Skip to main content
SpringerLink
Log in

Dural Puncture Epidural Technique: a Novel Method for Labor Analgesia

  • Obstetric Anesthesia (LR Leffert, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

In recent years, the dural puncture epidural (DPE) technique has emerged as a novel method of labor analgesia. The DPE technique involves the technical elements of a combined spinal epidural (CSE) technique but avoids the direct administration of intrathecal medications. The underlying mechanism responsible for the unique blockade qualities of the DPE technique is believed to be the translocation of medications from the epidural space into the dural sac; laboratory studies have found a positive correlation between translocation flux and the size of dural perforation. Clinically, earlier and greater sacral spread and dermatomal block symmetry have been observed in obstetric and surgical patients receiving the DPE technique compared to the epidural (EPL) technique. Moreover, the DPE technique appears to have fewer side effects than the CSE technique. The DPE technique appears to offer a paradigm shift in obstetric analgesia and anesthesia, but further investigation is warranted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Toledano RD, Tsen LC. Epidural catheter design: history, innovations, and clinical implications. Anesthesiology. 2014;121(1):9–17.

    Article  Google Scholar 

  2. Thomas JA, Pan PH, Harris LC, Owen MD, D'Angelo R. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology. 2005;103(5):1046–51.

    Article  Google Scholar 

  3. Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg. 1996;82(5):1040–2.

    CAS  PubMed  Google Scholar 

  4. Cappiello E, O’Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg. 2008;107(5):1646–51.

    Article  Google Scholar 

  5. Sykes MK. Delayed spinal analgesia; a complication of epidural analgesia. Anaesthesia. 1958;13(1):78–83.

    Article  CAS  Google Scholar 

  6. Leach A, Smith GB. Subarachnoid spread of epidural local anaesthetic following dural puncture. Anaesthesia. 1988;43(8):671–4.

    Article  CAS  Google Scholar 

  7. Collis RE, Davies DW, Aveling W. Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet. 1995;345(8962):1413–6.

    Article  CAS  Google Scholar 

  8. Coates MB. Combined subarachnoid and epidural techniques. Anaesthesia. 1982;37(1):89–90.

    Article  CAS  Google Scholar 

  9. Bernards CM, Kopacz DJ, Michel MZ. Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anesthesia. Anesthesiology. 1994;80(4):853–8.

    Article  CAS  Google Scholar 

  10. Park WY. Factors influencing distribution of local anesthetics in the epidural space. Reg Anesth Pain Med. 1988;13(2):49–57.

    CAS  Google Scholar 

  11. Yokoyama M, Hanazaki M, Fujii H, Mizobuchi S, Nakatsuka H, Takahashi T, Matsumi M, Takeuchi M, Morita K. Correlation between the distribution of contrast medium and the extent of blockade during epidural anesthesia. Anesthesiology. 2004;100(6):1504–10.

    Article  Google Scholar 

  12. Arendt K, Segal S. Why epidurals do not always work. Rev Obstet Gynecol. 2008;1(2):49–55.

    PubMed  PubMed Central  Google Scholar 

  13. Sanchez R, Acuna L, Rocha F. An analysis of the radiological visualization of the catheters placed in the epidural space. Br J Anaesth. 1967;39(6):485–9.

    Article  CAS  Google Scholar 

  14. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19, 259 deliveries. Int J Obstet Anesth. 2004;13(4):227–33.

    Article  CAS  Google Scholar 

  15. •• Mankowitz SK, Gonzalez Fiol A, Smiley R. Failure to extend epidural labor analgesia for cesarean delivery anesthesia: a focused review. Anesth Analg. 2016;123(5):1174–80. Factors and options for failed epidural labor analgesia are discussed in this focused review

  16. Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology. 2001;95(4):913–20.

    Article  CAS  Google Scholar 

  17. Eappen S, Blinn A, Segal S. Incidence of epidural catheter replacement in parturients: a retrospective chart review. Int J Obstet Anesth. 1998;7(4):220–5.

    Article  CAS  Google Scholar 

  18. van de Velde M, Teunkens A, Hanssens M, van Assche FA, Vandermeersch E. Post dural puncture headache following combined spinal epidural or epidural anaesthesia in obstetric patients. Anaesth Intensive Care. 2001;29(6):595–9.

    Article  Google Scholar 

  19. • Groden J, Gonzalez-Fiol A, Aaronson J, Sachs A, Smiley R. Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor. Int J Obstet Anesth. 2016;26:4–7. Epidural catheters placed using a combined spinal-epidural technique have lower failure rates and failed significantly later in labor compared to epidural technique

    Article  CAS  Google Scholar 

  20. Goodman SR, Smiley RM, Negron MA, Freedman PA, Landau R. A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women. Anesth Analg. 2009;108(1):246–51.

