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Indian J. Anaesth. 2005; 49 (6) : 450 - 458

INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005

450

REVIEW ARTICLE

COMBINED SPINAL-EPIDURAL ANAESTHESIA

TECHNIQUES.......... A REVIEW
Dr. Chandola H.C. 1

Dr. Zubair Umer Mohamed2

Dr. Asok Jayaraj Pullani3

SUMMARY
Combined Spinal Epidural (CSE) anaesthesia commands a unique place among the various techniques used for neuraxial blockade. In
this article we delve into the history of CSE and try to enumerate the types of specialised needles devised for this technique. The
spinal needles that are, and in the future may well be associated with this technique are also discussed. The methods used to locate
the epidural space have been researched exhaustively and an attempt has been made to classify the various options available for CSE.
Controversial aspects such as the preferred approach, catheter threading prior to or after subarachnoid block and the need for test dosing
have also been addressed.

Keywords : Combined Spinal Epidural, CSE, Tuohy Needle, Spinal needle, Catheter.
Introduction
Among the various techniques used for neuraxial
blockade, CSE commands a unique place. The singularity
lies in its ability to combine the rapidity, density, and
reliability of the subarachnoid block with the flexibility of
continuous epidural block to titrate a desired sensory level,
vary the intensity of the block, control the duration of
anaesthesia, and deliver postoperative analgesia. Of late,
this procedure has come back in a big way, the fact justified
by its use extended to paediatric and even infant
laparotomies, apart from its use in orthopedic surgery,
obstetrics, very old patients and in other high-risk patients.1
Although at first sight the CSE technique appears to be
more complicated than either epidural or spinal block,
intrathecal drug administration and placement of the epidural
catheter are both facilitated by the various modifications of
the combined spinal-epidural technique.1,2 In this article
we try to follow the evolution and also summarise the
various developments in this technique described by various
authors over the years.
History
Leafing through the archives of anaesthesia, we find
that CSE was first described in 1937 by Soresi3, who used
the episubdural technique by first injecting a dose of
local anesthetic epidurally and, after advancing the needle
inside the dural cavity, injecting the spinal dose. Curelaru4
1. M.D., Asso. Prof.
2. M.B.B.S., PG Student
3. M.B.B.S. PG Student
M.L.N. Medical College, Allahabad, UP.
Department of Anaesthesiology,
M.L.N. Medical College, Allahabad, Uttar Pradesh - 211001.
Correspond to :
Dr. H. C. Chandola
E-mail : chandola@sancharnet.in
(Accepted for publication on 30 - 08 - 2005)

performed the first combined spinal anesthesia and

catheter-based epidural anaesthesia in 1979. He introduced
an epidural catheter through a Tuohy needle, administered
a test dose, and then performed a traditional dural puncture
12 lumbar segments distally using a 26-gauge spinal
needle. CSE was performed in 1982 on a single spinal
segment for lower limb surgery by Coates5 and Mumtaz6
et al. Epidural anaesthesia was performed using a 16-gauge
Tuohy needle, after which a 25-to 26-gauge spinal
needle, approximately 1 cm longer than the epidural
needle, was introduced with the Tuohy needle as introducer.
After the injection of local anesthetic, the spinal needle
was withdrawn and the epidural catheter inserted. In
1986, Rawal described a single segment sequential CSE
for caesarean delivery. (see below Sequential CSE).
Over the years, a variety of spinal, epidural and specialised
combined spinal-epidural needles have been devised and a
myriad of techniques described to refine this procedure.
Classification
The various options in CSE can be classified broadly
according to the number of interspaces used for performing
the procedure (table 1). If both the epidural and the spinal
punctures are performed in the same interspace it is called
single segment technique (SST) or single interspace CSE
technique and the others are named double segment techniques
(DST) or double interspace CSE technique. These can be
further classified according to the type of needle used and
the approach.
Single and double segment techniques
The reduced number of skin punctures in SST
decreases the incidence of patient discomfort, trauma, pain,
infection at puncture sites, epidural venous puncture and
formation of hematomas.1 The use of an epidural needle as
an introducer for the spinal needle lessens the likelihood of
contamination of the spinal needle with skin-borne

