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    Combined Spinal-Epidural Anesthesia
    Combined Spinal-Epidural Anesthesia
    Combined Spinal-Epidural Anesthesia
    Ebook161 pages4 hours

    Combined Spinal-Epidural Anesthesia

    By Joseph Eldor

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    About this ebook

    The first epidural analgesia was done by Corning in 1885 inadvertently. Lumbar dural puncture was introduced in 1891 by Wynter in England and Quincke in Germany. Von Ziemssen in 1894 suggested the feasibility of injecting drugs by means of lumbar dural puncture. Bier, a surgeon at the Royal Chirurgical Clinic in Kiel, was the first to inject cocaine into the spinal space. It was between August 16 and 27, 1898. It took 38 years since Corning`s discovery of the epidural analgesia and 25 years since Bier`s spinal anesthesia that these two compartments were first combined by Dr. Ryszard RODZINSKI (POLSKA GAZETA LEKARSKA, 1923) in 1923 and then by Soresi in 1937. It took another 42 years until Curelaru in 1979 used this combined spinal-epidural anesthesia again. Even the discoveries of Corning and Bier are 13 years apart. However, the first anesthesia (maybe it was combined spinal-epidural anesthesia - who knows?...) was done by God "caused a deep sleep to fall upon Adam" for rib extraction. The combined approach can also have its origin in the Bible: "Two are better than one" . Or you can look at it from Mark Twain`s point of view: "Name the greatest of all the inventors. Accident".
    CSEA (combined spinal-epidural anesthesia) and CSEGA (combined spinal-epidural-general anesthesia) are new modalities of anesthesia for almost any patient at any age. This book highlights the subject from various points of view. It can be used as an Opioid Free Anesthesia (OFA).

    LanguageEnglish
    PublisherJoseph Eldor
    Release dateNov 22, 2017
    ISBN9781370647163
    Combined Spinal-Epidural Anesthesia

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      Book preview

      Combined Spinal-Epidural Anesthesia - Joseph Eldor

      Preface

      CSEA (combined spinal-epidural anesthesia) and CSEGA (combined spinal-epidural-general anesthesia) are new modalities of anesthesia for almost any patient at any age. This book highlights the subject from various points of view. It doen`t intend to teach. It`s goal is to encourage the anesthesiologists to practise what they already know in the best way they think is good for themselves while being a patient. It is a kind of a balanced anesthesia which uses techniques instead of drugs to accomplish the ideal kind of anesthesia for the patients. This new frontier in anesthesia should open a new era of anesthetic quality and cost-effectiveness. However, in the second edition of Principles and Practice of Obstetric Analgesia and Anesthesia, edited by Bonica JJ and McDonald JS, and published in 1995 by Williams & Wilkins, there are 1344 pages. The chapter on epidural analgesia and anesthesia contains 127 pages. That on subarachnoid block - 26 pages. On subarachnoid/epidural combination there is only half a page with only 2 references in the chapter on cesarean section. So, the new combined spinal-epidural anesthesia gained only 0.03% of the space in a book published in 1995 on the practice of obstetric analgesia and anesthesia. This is really not its present worth, neither its future.

      It has long been an axiom of mine that the little things are infinitely the most important (Arthur Conan Doyle). If pain could have cured us we should long ago have been saved (George Santayana).

      The greatest evil is physical pain (St. Augustine of Hippo).

      Origin

      The first epidural analgesia was done by Corning (1) in 1885 inadvertently. Lumbar dural puncture was introduced in 1891 by Wynter (2) in England and Quincke (3) in Germany. Von Ziemssen (4) in 1894 suggested the feasibility of injecting drugs by means of lumbar dural puncture. Bier (5), a surgeon at the Royal Chirurgical Clinic in Kiel, was the first to inject cocaine into the spinal space. It was between August 16 and 27, 1898. It took 38 years since Corning`s discovery of the epidural analgesia and 25 years since Bier`s spinal anesthesia that these two compartments were first combined by Dr. Ryszard RODZINSKI (POLSKA GAZETA LEKARSKA, 1923) in 1923 and then by Soresi (6) in 1937. It took another 42 years until Curelaru (7) in 1979 used this combined spinal-epidural anesthesia again. Even the discoveries of Corning and Bier are 13 years apart. However, the first anesthesia (maybe it was combined spinal-epidural anesthesia - who knows?…) was done by God (8) caused a deep sleep to fall upon Adam for rib extraction. The combined approach can also have its origin in the Bible: Two are better than one (9). Or you can look at it from Mark Twain`s point of view: Name the greatest of all the inventors. Accident.

      1. Corning JL. Spinal anaesthesia and local medication of the cord. NY Med J 1885;42:483-485

      2. Wynter WE. Lumbar puncture. Lancet 1891;1:981-982

      3. Quincke HI. Die technik der lumbalpunktion. Verh Dtsch Ges Inn Med 1891;10:321-331

      4. Von Ziemssen HW. Allgemeine behandlung der infektionskrankenheiten. Jena 1894

      5. Bier A. Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Ztschr Chir 1899;51:361-369

      6. Soresi AL. Episubdural anesthesia. Anesth Analg 1937;16:306-310

      7. Curelaru I. Long duration subarachnoid anaesthesia with continuous epidural block. Praktische Anasthesie Wiederbelelung und Intensivtherapie 1979;14:71-78

      8. Genesis 2:21 9. Ecclesiastes 4:9

      Soresi technique

      Soresi (1) used a fine needle without stilet and introduced it into the epidural space using the hanging drop technique. While in the epidural space he injected 7-8 ml of dissolved novocain. Then he pierced the dura and poured another 2 ml of dissolved novocain into the spinal space. This gave his patients anesthesia for a period of 24-48 hours! He and his colleagues employed this method in over 200 patients. He concluded that by combining the two methods many of the disadvantages of both methods are eliminated and their advantages are enhanced to an almost incredible degree.

