
Epidural catheter placement

75
Continuous infusion

76
 CAUTION
 NEVER pull the catheter back through the needle once it has

been inserted
 It is possible to catch the catheter on the needle tip and shear or
cut the tip off
 Then it becomes a permanent new addition to the epidural space
and will be there for the rest of the patient’s life!!!!
 Epidural Dosing
As a general guideline,
1. 1–2 mL per segment in a lumbar epidural,
2. 0.7 mL per segment in a thoracic epidural, and
3. 3 mL per segment for a sacral/caudal epidural
is used as an initial loading dose.
• Test Dose
• Incremental Dosing
• Aspiration to check for blood or CSF before each dose.
• After the initial loading dose, one quarter to one third of the amount
can be administered 10–15 min later to intensify the sensory block.
The overall level of the block will not be significantly increased
with this method.

78
 Test Dose
• The purpose of the “test dose” is to make sure that the catheter is not in
the subarachnoid, intravascular, or subdural space.
• The classic test dose combines 3 mL of 1.5% lidocaine with 15 mcg of
epinephrine.
• The intrathecal injection of 45 mg of lidocaine will produce a
significant motor block consistent with spinal anesthesia.
• A change in heart rate of 20% or greater is an indication of
intravascular injection warranting the removal and replacement of the
catheter.
• If the heart rate does not increase by 20% or greater, or if a significant
motor block does not develop within 5 min of administering the test
dose, it is considered negative.
• False-ve if pt is on β blocker, false +ve in pregnancy if coincides with
labour pain.

79
 Incremental Dosing
• Its purpose is to avoid excessively high anaesthetic levels.
• The loading dose should be given in 5-mL aliquots through the
catheter, repeated at 3- to 5-min intervals, giving the clinician time to
assess the patient’s response to dosing.
• If at any time the patient demonstrates an exaggerated response,
further incremental doses should be withheld and the patient
reassessed.

80
 Repeat dose of LA:
Doses are administered before the block regresses to the point where
the patient experiences pain, the “time to two-segment regression.”
Defined as the time it takes for the sensory block to regress by two
dermatome levels. At this point, one-third to one-half of the initial
loading dose can safely be administered to maintain the block.
Depends on the duration of action of the drug
Table 8. Clinical Effects of Epidurally Injected Local Anesthetics

Recommended Time for "Top-Up"

Drug (Concentration Time to Two-segment
Dose from Initial Activation of
%) Regression (min)
Dose (min)

Chloroprocaine (3) 45–75 45

Lidocaine (2) 60–140 60
Mepivacaine (2) 90–160 90
Bupivacaine (0.5) 180–260 120
Ropivacaine (0.5– 120
180–260
0.75)   81
 Thoracic Epidural
• The paramedian approach is easier especially in the midthoracic region.
• Expect more frequent false loss of resistance, especially if the midline
approach is used.
• The test dose not only identifies intravascular injection, but also serves
as a means of identifying placement as a band of anesthesia should
develop in the segment where the local anesthetic was injected.
• Because of the proximity to cardiac accelerator fibers, smaller bolus
doses of local anesthetic should be used and response checked carefully
before redosing to prevent large drops in heart rate or blood pressure.
• Remember that hypotension can occur in nearly all patients with a high
thoracic epidural blockade. In fact, it has been said that if there is no
hypotension after an initial bolus in the high thoracic epidural space, it is
likely that the epidural catheter is not in the epidural space.

82
 Factors affecting Epidural Anesthesia
 Site of injection-
 Lumbar- spread cranially more than caudally
 Thoracic- spread evenly from site of injection

 Upper thoracic & lower cervical fibers are comparatively

resistant d/t larger size of nerve roots-requires larger dose of LA.
 Thoracic epidural space is smaller, require lower volume of drug.
 Dose- 1-2 ml /segment.

 Depends on volume & concentration of drug. Higher conc.

produces a profound motor and sensory block, whereas low conc. a
selective sensory block.
83
 Age - as patient age increases reduced size of intervertebral
foramina decreased epidural space size and compliance.
Decreased epidural fat necessitates decrease of dose in elderly.