CHANDOLA, MOHAMED, PULLANI : COMBINED SPINAL-EPIDURAL ANAESTHESIA

microorganisms7. However, no quantitative studies have been

performed to confirm these assumptions. In DST, there is
always a theoretical possibility of damaging the epidural
catheter with the spinal needle if the catheter is threaded
before subarachnoid block. The advantage of DST is that it
does not require specialised CSE needles that are more
expensive than the usual epidural and spinal needles.
Table - 1 : Classification of CSE Techniques
Single Segment
Needle-Through-Needle
Without Spinal Needle Support
Median Approach
Paramedian Approach
With Spinal Needle Support
Spinal Needle Sleeve
Median Approach
Paramedian Approach
Spinal Needle Lock
Median Approach
Paramedian Approach
Needle-Beside-Needle (Double Barrel/Lumen)
Without Attached Spinal Needle Guide/Separate Needle
Median Approach
aramedian Approach
Combined Median/Paramedian Approach
With Attached Spinal Needle Guide
Guide alongside Epidural Needle
Median Approach
Paramedian Approach
Guide incorporated within Epidural Needle
Median Approach
Paramedian Approach
Double Segment
Median Approach
Paramedian Approach
Each of these can be performed with or with out epidural and/or spinal
catheters

Fig. 1: Different types of needles used for CSE technique.

A : needle through needle, B: Huber and Hanaoka needle,
C: Eldor needle, D: Eldor, Coombs and Torrieri needle.

451

Needles
Single Lumen Epidural Needles (Needle-ThroughNeedle technique)
1.
Epidural Needle with Single Aperture: This most
commonly used set consists of a conventional 16-18
gauge epidural needle (Fig. 1A) to locate the epidural
space. A spinal needle is then introduced through the
epidural needle to exit it through the Huber eye and
proceed to puncture the dural wall and enter the
subarachnoid space.
2.

CSE Needle with Additional Aperture (Huber and

Hanaoka Needles): This is basically an epidural needle
with an additional aperture (back eye) situated at
the end of the longitudinal axis.8,9 (Fig. 1B)

The usual technique is used for identification of

the epidural space. The spinal needle is then introduced
through the proximal port of the epidural needle to exit
at the back eye and after dural puncture and drug
administration the spinal needle is withdrawn and the
catheter inserted. The larger diameter of the catheter
causes it to pass through the usual Huber opening. These
modified needles function as a suitable introducer for even
the thinnest spinal needle, as kinking and friction in the
Huber eye of the epidural needle is avoided. Advancing the
spinal needle through the back eye may offer a more
distinct sensation of dural puncture.10 To accomplish
proper passage through the back eye, however, the distal
end of the spinal needle must face the same way as the
Huber opening of the epidural needle; otherwise the spinal
needle may pass through the Huber eye.11 But a traditional
insertion of the epidural needle with the Huber eye facing
cephalad will then cause the cutting bevel of the spinal
needle to cut the dural fibers perpendicular to its alignment,
which may increase the risk of postdural puncture
headache.12 With the needle through needle technique, there
is a concern about the tip of the spinal needle scraping the
inner wall of the epidural needle and thereby leading to
deposition of metal particles in the epidural and/or
subarachnoid spaces and possible, subsequent neurological
sequelae.13 However, studies by Herman et al14 failed to
find any evidence of additional metal particles produced by
the needle-through-needle technique and puts these doubts
to rest. The risk of damage to the bevel of the spinal needle
has been circumvented by the introduction of a plastic sleeve
for the spinal needle by the Espocan system.1 The plastic
sleeve keeps the spinal needle centrally in the epidural
needle and guides it through the back eye.
In this technique, the spinal needle is in contact
with only dura and the epidural needle, which may increase
the risk of displacement of the spinal needle at the time of

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INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005

syringe connection, aspiration of CSF or injection of local

anaesthetic.1 A study conducted by Tanaka N and coworkers15 and Hoffmann et al16 clearly demonstrated that
the lockable CSE provided safe and stable conditions and
a good success rate of subarachnoid block. But the feel of
the dural click was diminished when lockable CSE was
used.

larger distal side port of the Sprotte needle, as well as its

greater distance from the tip, may account for the slightly
greater deflection observed with Sprotte needles compared
to Whitacre needles. (Fig. 2)

