Epidural Anesthesia: New Indications for an Old Technique?

  • A. Gottschalk
  • C. Ertmer
  • M. Westphal
Conference paper


Fernand Cathélin (1873–1929) and Jean Athanase Sicard (1872–1929) were the pioneer researchers who independently tried to establish an analgesic technique via the epidural space. Cathélin, however, was the first to report experiences in blocking the last sacral and coccygeal nerves using an anesthetic solution (which is still unknown). Although Cathélin was able to apply this technique in the treatment of various urological diseases, he failed to produce effective anesthesia for surgical procedures [1]. Now, about one century later, epidural anesthesia is a widely used and accepted technique for perioperative analgesia in thoracic, abdominal, and orthopedic surgery. In addition, epidural anesthesia is often applied in women during labor and delivery and represents a useful approach in the treatment of chronic pain (especially related to pancreatic cancer and pancreatitis). Moreover, besides providing effective pain relief, epidural anesthesia represents a reliable and reversible neural deafferentation technique that effectively contributes to a reduction in the surgical stress response [2]. The clinical effects of thoracic epidural anesthesia are primarily related to a segmental sympathetic blockade [3]. In this context, it is note- worthy that epidural anesthesia is linked to vasodilation in the blocked area and a reflex increase in sympathetic activity outside the anesthetized segments [4]. Current evidence supports the concept that only thoracic epidural anesthesia exerts positive effects on cardiopulmonary and gastrointestinal functions. This book chapter is not exhaustive, but aims to summarize the current knowledge on the effects of epidural anesthesia on pain management, cardiopulmonary and gastrointestinal functions, as well as the immune system and outcome (Fig. 1.).

Fig. 1.

The effects of epidural anesthesia.