    Article  Google Scholar 

  21. •• Gambling D, Berkowitz J, Farrell TR, Pue A, Shay D. A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during first and second stages of labor and at delivery. Anesth Analg. 2013;116(3):636–43. This prospective study compares analgesia using combined spinal-epidural with traditional epidural labor analgesia techniques in a private practice setting

    Article  CAS  Google Scholar 

  22. Hughes D, Simmons SW, Brown J, Cyna AM. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2003;4:CD003401.

    Google Scholar 

  23. Simmons SW, Taghizadeh N, Dennis AT, Hughes D, Cyna AM. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2012;10:CD003401.

    PubMed  Google Scholar 

  24. •• Heesen M, Van de Velde M, Klohr S, Lehberger J, Rossaint R, Straube S. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. Anaesthesia. 2014;69(1):64–71. This systematic review included 1722 parturients from 10 randomized controlled trials comparing combined spinal-epidural and epidural analgesia techniques in labor and found that there is a lower rate of unilateral block with the combined spinal-epidural technique

    Article  CAS  Google Scholar 

  25. •• Chau A, Bibbo C, Huang CC, Elterman K, Cappiello EC, Robinson JN, Tsen LC: A prospective, randomized trial of standard epidural, dural puncture epidural and combined spinal epidural labor analgesia techniques on maternal and fetal outcomes. Anesth Analg. 2017;124(2):560–9. The dural-puncture epidural technique was demonstrated to have better block quality compared to the epidural technique and fewer side effects compared to the combined spinal-epidural techniques in patients requesting early labor analgesia.

  26. Booth JM, Pan JC, Ross VH, Russell GB, Harris LC, Pan PH. Combined spinal epidural technique for labor analgesia does not delay recognition of epidural catheter failures: a single-center retrospective cohort survival analysis. Anesthesiology. 2016;125(3):516–24.

    Article  CAS  Google Scholar 

  27. Patel NP, Armstrong SL, Fernando R, Columb MO, Bray JK, Sodhi V, Lyons GR. Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine? Anaesthesia. 2012;67(6):584–93.

    Article  CAS  Google Scholar 

  28. Van de Velde M, Schepers R, Berends N, Vandermeersch E, De Buck F. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth. 2008;17(4):329–35.

    Article  CAS  Google Scholar 

  29. Miro M, Guasch E, Gilsanz F. Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases. Int J Obstet Anesth. 2008;17(1):15–9.

    Article  CAS  Google Scholar 

  30. Wang YF, Fuh JL, Lirng JF, Chen SP, Hseu SS, Wu JC, Wang SJ. Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study. Brain. 2015;138(Pt 6):1492–8.

    Article  Google Scholar 

  31. Norris MC. Are combined spinal-epidural catheters reliable? Int J Obstet Anesth. 2000;9(1):3–6.

    Article  CAS  Google Scholar 

  32. Lee S, Lew E, Lim Y, Sia AT. Failure of augmentation of labor epidural analgesia for intrapartum cesarean delivery: a retrospective review. Anesth Analg. 2009;108(1):252–4.

    Article  Google Scholar 

  33. Michaan N, Lotan M, Galiner M, Amzalag S, Many A. Risk factors for accidental dural puncture during epidural anesthesia for laboring women. J Matern Fetal Neonatal Med. 2016;29(17):2845–7.

    CAS  PubMed  Google Scholar 

  34. •• Hattler J, Klimek M, Rossaint R, Heesen M. The effect of combined spinal-epidural versus epidural analgesia in laboring women on nonreassuring fetal heart rate tracings: systematic review and meta-analysis. Anesth Analg. 2016;123(4):955–64. This systematic review included 3947 parturients from 17 randomized trials comparing the effect of combined spinal-epidural and epidural techniques on fetal heart rate tracing and found that the combined spinal-epidural technique was associated with a higher risk of nonreassuring fetal heart rate tracings than the epidural technique

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesia, BC Women’s Hospital, Vancouver, BC, Canada

    Anthony Chau

  2. Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada

    Anthony Chau

  3. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Lawrence C. Tsen

  4. Harvard Medical School, Boston, MA, USA

    Lawrence C. Tsen

Authors
  1. Anthony Chau
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lawrence C. Tsen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anthony Chau.

Ethics declarations

Conflict of Interest

Anthony Chau and Lawrence C. Tsen declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Obstetric Anesthesia

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chau, A., Tsen, L.C. Dural Puncture Epidural Technique: a Novel Method for Labor Analgesia. Curr Anesthesiol Rep 7, 49–54 (2017). https://doi.org/10.1007/s40140-017-0197-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40140-017-0197-6

Keywords

Search

Navigation