Double-Lumen Needles: (Needle-Beside-Needle

technique)
In this technique, an epidural needle and spinal needle
are introduced through separate lumen or barrels. The spinal
needle guide may or may not be attached to the epidural
needle.
Separate Needle
In the technique described by Eldor and Olshwang,
the epidural needle is first placed in the epidural space by
the usual method followed by the introduction of the spinal
needle beside the epidural needle to perform the subarachnoid
puncture.17
A recent article by Cook described a variation from
this sequence by first locating the spinal needle in the
subarachnoid space and observing the free flow of CSF.
The stylet of the spinal needle is then replaced. The epidural
needle is then introduced via the median or paramedian
approach and catheter threaded, following which the
intrathecal drug is administered.18
Attached Needle
A parallel tube is attached to the epidural needle,
which acts as the introducer for the spinal needle. The
parallel tube may be either bent at the proximal end or
straight through out. The Eldor Needle (Fig. 1C) has a
straight tube attached while the Eldor, Coombs and Torrieri
Needle (Fig. 1D) has a bent spinal needle attached.7,9,19
The T-A needle is a further modification where both the
needles are welded together and the distal ends of the
needles make a common tip. The epidural needle points
cephalad and the spinal needle points caudad.20 The more
recently introduced E-SP needle has a needle wall
configuration that is over-under rather than parallel.1
Spinal Needles
The gauge and type of the spinal needle influences
the success of the procedure and the incidence of outcome.
The use of smaller gauge needles and ones with a conical
tip reduces the incidence of post dural puncture headache.21,22
Lipov23 et al. demonstrated that the axial force needed to
deform the Sprotte needle tip was less than that needed for
the Whitacre and Quincke needles of similar size. The

Fig. 2 : Tip of different types of spinal needles.

A: Sprotte, B: Whitacre, C: modified pencil-point,
D: ball pen, E: double-hole pencil-point, F: Quincke, G: Atraucan.

Newer needles have been designed to improve

efficacy. The Atraucan needle has a double bevel with the
distal cutting bevel making a cutting incision in the dura.
The second part of this needle dilates this incision rather
than cutting through the fibres leaving only a small hole in
the dura. The sharp tip however is prone to damage.24 A
new pencil-point spinal needle described is the double-hole
pencil-point (DHPP) spinal needle, and is composed of a
blunt ogival tip and two circular holes opposing each other
just proximal to the tip. The area of the two windows is
almost the same as of the single holed Sprotte needles
area, which enables more rapid CSF reflux. The anesthetic
solution injection spreads through both windows. This allows
a more diffuse anesthetic distribution and less anesthetic
solution dosage. The DHPP spinal needle allows anesthetic
solution injection even when a tissue fragment obstructs
one of the holes. More recently, the ball pen needles have
been marketed in France. The tip of this needle is actually
the tip of the stylet leaving a hollow cannula when the
stylet is removed. The proposed advantages of this needle
are that the tip of the needle is always completely in the
subarachnoid space and on removal of the stylet there is no
needle tip projecting beyond the orifice causing damage to
the neurological tissue. There is no mechanical weakening
at the tip caused by the presence of a lateral orifice. The
open end of the needle allows laminar flow of cerebrospinal
fluid, which results in faster identification of the subarachnoid
space.24
Optimal Length of the Spinal Needle Beyond the
Epidural Needle Tip
The distance from the tip of the epidural needle to
the posterior wall of the dural sac in the midline varies
considerably among patients (0.3-1.03 cm). 25,26 Further, the