 Weight - There is little correlation between the spread of

analgesia and the weight of the patient.
In morbidly obese patients, there may be compression of the
epidural space secondarily to increased intra-abdominal pressure,
creating a higher block for a given dose of local anesthetic.

84
 Height - The correlation with height is usually not clinically
significant.
Ht. <5 ft 2 inch, reduce the dose to 1 ml/segment to be blocked.

Bromage dosing regime - Increasing the dose of local anaesthetic by

0.1 mL per segment for each 2 inch over 5 ft of height.

 Addition of Vasoconstrictors - Epinephrine 5 mcg/ml (1:200000)

is most commonly added.
 Prolongs duration of action by reducing the vascular absorption of
drug.

85
 Posture-

Block Ht. - Whether the patient is sitting or in the lateral position,

there is no significant difference in block height. This is explained
by the fact that gravity and soln. baricity are not intimately related to
block spread.

Onset, Duration & Density - slightly faster on the dependent side

when the epidural in placed with the patient in the lateral position
 Pregnancy- Increased sensitivity to regional anesthetics leads to
faster onset time.
Engorgement of Epidural veins from caval compression leads to
increased incidence of blood vessel puncture during procedure.
86
 Alkalinisation of local anaesthetic

8.4% NaHco3
(1meq/10 ml of local
anaesthetic)

Raise the PH & non

ionised portion

Speed the onset of

block 87
 Complications
Drug Related Complications-
• CNS toxicity
• CVS toxicity
Procedure Related Complications-
• Minor Back Pain
• Postdural Puncture Headache
• Subarachnoid Injection/High or Total Spinal
• Major Subdural Injection
• Sheering of catheter
Neurologic Complications-
• Spinal nerve neuropathy
• Transient neurological symptoms
• Anterior spinal artery syndrome
• Adhesive arachnoiditis
• Epidural hematoma
• Epidural abscess
• Postdural Puncture Headache : Due to inadvertent dural
puncture.
TOC – Epidural blood patch.
 Cosyntropin, ( ACTH analogue) . 
 Postulated mechanisms include increased CSF production via sodium
channels; aldosterone mediated salt and water retention, and possibly
increased β endorphin output.
 One of the trials used 1 mg of cosyntropin for the prophylaxis of PDPH.
It showed more than 50% reduction in the incidence of PDPH
 Mannitol-
 It acts “ acute increases in blood osmolality decreases brain water
content (mainly in healthy brain tissue with intact blood brain
barrier)decrease brain bulk, intracranial pressure, increased intracranial
compliances.” decrease brain bulk, causes brain re-float in contracted
CSF volume.
 It believe that re-floatation of brain is an important factor to alleviate
PDPH with other factors.

89
 Neuraxial block in setting of anticoagulant and
antiplatelet drugs
(recommended by American Society of Regional Anesthesia)

• Neuraxial block and indwelling catheters are safe in patients on

aspirin , NSAID’s & cox-2 inhibitors.
• Discontinue clopidogrel for 7 days ,ticlopidine for 14
days ,abciximab for 24-48 hrs ,tirofiban & eptifibatide for 4-8
hrs before technique.
• Wait at least 12 hrs before last thromboprophylaxis dose of
LMWH and 24 hrs after last full dose
• When LMWH is begun post-op first dose should be withheld for
at least 24 hrs if using a twice daily dosing regimen and 6-8 hrs
if using once daily dosing regimen

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• An indwelling epidural catheter should not be removed until 12 hrs
after the last prophylaxis dose of LMWH, and the next dose should
be administered no sooner than 2 hrs after catheter removal
• If a single daily thromboprophylaxis dose of LMWH is
administered, then indwelling catheters may be maintained
postoperatively. But the concurrent use of twice daily or therapeutic
LMWH and an indwelling epidural catheter is not recommended.
• The LMWH dose is delayed for 24 hr if the patient experienced
excessive trauma during attempted epidural or spinal anesthesia.
• Neuraxial blocks should not be performed in patients chronically
taking warfarin unless the warfarin is stopped and the INR is <1.5
• Neuraxial catheters should be removed only when the INR is <1.5

