Abstract
In a controlled study a single segment combined spinal epidural (CSE) block was compared with spinal or epidural block for major orthopaedic surgery. Seventy-five patients, age 52–86 yr, were randomly assigned to receive one of the three blocks. Bupivacaine 0.5% was used for surgical analgesia. The postoperative pain relief after 4.0 mg epidural morphine was compared with the analgesic effect of 0.2 or 0.4 mg morphine administered intrathecally. With the spinal technique good or excellent surgical analgesia and muscle relaxation were achieved rapidly (11.8 ± 1.1 min). The time taken to provide an equally effective and reliable block with the CSE technique was no longer (14.9 ± 2.2 min). For epidural block with the catheter technique more time was required (35.9 ± 3.9 min) to provide acceptable surgical conditions (P < 0.05). Perioperative sedatives and concomitant analgesics were required more frequently and in larger doses by the patients undergoing surgery with epidural block (P < 0.05) than with CSE or spinal block. Our study demonstrated that the analgesia after surgery provided by 0.2 and 0.4 mg morphine administered intrathecally was comparable to that provided by 4.0 mg of epidural morphine. It is concluded that the analgesia and surgical conditions provided by the spinal and CSE blocks were similar and were superior to those provided by an epidural block.
Résumé
Lors d’une étude contrôlée, on compare le bloc que produit l’association rachi-épidurale (CSE) à celui que produit chacune des deux techniques utilisées séparément en chirurgie orthopédique lourde. Soixante-quinze patients âgés de 52 à 86 ans sont assignés au hasard à recevoir un des trois blocs. La bupivacaïne 0,5% est employée pour l’analgésie chirurgicale. Le soulagement postopératoire avec morphine épidurale 4,0 mg est comparé avec celui que procure la morphine 0,2 ou 0,4 intrathécale. Avec la technique rachidienne, une analgésie de bonne à excellente et la relaxation musculaire surviennent rapidement (11,8 ±1,1 min). Le temps requis pour obtenir les mêmes résultats avec la technique CSE n’est pas plus long (14,9 ± 2,2 min). Pour le bloc épidural avec cathéter, plus de temps est requis (35,9 ± 3,9 min) pour l’atteinte de conditions chirurgicales acceptables (P < 0,05) qu’avec le CSE ou la rachi. Notre étude montre que l’analgésie postopératoire obtenue par la morphine 0,2 et 0,4 mg intrathécale est comparable à celle produite par la morphine 0,4 épidurale. On conclut que les condition produites par la rachi et la CSE sont indentiques entre elles et supérieures à celles du bloc épidural.
Article PDF
Similar content being viewed by others
References
Modig J, Hjelmstedt Å, Sahlstedt B, Maripuu E. Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement. Acta Chir Scand 1981; 147: 125–30.
Rosberg B, Fredin H, Gustafson C. Anesthetic techniques and surgical blood loss in total hip arthroplasty. Acta Anaesthesiol Scand 1982; 26: 189–93.
Johnson A, Bengtsson M, Merits H, Löfström JB. Anesthesia for major hip surgery. A clinical study of spinal and general anesthesia in 244 patients. Reg Anesth 1986; 11: 83–8.
Coates MB. Combined subarachnoid and epidural techniques (Letter). Anaesthesia 1982; 37: 89–90.
Rawal N. Single segment combined subarachnoid and epidural block for Caesarean section (Letter). Can Anaesth Soc J 1986; 33: 254–5.
Rawal N, Schottin J, Wesström G. Epidural versus combined spinal epidural block for cesarean section. Acta Anaesthesiol Scand 1988; 32: 61–6.
Carrie LES. Extradural, spinal or combined block for obstetric surgical anaesthesia. Br J Anaesth 1990; 65: 225–33.
Tadoori P, Ravella R, Doss N, Gintautas J, Abadir AR. Combined epidural spinal (ESP) anesthesia for cesarean section using lidocaine 1.5% with 1:200,000 epinephrine. Reg Anesth 1991; 15: suppl 13: 84.
Vandermeersch E, Kick O, Möllmann M, de Gouw N, Van Aken H. Combined spinal and epidural anesthesia. Reg Anaesth 1991; 14: 108–12.
Stenseth R, Sellevold O, Breivik H. Epidural morphine for postoperative pain: experience with 1085 patients. Acta Anaesthesiol Scand 1985; 29: 148–56.
Bromage PR. A comparison of the hydrochloride and carbon dioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand Suppl 1965; 16: 55–69.
Tamsen A, Bondesson U, Dahlström B, Hartvig P. Patient-controlled analgesic therapy, Part III: pharmacokinetics and analgesic plasma concentrations of keotbemidone. Clin Pharmacokinet 1982; 7: 252–65.
Cousins MJ. Epidural neural blockade.In: Cousins MJ, Bridenbaugh PO (Eds.). Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia: JB Lippincott, 1988: 310–11.
Nydahl P-A, Axebson K, Philipson L, Leissner P, Larsson PG. Motor blockade and EMG recordings in epidural anaesthesia. A comparison between mepivacaine 2%, bupivacaine 0.5% and etidocaine 1.5%. Acta Anaesthesiol Scand 1989; 33: 597–604.
Kalso E, Tuominen M, Rosenberg PH. Effect of posture and some C.S.E characteristics on spinal anaesthesia with isobaric 0.5% bupivacaine. Br J Anaesth 1982; 54: 1179–84.
Cousins MJ. The spinal route of analgesia. Acta Anaesthesiol Belg, Suppl 2, 1988; 39: 71–82.
Gustafsson LL, Wiesenfeld-Hallin Z. Spinal opioid analgesia: a critical update. Drugs 1988; 35: 597–603.
Bengtsson M, Löfström JB, Merits H. Postoperative pain relief with intrathecal morphine after major hip surgery. Reg Anesth 1983; 8: 139–43.
Chadwick HS, Ready LB. Intrathecal and epidural morphine sulphate for post-cesarean analgesia — a clinical comparison. Anesthesiology 1988; 62: 925–9.
Etches RC, Sandier AN, Daley MD. Respiratory depression and spinal opioids. Can J Anaesth 1989, 36: 165–85.
Abouleish E, Rawal N, Fallon K, Hernandez D. Combined intrathecal morphine and bupivacaine for Cesarean section. Anesth Analg 1988; 67: 370–4.
Rawal N, Arnér S, Gustafsson LL Allvin R. Present state of extradural and intrathecal opioid analgesia in Sweden a nationwide follow-up survey. Br J Anaesth 1987; 59: 791–9.
Gielen M. Post durai puncture headache (PDPH): a review. Reg Anesth 1989; 14: 101–6.
Hurley RJ, Lambert DH. Continuous spinal anesthesia with a microcatheter technique: preliminary experience. Anesth Analg 1990; 70: 97–102.
Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 1991; 72: 275–81.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Holmström, B., Laugaland, K., Rawal, N. et al. Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery. Can J Anaesth 40, 601–606 (1993). https://doi.org/10.1007/BF03009695
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03009695