CHANDOLA, MOHAMED, PULLANI : COMBINED SPINAL-EPIDURAL ANAESTHESIA

anteroposterior diameter of the dural sac varies considerably

during flexion and extension of the spinal column. At L3L4, the diameter increases from a range of 9-20 mm in
extension to a range of 11-25 mm in flexion.27 Additionally,
these findings are only valid when the epidural puncture is
performed in midline. This is because the dural sac is
triangular with its base resting on the vertebral body and
the triangle top points posteriorly to ligamentum flavum.28
A minimum of 13 mm length of the spinal needle protrusion
beyond the epidural needle tip is recommended for the CSE
sets for a reasonably high success rate.10 Also, because of
needle design, the length of protrusion for needles with side
orifice should be greater than that for end orifice needles.29
Techniques
The first neuraxial blockade performed by Corning
must have been an epidural rather than a spinal block.30
The earlier methods to identify the epidural space were the
feel and hear method of Pages, positive plunger pressure by
Dogliotti, hanging drop method by Gutierrez and the
balloon deflation technique by Macintosh and Oxford.31 Most
of these techniques were based on the concept of negative
pressure in the extradural space. However, the experiments
of Urayama32 and Shah JL33 showed that 77% of the lumbar
cerebrospinal fluid pulse wave, which is directly transmitted
to the extradural space as an extradural pressure wave
originates in the vascular system (arteries and veins), and
not in the brain. So, any rise in the blood pressure, which
is not an infrequent observation during epidural needle
insertion, can give a concomitant rise in the extradural
pressure with the loss of the negative pressure in the
extradural space and unreliable hanging drop and balloon
indicator techniques. Many feel the loss of resistance to
saline or demonstration of a free flow of the saline column
is a superior method for properly identifying the epidural
space. However, when administering CSE, the use of air
has been advocated so that there is no confusion that the
fluid returning is CSF when the spinal needle is subsequently
placed. These techniques have the disadvantage of identifying
only the epidural space and not the subarachnoid space.
Kopacz et al34 describes a further modification of this
technique which may increase the success rate and ease
with which it is performed. The modification described
allows the continued use of saline for loss of resistance
using an epidural needle with a transparent hub. First,
close attention is paid to the location of the saline meniscus
left within the epidural hub after demonstrating the loss of
resistance using saline. If a loss of resistance to air technique
is used, a small amount of saline can be introduced to
create this meniscus. The spinal needle is advanced in the
usual fashion until it is felt to exit the epidural needle. As
the spinal needle is advanced further to contact and indent

453

the dura, the tenting of the dura generates a negative pressure

within the epidural space, causing the meniscus to be drawn
in. This is similar to what is seen when performing the
hanging drop technique of identifying the epidural space.
As the spinal needle is advanced further, the dura is punctured
and the meniscus returns to near its original location as the
pressure within the epidural space returns to baseline.
Finally, CSF is observed to flow into the spinal needle to
ultimately drip from its hub. The point at which the meniscus
starts to advance is dependent on the dimensions of each
particular patients epidural space and to what distance the
needle has traversed the epidural space. This phenomenon
is reported to be a very specific indicator of needle location
and is most easily seen when a Whitacre spinal needle is
used. When a Quincke or Sprotte needle is used, the
movements of the meniscus may occur so suddenly that
often only a pop or splash of the fluid is detected, or
no movement is seen at all. These observations agree with
the studies showing that more force is required to penetrate
the dura with a Whitacre needle compared to a Quincke
needle.35
The membrane in syringe technique is, in principle,
a modification of the loss of resistance technique for
identifying the epidural space.36 A novel method to identify
the epidural space using an acoustic device was described
by Jacob S and Tierney E.37 The traditional loss of resistance
technique is combined with amplification of the sound made
by the epidural needle as it traverses the interspinous
ligament and the ligamentum flavum and then enters the
epidural space. Lechner TJ and associates38 described a
variant of the previous method. This consisted of translating
the pressure generated during the epidural puncture procedure
into a corresponding acoustic signal. Both these methods
combine the loss of resistance techniques with a newer
approach to improve the success rate by giving an early
warning of entry into epidural space. In addition, these can
be excellent teaching aids for beginners.
A still newer method to locate the epidural space
using real-time ultrasonic guidance has been described by
Grau T and colleagues.39 Epidural space localization has
also been reported by using an electronic device known as
Episensor but with limited success.40
Sequential CSE Technique
Rawal first described this variation of the standard
CSE technique.1 The spinal block is performed in the sitting
position and a low dose of hyperbaric bupivacaine is
administered to achieve a S5 to T8-T9 block. The patient
is placed supine with a left lateral tilt. When the spinal
block is fixed it is extended to T4 by injecting fractionated
doses of local anaesthetic into the epidural catheter.

