Neuraxial Blockade: Epidural Anesthesia

  • Sreekumar Kunnumpurath
  • Suneil Ramessur
  • Adam Fendius
  • Nalini Vadivelu
  • Jasmina Perinpanayagam


The first epidural injection was performed in 1901 by Jean-Athanase Sicard and Ferdinand Catheline through caudal route. Touhy needle was developed for continuous spinal catheter technique and later adapted for epidural anesthesia by Manual Martinez Curbelo. Its popularity increased due to the possible serious neurological sequelae of spinal injections and the availability of long-acting local anesthetic agents such as bupivacaine. As a result of its versatility, it certainly remains a popular regional anesthetic technique in the USA and UK.


Epidural Neuraxial Spinal cord Caudal Vertebrae Local anesthetic Chronic pain Post-dural-puncture headache Paramedian Tuohy Batson’s plexus 


  1. 1.
    Moraca RJ, Sheldon DG, et al. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg. 2003;238(5):663–73.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Neal JM. Epidural anesthesia. In: Rathmell JP, Neal JM, Viscomi CM, editors. Regional anesthesia—the requisites in anaesthesiology. Philadelphia, PA: Elselvier/Mosby; 2004. p. 99–113.Google Scholar
  3. 3.
    Baron J, Decaux-Jacolot A, Edouard A, et al. Influence of venous return on baro-reflex control of heart rate during lumbar epidural anesthesia in humans. Anesthesiology. 1986;64:188.CrossRefPubMedGoogle Scholar
  4. 4.
    Kunnumpurath S, et al. Spinal cord stimulation: principles of past, present and future practice: a review. J Clin Monit Comput. 2009;23(5):333–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Stone PA, Kilpatrick AW, Thorburn J. Posture and epidural catheter insertion. The relationship between skill, experience and maternal posture on the outcome of epidural catheter insertion. Anaesthesia. 1990;45(11):920–3.CrossRefPubMedGoogle Scholar
  6. 6.
    AnaesthesiaDotCalm.Org Epidural Abscess. 2007. Abscess.pdf. Accessed 13 May 2010.
  7. 7.
    Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology. 1997;86(4):778–84.CrossRefPubMedGoogle Scholar
  8. 8.
    Moore JM, Liu SS, Neal JM. Premedication with fentanyl and midazolam decreases the reliability of intravenous lidocaine test dose. Anesth Analg. 1998;86:1015–7.CrossRefPubMedGoogle Scholar
  9. 9.
    OAA Epidural Information card. 2008. Online: Accessed 24 Nov 2016.
  10. 10.
    Shanthanna H, Mendis N, Goel A. Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale and technical considerations. Br J Anaesth. 2016;116(2):192–207.CrossRefPubMedGoogle Scholar
  11. 11.
    Camorcia M, Capogna G. Sensory assessment of epidural block for Caesarean section: a systematic comparison of pinprick, cold and touch sensation [Abstract]. Eur J Anaesthesiol. 2006;23(7):611–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Hogan Q. Epidural catheter tip position and distribution of injectate evaluated by computed tomography. Anesthesiology. 1999;90:964–70.CrossRefPubMedGoogle Scholar
  13. 13.
    Hogan Q. Distribution of solution in the epidural space: examination by cryomicrotome section. Reg Anesth Pain Med. 2002;27:150–6.PubMedGoogle Scholar
  14. 14.
    Higuchi H, et al. Factors affecting the spread and duration of epidural anesthesia with ropivacaine. Anesthesiology. 2004;101(2):451–60.CrossRefPubMedGoogle Scholar
  15. 15.
    Mulroy MF, Bernards CM, McDonald SB, Salinas FV. A practical approach to regional anesthesia. 4th ed. Phildelphia: Lippincott; 2009.Google Scholar
  16. 16.
    Nesacaine Product Monograph (Revised 29 Jun 2006). Accessed 14 May 2010.
  17. 17.
    Xylocaine Parenteral Injections Product Monograph (Revised 17 Apr 2008). Accessed 14 May 2010.
  18. 18.
  19. 19.
    Carbocaine Product Monograph (Revised Apr 2010). Accessed 14 May 2010.
  20. 20.
    The New York School of Regional Anesthesia. Local anesthetics (16 Mar 2009). Accessed 14 May 2010.
  21. 21.
    Naropin Product Monograph (Prepared Feb 2000, Rev Mar 2008). Accessed 14 May 2010.
  22. 22.
  23. 23.
    Anaesthetics (Parenteral-Local). Accessed 14 May 2010.
  24. 24.
    Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic cardiotoxic effects of racemic bupivacaine, levobupivacaine, and ropivacaine in anesthetized swine. Anesth Analg. 2000;90:1308–14.CrossRefPubMedGoogle Scholar
  25. 25.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455–63.CrossRefPubMedGoogle Scholar
  26. 26.
    Lowson SM, Alexander JI, Black AM, Bambridge AD. Epidural diamorphine infusions with and without 0.167% bupivacaine for post-operative analgesia. Eur J Anaesthesiol. 1994;11(5):345–52.PubMedGoogle Scholar
  27. 27.
    de Leon-Casasola OA, Lema MJ. Postoperative epidural opioid analgesia: what are the choices. Anesth Analg. 1996;83:867–75.CrossRefPubMedGoogle Scholar
  28. 28.
    Mulroy MF, Norris MC, Liu SS. Safety steps for epidural injection of local anesthetics: review of the literature and recommendations. Anesth Analg. 1997;85:1346–56.CrossRefPubMedGoogle Scholar
  29. 29.
    Eisenach J, De Kock M, Klimscha W. Alpha-2 adrenergic agonists for regional anesthesia: a clinical review of clonidine (1984–1995). Anesthesiology. 1996;85(3):655–74.CrossRefPubMedGoogle Scholar
  30. 30.
    Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review. Anesth Analg. 2004;99(2):482–95.CrossRefPubMedGoogle Scholar
  31. 31.
    Mulroy MF. Regional anesthesia—an illustrated procedural guide. 3rd ed. Philadelphia, PA: Lippincott; 2002. p. 93–118.Google Scholar
  32. 32.
    Weinberg G, et al. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med. 2003;28:198–202.CrossRefPubMedGoogle Scholar
  33. 33.
    Lubenow T, Keh-Wong E, Kristof K, et al. Inadvertent subdural injection: a complication of epidural block. Anesth Analg. 1988;67:175–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Drasner K, Rigler ML, Sessler ID, et al. Cauda equina syndrome after incidental total spinal anesthesia with 2% lidocaine. Anesthesiology. 1992;77:582–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines. Reg Anesth Pain Med. 2010;35(1):64–101.CrossRefPubMedGoogle Scholar