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 Epidural Analgesia for labour
• Mainstay for many years
• Only therapy providing complete analgesia for both stages by
allowing cephalad and caudal spread of
• LA T10-L1 (relieve pain of uterine contractions and cervical dilatation)
S2-S4 (relieve pain of vaginal and perineal distension)
Most commonly: Mid-lumbar midline placement
• Generally initiated when the parturient wants it & the obstetrician
approves it.
• Commonly accepted criteria for placement:
1. No fetal distress
2. Good regular contractions 3-4 min apart & lasting abt. 1 min
3. Adequate cervical dilatation i.e. 3-4cm
4. Engagement of the fetal head.
Maternal positioning
Lateral position :
Advantages -
• orthostatic hypotension less likely
• continuous FHR monitoring
Disadvantage –
• concealed aortocaval compression
Sitting position : Preferred in obese
NEVER SUPINE. AVOID AORTOCAVAL COMPRESSION
AT ALL TIMES
 Initial bolus options: Epidural route
Can be given with - LA alone
- Opioid alone
- LA + Opioid ( synergistic )
Volume is more important than concentration.
1) Bupivacaine 0.125-0.25% , Ropivacaine 0.1-0.2%,
Lidocaine 1%, Chloroprocaine 2% (10-15 ml)

2) Fentanyl (50-100 µg in 10 ml saline), Sufentanyl

10- 25 µg in 10 ml saline

3) Bupivacaine 0.0625-0.125% + Fentanyl 50 µg/

Sufentanyl 10 µg
 Subsequent analgesia: Options
• Intermittently repeat epidural bolus : 8 - 12 ml bupivacaine
0.06 - 0.125 %
• Continuous infusion 8 - 15 ml / hour:
1)Bupivacaine 0.0625 - 0.125 %
2)Bupivacaine 0.05 - 0.125 % / Ropivacaine 0.05 - 0.2 % +
Fentanyl 1 - 2 µg / ml or Sufentanyl 0.2 - 0.33 µg / ml

• PCEA( Patient-controlled epidural analgesia )
- Bupivacaine 0.05 - 0.125 % + Fentanyl 2 µg / ml
- 5 ml bolus
- Background infusion 5-10 ml / hr
- Hourly limit 30 ml
- lockout interval 5 - 15 mins
 Administration Techniques
• Intermittent bolus
- additional therapeutic bolus doses of local anaesthetic
when analgesia begins to wane
- disadvantage : pain relief constantly interrupted by
periods of regression of analgesia
• Continuous infusion
- maintainence of stable level of analgesia, less frequent
need for bolus doses, maternal haemodyanamic
stability
- decreased workload for anaesthesiologist
- disadvantage : administration of larger dose of local
anaesthetic
• Patient controlled epidural analgesia(PCEA)
and Computer controlled PCEA pumps

Advantages over bolus/continuous infusion:

- better patient satisfaction, less breakthrough pain
- reduced consumption of local anaesthetics
- optimal analgesia with minimal side effects
- less incidence of motor blockade
- stable haemodyanamics
- less need for anesthesia provider intervention
 conclusion 
• Epidural placement is a safe, effective means of providing surgical anesthesia or postoperative analgesia. • It
reduces the adverse physiologic responses to surgery, may decrease the incidence of myocardial infarctions
and postoperative pulmonary sequelae. • Mastery of epidural placement comes with practice, attention to
detail, and persistence. A thorough knowledge of anatomy, physiology, and the pharmacology of anesthetic
agents is required for safe application.
 REFERENCES
1. Miller’s anesthesia 9th edition
2. Barash clinical anesthesia 8th edition
3. Regional Collins 3rd edition
4. Guyton physiology