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INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005

Two Catheter CSE Technique

A technique of providing CSE anaesthesia using
both spinal and epidural catheters in the same and
different interspace was described by Dahl et al41 and
Vercauteren et al42 respectively. The main advantage was
the possibility of titrating the intrathecal dose of the local
anaesthetic to the desired dermatomal level and to test the
correct position of epidural catheter before injecting the
drugs. Because of the requirement of a large diameter
spinal needle (22-gauge), the risk of catheter penetration
may be high; knotting of the catheters is also a theoretical
risk.42

Catheter
Holmstrm et al51 states that the distribution of
fat, rather than any dorso median connective tissue band,
influences the course of epidural catheter in epidural
space. Single-holed, open-end (uniport) and multiple
lateral holed, closed-end (multiport) epidural catheters are
commonly used; however, the risks and benefits associated
with each are controversial. Advantages cited in favor of
the blunt-tipped multiport epidural catheter include a reduced
likelihood of intravenous (IV) cannulation, since the catheter
tip is less likely to traumatize an epidural vein during
insertion,52 and a reduced incidence of inadequate analgesia,
since local anesthetic distribution may be enhanced by the
total separation of the three lateral ports. In contrast,
multiport epidural catheters have the theoretical disadvantage
of multicompartment placement when at least one port is
intrathecal, subdural, or IV, while the other port lies within
the epidural space. Multicompartment placement increases
the risk of high spinal blockade or local anesthetic toxicity
when local anesthetics are rapidly administered. But
DAngelo et al53 found that multiport epidural catheters
were associated with less inadequate analgesia and required
manipulation less often than uniport epidural catheters.
A newer version of epidural catheter is the combined
end-multiple lateral hole (CEMLH) catheter. It has 7 holes
within its 1.5 cm head: One at the tip; the first 3 lateral
holes are arranged circumferentially at 1 mm from each
other; the other 3 holes have a 4 mm distance from one to
the other.

Approach
Blomberg et al,43 Gaynor A44 and Hatfalvi BI45
compared the midline and paramedian approaches for lumbar
epidural block and concluded that the paramedian approach
was superior due to the following reasons.
1.

Easier to locate the epidural space and reduced

incidence of technical and catheter-related problems extreme flexion of the back to open up the interlaminar
space is not required;

2.

Reduced risk of trauma to the epidural veins and

lower incidence of epidural vein cannulation;

3.

Easier catheter insertion - the needle is angulated

substantially more cephalad resulting in less tenting
of the dura and a straighter catheter path;

4.

Lower incidence of dural puncture;

5.

Less paresthesia on catheter insertion and fewer

traumas to the ligaments of the back, with fewer
complaints of postpartum backache;

Muranaka K and colleagues46 concluded that though

the paramedian approach may be extremely useful for
patients with a midline scar or for those with a rigid spine,
it requires a longer spinal needle compared to the median
approach.
Rotation of Epidural Needle
Rotation of the epidural needle by 180 between
administration of the subarachnoid injection and threading
of the epidural catheter had been advocated so that the site
of the dural puncture is away from the point at which the
catheter impinges.47,48,49 This was presumed to decrease the
chance of subarachnoid placement of the catheter. But, in
fact, rotation of the epidural needle increased the chance
of inadvertent dural tear or puncture and subarachnoid
catheter placement.10,50 This practice has hence been
condemned.1

Beilin54 et al found that women in labor, who had

multi-orifice epidural catheters threaded 5 cm into the
epidural space through a cranially directed epidural needle
orifice at the L2-3 or L3-4 interspace, had the highest
incidence of successful analgesia with 0.25% bupivacaine,
as compared to women with catheters threaded 3 or 7 cm
into the epidural space. The studies of Holmstrm et al51
indicate that the risk of epidural catheter migration through
the dural hole during uncomplicated combined spinal epidural
block is very small.
Among the blind end catheters the softer tip ones
were least likely to cause transient paresthesias during
epidural catheter placement but the wire reinforced ones
were easier to insert and maneuver.55,56,57,58 Threading of
the epidural catheter may at times be a tricky affair and
consume a considerable amount of time. There are two
schools of thought regarding whether the catheter should be
threaded before or after the subarachnoid block. If catheter
insertion is attempted after spinal drug administration,
1.