Suggested Reading

  1. Moore DC. Regional block: a handbook for use in the clinical practice of medicine and surgery. 4th ed (10th printing). Charles C Thomas: Springfield, IL; 1981.Google Scholar
  2. Mulroy FM, Bernards CM, McDonald SB, Salinas FV. A practical approach to regional anesthesia. 4th ed. Philadelphia, PA: Lippincott; 2009.Google Scholar
  3. Pinnock CA, Lin T, Smith T. Fundamentals of anaesthesia. 2nd ed. London: Greenwich Medical Media Ltd; 2002.Google Scholar
  4. Wong CA. Spinal and epidural anesthesia. 1st ed. McGraw-Hill Professional: Columbus, OH; 2007.Google Scholar
  5. Yentis SM, Hirsch NP, Smith GB. Anaesthesia and intensive care A-Z an encyclopaedia of principles and practice. 3rd ed. London: Elsevier (Butterworth Heineman); 2004.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Sreekumar Kunnumpurath
    • 1
  • Suneil Ramessur
    • 2
  • Adam Fendius
    • 3
  • Nalini Vadivelu
    • 4
  • Jasmina Perinpanayagam
    • 5
  1. 1.Pain ManagementEpsom and St. Helier University Hospitals NHS TrustCarshaltonUK
  2. 2.AnaestheticsGuys and St. Thomas’ NHS Foundation TrustLondonUK
  3. 3.AnaesthesiaOxford University Hospitals NHS Foundation TrustOxfordUK
  4. 4.Department of AnesthesiologyYale UniversityNew HavenUSA
  5. 5.AnaestheticsSt George’s University HospitalLondonUK

Personalised recommendations