      Soresi AL. Episubdural anesthesia. Anesth Analg 1937;16:306-310

      Curelaru technique

      Forty two years later, the Swedish anesthesiologist, Curelaru (1), while working in Bucharest, Romania, tested on 150 patients the method of spinal anesthesia with continuous epidural block. The punctures of the epidural and subarachnoid spaces were done through two intervertebral spaces. The puncture of the epidural space was performed 1-2 intervertebral spaces higher than the subarachnoid. Anesthesia was always started with the introduction of an epidural catheter. After introducing the epidural catheter, the puncture of the subarachnoid space was done, followed by subarachnoid injection of the anesthetic solution. Curelaru concluded its advantages as the possibility of obtaining a high quality conduction anaesthesia, virtually unlimited in time, the ability to extend over several anatomical regions the surgical field, minimal toxicity, the absence of postoperative pulmonary complications and the economy.

      Curelaru I. Long duration subarachnoid anaesthesia with continuous epidural block. Praktische Anasthesie Wiederbelelung und Intensivtherapie 1979;14:71-78

      Nedle-through-needle technique

      Coates (1) from England and Mumtaz, Daz and Kuz (2) from Sweden, in two separate letters in the same issue of Anaesthesia, in 1982, first described the insertion of a long spinal needle through the epidural needle for performing the combined spinal-epidural anesthesia. Coates found the technique simple, reliable and relatively quick to perform. After injecting the anesthetic solution into the subarachnoid space, the spinal needle is withdrawn and an epidural catheter is threaded through the same lumen of the epidural needle, through which the spinal needle was inserted.

      1. Coates MB. Combined subarachnoid and epidural techniques. A single space technique for surgery of the hip and lower limb. Anaesthesia 1982;37:89-90

      2. Mumtaz MH, Daz M, Kuz M. Combined subarachnoid and epidural techniques: Another single space technique for orthopaedic surgery. Anaesthesia 1982;37:90

      Eldor needle technique

      The Eldor needle (1) was first described in 1990. The Eldor needle is a combined spinal-epidural needle which is composed of an 18 gauge epidural needle with a 20 gauge spinal conduit. This is a specialized needle for the combined spinal-epidural anesthesia. There is no need of long spinal needles. The epidural catheter can be inserted before the spinal anesthetic injection. The Eldor needle facilitates the insertion of very small gauge spinal needles through its spinal conduit, so significantly reduces the incidence of post-dural puncture headache. There is no danger of epidural catheter protrusion through the dural hole made by the spinal needle. There are no metallic particles production while the spinal needle passes through the bent epidural needle tip, as in the needle-through-needle technique. The procedure of the Eldor needle is quite simple and straightforward. First, the spinal needle is introduced into the guide needle as far as the distal end of the latter. Then, the now Eldor needle is introduced into the selected intervertebral space and the epidural space is located using the well-known indicator methods. After that the epidural catheter is introduced into the epidural space, confirming its position by the test dose technique. Then, the spinal needle is slowly pushed in to puncture the dura, until cerebrospinal fluid is obtained. The anesthetic solution is injected through the spinal needle into the spinal space. Subsequently, the spinal needle is slowly withdrawn from the guide needle and then the Eldor needle is withdrawn, leaving the epidural catheter in position in the epidural space.

      Eldor J, Guedj P. Une nouvelle auguille pour l`anesthesie rachidienne et peridurale conjointe. Ann Fr Anesth Reanim 1990;9:571-572.

      Huber needle technique

      Huber (1), the inventor of the Tuohy epidural needle, also patented in 1953 an hypodermic needle with an auxiliary outlet being disposed in transverse alignment with the channel outlet (2). Hanaoka (3) described in 1986 its use in 500 patients. This needle has a very small hole behind the epidural needle tip (back eye). A small gauge spinal needle is inserted through that hole and punctures the dura. After withdrawing the spinal needle an epidural catheter is introduced through the epidural needle.

      1. Eldor J. Huber needle and Tuohy catheter. Reg Anesth 1995;20:252-253

      2. Huber RL. Hypodermic needle. US Patent No. 2,748,769

      3. Hanaoka K. Experience in the use of Hanaoka`s needles for spinal-continuous epidural anaesthesia (500 cases). 7th Asian Australasian Congress of Anaesthesiologists Abstracts. Hong Kong, 1986;161-162.

      Eldor, Coombs and Torrieri technique

      Eldor (1) and Torrieri (2) described in separate letters, in 1988, an epidural needle with a spinal needle attached to it. Through the spinal needle a longer spinal needle is inserted into the subarachnoid space, while an epidural catheter is introduced through the epidural needle into the epidural space. A few months before the publication of these letters, Coombs (3) applied for a patent on the same device.

      1. Eldor J, Chaimsky G. Combined spinal-epidural needle (CSEN). Can Anaesth Soc J 1988;35:537-8

      2. Torrieri A, Aldrete JA. Letter to the Editor. Acta Anaesthesiologica Belgica 1988;39:65-66

      3. Coombs DW. Multi-lumen epidural-spinal needle. US Patent No. 4,808,157.

      Indications

      Combined spinal-epidural anesthesia is like to paint the fence from both its sides. The

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