This may lead to the spinal drug fixing before the

patient is positioned.

CHANDOLA, MOHAMED, PULLANI : COMBINED SPINAL-EPIDURAL ANAESTHESIA

2.

There is also a theoretical risk of the spinal anaesthetic

obscuring paresthesia during the epidural catheter
insertion.

3.

It may be difficult to verify the position of the catheter

because of difficulty identifying unintentional
subarachnoid injections in the presence of existing
spinal anaesthesia.1

These problems can be overcome if the double

segment technique is used and the epidural space location
and catheter threading is performed prior to subarachnoid
puncture, by using Cooks technique or by using the double
lumen needles.
However the problems of prior placement of the
epidural catheter has been enumerated by Rawal.1
1.

Epidural test dose may make differentiation between

spinal and epidural block difficult.

2.

A portion of epidural test dose may appear in the hub

of the spinal needle and cause confusion.

3.

The final direction of epidural catheter is unpredictable.

And may even tie itself in a knot.

4.

Because, epidural catheter migration can occur over

time, only a recent test dose holds significance.

5.

The incidence of epidural catheter penetration through

the dura has been reported to be more common with
double segment technique than the single segment
technique.

Tseng CH et al59 found that injection of 10 ml saline

into the epidural space before catheter insertion could
significantly diminish the incidence of epidural venous
puncture by the catheter. Another method to ease the insertion
of the catheter into the epidural space is by asking the
patient to hold breath in deep inspiration so as to expand the
epidural space cross-sectional area.60 Withdrawing the
catheter 1-2 cm, rotating it along the long axis and
re-advancing may also help in some cases of difficult
catheterisation.57
Long term indwelling epidural catheters are best
cleaned with pledgets impregnated with 10% povidoneiodine.61 The removal of catheter in the lateral position is
reported to have a higher success rate than removing in the
sitting position.62 Blackshear et al reported that catheters
of high tensile strength should be used to minimize the
chance of catheter tip breaking in the epidural space.63
Position
Yun et al64 found that hypotension was more severe
and more difficult to treat when CSE for cesarean section
was induced in the sitting versus the lateral position.

455

Test Dose
The location of the epidural catheter cannot be tested
by injecting the usual volume of local anesthetic65, because
of the risk of total spinal anesthesia if the catheter is
placed spinally. The conventional epidural catheter test
dose consists of either 1 ml of hyperbaric lidocaine with
adrenaline or 2 ml of 0.5% bupivacaine with adrenaline.66
With a correctly inserted epidural catheter, the block height
will increase only approximately two segments. If the
catheter has entered the spinal canal, the resulting block
will not extend to a level causing diaphragmatic paralysis.
Crawford in his review of 27,000 lumbar epidural blocks
concluded that the requirements for safety are that all top
ups are given in divided dose, with an interval of
approximately 5 minutes between two increments.67
When CSE is used in labour analgesia, a traditional
epidural test dose causes unwanted loss of motor and
proprioceptive functions, defeating the whole purpose of
ambulatory analgesia or walking epidural in labour. In
addition, traditional test doses frequently fail to detect
subdural catheter placement.68 These concerns have urged
some workers to advocate that when low-dose mixtures of
opioid and local anesthetic are used, as in the CSE technique
or for epidural analgesia alone for labour, epidural test
doses are unnecessary.69
The debate on test dosing the epidural catheter with
local anaesthetic may well be put to rest if the method
described by Tsui BC et al 70 and Ozawa T et al71 becomes
simpler and more applicable. This method was to electrically
stimulate the catheter tip and see the neuromuscular response
and was reported to be more sensitive and specific than the
standard test dose (3 ml lidocaine 1.5% with 1:200,000
epinephrine). The main drawbacks of this method being that
the epidural catheter has already been placed and this method
only verifies whether the catheter tip is in contact with a
nerve or not. It cannot differentiate between an epidurally
and a subdurally placed catheter.
Dosage in CSE
CSE often produces a more extensive block than
expected. The following possible mechanisms have been
postulated for the reduced epidural drug requirement in
CSE.
1.

Leakage of epidural local anaesthetic through the dural

hole into the subarachnoid space.72

2.