Epidural Analgesia Epidural Anesthesia Epidural Catheter Epidural Hematoma Epidural Abscess 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Goerig M, Freitag M, Standl T (2002) One hundred years of epidural anaesthesia — the men behind the technical development. International Congress Series 1242: 203–212CrossRefGoogle Scholar
  2. 2.
    Ahlers 0, Nachtigall I, Lenze J, et al (2008) Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 101: 781–787CrossRefPubMedGoogle Scholar
  3. 3.
    Freise H, Meissner A, Lauer S, et al (2008) Thoracic epidural analgesia with low concentration of bupivacaine induces thoracic lumbar sympathetic block. Anesthesiology 109: 1107–1112CrossRefPubMedGoogle Scholar
  4. 4.
    Freise H, Anthonsen S, Fischer LG, Van Aken HK, Sielenkamper AW (2005) Continuous thoracic epidural anesthesia induces segmental sympathetic block in the awake rat. Anesth Analg 100: 255–262CrossRefPubMedGoogle Scholar
  5. 5.
    Liebeskind JC (1991) Pain can kill. Pain 44: 3–4CrossRefPubMedGoogle Scholar
  6. 6.
    Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM (2008) Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth 101: 832–840CrossRefPubMedGoogle Scholar
  7. 7.
    Wu CL, Cohen SR, Richman JM, et al (2005) Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 103: 1079–1088CrossRefPubMedGoogle Scholar
  8. 8.
    Werawatganon T, Charuluxanun S (2005) Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev CD004088Google Scholar
  9. 9.
    Jordan B, Devi LA (1998) Molecular mechanisms of opioid receptor signal transduction. Br J Anaesth 81: 12–19PubMedGoogle Scholar
  10. 10.
    Trafton JA, Abbadie C, Marek K, Basbaum AI (2000) Postsynaptic signaling via the [mu]-opioid receptor: responses of dorsal horn neurons to exogenous opioids and noxious stimulation. J Neurosci 20: 8578–8584PubMedGoogle Scholar
  11. 11.
    Gardell LR, Wang R, Burgess SE, et al (2002) Sustained morphine exposure induces a spinal dynorphin-dependent enhancement of excitatory transmitter release from primary afferent fibers. J Neurosci 22: 6747–6755PubMedGoogle Scholar
  12. 12.
    Borgland SL (2001) Acute opioid receptor desensitization and tolerance: is there a link? Clin Exp Pharmacol Physiol 28: 147–154CrossRefPubMedGoogle Scholar
  13. 13.
    Gottschalk A, Freitag M, Tank S, et al (2004) Quality of postoperative pain using an intraoperatively placed epidural catheter after major lumbar spinal surgery. Anesthesiology 101: 175–180CrossRefPubMedGoogle Scholar
  14. 14.
    Blumenthal S, Min K, Nadig M, Borgeat A (2005) Double epidural catheter with ropivacaine versus intravenous morphine: A comparison for postoperative analgesia after scoliosis correction surgery. Anesthesiology 102: 175–180CrossRefPubMedGoogle Scholar
  15. 15.
    Blumenthal S, Borgeat A, Nadig M, Min K (2006) Postoperative analgesia after anterior correction of thoracic scoliosis. Spine 31: 1646–1651CrossRefPubMedGoogle Scholar
  16. 16.
    Gauger T, Voepel-Lewis T, Burke C, et al (2009) Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion. J Pediatr Orthop 29: 588–593PubMedGoogle Scholar
  17. 17.
    Berendes E, Schmidt C, Van Aken H, et al (2003) Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting: a randomized trial. Arch Surg 138: 1283–1290CrossRefPubMedGoogle Scholar
  18. 18.
    Loick HM, Schmidt C, Van Aken H, et al (1999) High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg 88: 701–709CrossRefPubMedGoogle Scholar
  19. 19.
    Popping DM, Elia N, Marret E, Remy C, Tramer MR (2008) Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 143: 990–999CrossRefPubMedGoogle Scholar
  20. 20.
    Sielenkamper AW, Eicker K, Van Aken H (2000) Thoracic epidural anesthesia increases mucosal perfusion in ileum of rats. Anesthesiology 93: 844–851CrossRefPubMedGoogle Scholar
  21. 21.
    Freise H, Fischer LG (2009) Intestinal effects of thoracic epidural anesthesia. Curr Opin Anaesthesiol 22: 644–648CrossRefPubMedGoogle Scholar
  22. 22.
    Daudel F, Freise H, Westphal M, et al (2007) Continuous thoracic epidural anesthesia improves gut mucosal microcirculation in rats with sepsis. Shock 28: 610–614PubMedGoogle Scholar
  23. 23.
    Michelet P, D'Journo XB, Roch A, et al (2005) Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia. Chest 128: 3461–3466CrossRefPubMedGoogle Scholar
  24. 24.
    Fotiadis RJ, Badvie S, Weston MD, Allen-Mersh TG (2004) Epidural analgesia in gastrointestinal surgery. Br J Surg 91: 828–841CrossRefPubMedGoogle Scholar
  25. 25.
    Daudel F, Bone HG, Traber DL, et al (2006) Effects of thoracic epidural anesthesia on hemodynamics and global oxygen transport in ovine endotoxemia. Shock 26: 615–619CrossRefPubMedGoogle Scholar
  26. 26.
    Daudel F, Ertmer C, Stubbe HD, et al (2007) Hemodynamic effects of thoracic epidural analgesia in ovine hyperdynamic endotoxemia. Reg Anesth Pain Med 32: 311–316PubMedGoogle Scholar
  27. 27.
    Dossow V, Luetz A, Haas A, et al (2008) Effect of remifentanil and fentanyl on cell-mediated immune response in patients undergoing elective coronary artery bypass graft surgery. J Int Med Res 36: 1235–1247Google Scholar
  28. 28.
    Liu SS, Block BM, Wu CL (2004) Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 101: 153–161CrossRefPubMedGoogle Scholar
  29. 29.
    Tonnesen E, Wahlgreen C (1988) Influence of extradural and general anaesthesia on natural killer cell activity and lymphocyte subpopulations in patients undergoing hysterectomy. Br J Anaesth 60: 500–507CrossRefPubMedGoogle Scholar
  30. 30.
    Wada H, Seki S, Takahashi T, et al (2007) Combined spinal and general anesthesia attenuates liver metastasis by preserving TH1/TH2 cytokine balance. Anesthesiology 106: 499–506CrossRefPubMedGoogle Scholar
  31. 31.
    Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ (2008) Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology 109: 180–187CrossRefPubMedGoogle Scholar
  32. 32.
    Christopherson R, James KE, Tableman M, Marshall P, Johnson FE (2008) Long-term survival after colon cancer surgery: a variation associated with choice of anesthesia. Anesth Analg 107: 325–332CrossRefPubMedGoogle Scholar
  33. 33.
    Monk TG, Saini V, Weldon BC, Sigl JC (2005) Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 100: 4–10CrossRefPubMedGoogle Scholar
  34. 34.
    Sessler DI (2009) Long-term consequences of anesthetic management. Anesthesiology 111: 1–4CrossRefPubMedGoogle Scholar
  35. 35.
    Jorgensen H, Wetterslev J, Moiniche S, Dahl JB (2000) Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev CD001893Google Scholar
  36. 36.
    Rodgers A, Walker N, Schug S, et al (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321: 1493CrossRefPubMedGoogle Scholar
  37. 37.
    Rigg JRA, Jamrozik K, Myles PS, et al (2002) Epidural anaesthesia and analgesia and outcome of major surgery: a randomized trial. Lancet 359: 1276–1282CrossRefPubMedGoogle Scholar
  38. 38.
    Park WY, Thompson J, Lee KK (2001) Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 234: 560–569CrossRefPubMedGoogle Scholar
  39. 39.
    Grewal S, Hocking G, Wildsmith JA (2006) Epidural abscesses. Br J Anaesth 96: 292–302CrossRefPubMedGoogle Scholar
  40. 40.
    Cameron CM, Scott DA, McDonald WM, Davies MJ (2007) A review of neuraxial epidural morbidity: experience of more than 8, 000 cases at a single teaching hospital. Anesthesiology 106: 997–1002CrossRefPubMedGoogle Scholar
  41. 41.
    Christie IW, McCabe S (2007) Major complications of epidural analgesia after surgery: results of a six-year survey. Anaesthesia 62: 335–341CrossRefPubMedGoogle Scholar
  42. 42.
    Moen V, Dahlgren N, Irestedt L (2004) Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 101: 950–959CrossRefPubMedGoogle Scholar
  43. 43.
    Gogarten W, Van Aken H (2009) New guidelines on thromboembolism prophylaxis — implications for our specialty. Anästhesiologie und Intensivmedizin 5: 316–323Google Scholar

Copyright information

© Springer Science + Business Media Inc. 2010

Authors and Affiliations

  • A. Gottschalk
    • 1
  • C. Ertmer
    • 1
  • M. Westphal
    • 1
  1. 1.Department of Anesthesiology and Intensive CareUniversity of MuensterMuensterGermany

Personalised recommendations