Continuing spread of initial subarachnoid block

(unrelated to the epidural injection).1

3.

Existence of subclinical analgesia at a higher level

which is enhanced and becomes evident by perineural
or transdural spread of epidural local anaesthetic.73

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INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005

4.

Change in epidural pressure. The pressure becomes

atmospheric which may result in better spread of
local anaesthetic because of an effect on volume and
circulation of CSF.74

5.

Epidural Volume Extension (EVE): Compression of

subarachnoid space by the presence of epidural catheter
and by the volume of local anaesthetic, resulting in a
squeezing of CSF and more extensive spread of
local anaesthetic.50,65,75,76,77,78

The necessary epidural dose for extension of a spinal

block varies between 1.5 and 3 ml per added segment, less
than needed for extending a conventional epidural
anesthesia.50
Various aspects of the combined spinal epidural
anaesthesia, discussed above have been incorporated in many
of the commercially available kits. Research is on and
further improvements are expected in the near future.
References
1. Rawal N, Van Zundert A, Holmstrom B, Crowhurst JA.
Combined Spinal-epidural Technique. Reg Anesth 1997; 22(5):
406-23.
2. Rawal N, Holmstrom B, Crowhurst JA et al. The combined
spinal-epidural technique. Anesthesiol Clin North America.
2000; 18(2): 267-95.
3. Soresi AL. Episubdural anesthesia. Anesth Analg 1937; 16:
306-10.
4. Curelaru I. Long duration subarachnoid anesthesia with
continuous epidural blocks. Praktische Anaesthesie
Wiederbelebung und Intensivtherapie 1979; 14: 71-78.
5. Coates MB. Combined subarachnoid and epidural techniques
[letter] Anaesthesia 1982; 37: 89-90.
6. Mumtaz MH, Daz M, Kuz M. Another single space technique
for orthopedic surgery [letter] Anaesthesia 1982; 37: 90.
7. Eldor J, Chaimsky G. Combined spinal-epidural needle (CSEN)
[letter] Can J Anaesth 1988; 35: 537-39.

14. Herman N, Molin J, Knape KG. No additional metal particle

formation using the needle-through-needle combined
spinal/epidural technique. Acta Anaesthesiol Scand 1996; 40:
227-31.
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CAUSES OF DIFFICULT INTUBATION

(PNEUMONICS/ACRONYMS FOR EASY REMEMBRANCE)
A

Ankylosis of TM joint, Acromegaly,

Adentulous.

Obesity, Odema in Ac. Burns, Over confidence

of Anaesthesiologist.

Bull neck, Beard individual, Big breasts, Burns

contracture.

Peritonsillar abscess, Pierre Robbinson

Syndrome, Poor illumination of laryngoscope.

Collapsible pharynx, Cervical spine injuries,

Cystic Hygroma, Cleft Lip, Cleft palate.

Quinsy.

Down syndrome, Dentures.

Retrognathia, Rheumatoid arthritis of TMJ/

Cervical spine, Retropharyngeal abscess.

Epiglotitis, Excessive pharynzeal tissue.

SAS, Short Neck, Snorer.

Fascio-maxillary injuries/abnormalities, F.B.

Goitre, Golden hars Syndrome.

Tongue tie, Tracheal stenosis, Trismus,

Treacher collin syndrome.

Hydrocephalus, High arched palate.

Uvulitis/abscess.

Inter Incissor Distance > 3.8 cm., Irradiation

causing fixity of Larynx.

Visualisation of only Epiglotis/only soft palate.

Junior (Improperly trained) Anaesthesiologist.

Wrong tube size, wrong laryngoscope blade,

wrong assistant, wrong position and place,
Webbed neck.

Kippel Feil Syndrome.

Laryngeal oedema, Ludwigs Angina, Large

Tonsills, Large tongue, Lock jaw, Large
Incissors.

X-ray evidence of increased in mandibulo

hyoid distance. X ray evidence of decreased
space between C1 and occiput.

Micrognathia, macroglossia, Mallampati score

> 3.

Younger children infants, new borns/

Neonates.

Zygomatic bone # and/dislocation.

M
N

Neck mobility, Neoplasms, No teeth.

Dr.I.Rathnakar
Karimnagar (AP)