Epidural Space & Ligament Flavum

Figure 1. Epidural needle is placed in the epidural space

indentically to the technique in epidural anesthesia

Figure 2. Entry of the needle into the epidural space is

recognized by a sudden loss of resistance to injection of air.

Figure 3. A small-bore spinal needle is placed through the

epidural needle until CSF appears at the hub of the needle,
indicating successful entrance of the spinal needle into the
subarachnoid space. Typically, a loss of resistance is felt as
the needle makes a slight bend to exit through the curved tip
of the epidural needle and another as the spinal needle
pierces the dura and enters the subarachnoid space.
Figure 4. CSF appears in the hub of the spinal
needle, indicating the subarachnoid placement
of its tip.

Figure 5. A desired dose of local anesthetic

with or without additives is injected through
the spinal needle.

Figure 6. A flexible catheter is placed through

the epidural needle and left about 5 cm in the
epidural space.

Figure 7. Epidural catheter is checked by the aspiration test

to rule out its inadvertent intravascular (appearance of
blood in the catheter) or intrathecal (appearance of CSF)
placement.
 Complications & Concerns Of CSE Technique

Failure Of The Spinal Component

The most common method of performing a CSE is the single-interspace
NTN technique. In earlier reports, failure to achieve a spinal block with this
technique has been reported in 10 to 15% of cases in the past.However,
more recent reports have demonstrated failure rates in the range of 2 to
5%.

Subarachnoid Spread of Epidurally Administered Drugs

Clinical Pearls
 A dural puncture may allow dangerously large quantities of subsequently
administered epidural drugs to reach the subarachnoid space.
 The magnitude of flux was a function of the diameter of the spinal needle. The risk
may be decreased by using the smallest possible needle to puncture the meninges.
Hypotension
Does subarachnoid block induced by CSE (using loss of resistance to air)
render a higher level of sensory anesthesia than single-shot spinal (SSS)
when an identical mass of intrathecal anesthetic was injected?

Neurologic Injury
Neurologic complications directly related to spinal anesthesia may be
caused by trauma, cord ischemia, infection, and neurotoxicity.

Needle Trauma

Infectious Neurologic Complications

Postdural Puncture Headache

Fetal Bradycardia
 Caudal Anesthesia

Caudal anesthesia was first described at the turn of last century by two French
physicians, Fernand Cathelin and Jean-Anthanase Sicard. The technique predated the
lumbar approach to epidural block by several years.
A: Skeletal model demonstrating the sacral hiatus and its relationship to the coccyx and sacrum. The fifth
inferior articular processes project caudally and flank the sacral hiatus as sacral cornuae. B: Skeletal
specimen viewed from inferior to the sacral hiatus. The hiatus is seen as the oval shaped opening at the 12
o’clock position in the photograph. C: Skeletal specimen of the sacrum viewed from craniad to caudad
demonstrating the five dorsal foramina, situated bilaterally. D: Skeletal specimen of the sacrum
demonstrating the ventral sacral surface. Note the five bilateral intervertebral foramina, paired on either side
of the midline, defined by the retention screws used to hold the specimen together.
 Indications for Caudal Epidural Block

Clinical Pearls

 The indications for caudal epidural block are essentially the same as those
for lumbar epidural block.
 Caudal may be preferred over lumbar epidural block when sacral nerve
spread of anesthetics and adjuvants is preferred over lumbar nerve
spread.
 The unpredictability of ascertaining consistent cephalad spread of
anesthetics administered through the caudal canal limits the usefulness of
this technique when it is essential to provide lower thoracic and upper
abdominal neuraxial blockade.
 General Uses

• Administration of anesthesia in infants, children, and adults,

especially for surgery of the perineum, anus, and rectum;
inguinal and femoral herniorrhaphy; cystoscopy and urethral surgery;
hemorrhoidectomy; vaginal hysterectomy
• Prognostic neural blockade to evaluate pelvic, bladder, perineal,
genital, rectal, anal, and lower extremity pain
• Provide sympathetic block for individuals suffering from acute
vascular insufficiency of lower extremities secondary to
vasospastic or vasocclusive disease, including frostbite and
ergotamine toxicity
• Relief of labor pain (mostly historical)
• Conditions requiring epidural block where extensive segmental block
is not important
 Acute Pain Management
• Management of pelvic and lower extremity pain secondary to trauma
(without evidence of pelvic fracture)
• Postoperative pain management
• Temporizing measure for pain secondary to acute lumbar vertebral
compression fractures

Chronic PainManagement
• Injection of local anesthetics or medications for lumbar radiculopathy
secondary to herniated disks and spinal stenosis
• Approach to the epidural space in failed back surgery syndrome
• Diabetic polyneuropathy
• Postherpetic neuralgia
• Complex regional pain syndromes
• Orchalgia; pelvic pain syndromes
• Percutaneous epidural neuroplasty
 Cancer Pain Management

• Chemotherapy-related peripheral neuropathy

• Bony metastases to the pelvis
• Injection therapy for pain secondary to pelvic, perineal, genital, or rectal
malignancy
• Prognostic indicator prior to performing neurodestructive sacral nerve
ablation(s)
• Injection of hyperbaric phenol solutions for management of sacral pain
 The Technique Of Caudal Epidural Block
Anatomic Landmarks

Figure 1 Technique of palpating the midline over the sacral hiatus. The index and
middle fingers of the palpating fingers are spread over the fifth sacral vertebral
body. The sacrococcygeal ligament lies directly beneath the palpating fingers.

Figure 2. Technique of skin infiltration using a fine-bore needle and local

anesthetic. The needle is first above, and then into the substance of the
sacrococcygeal ligament.

Figure3. The fine-bore needle has been left in place, having

engaged the sacrococcygeal ligament.

Figure 4. The fine-bore needle has been left in place, having

engaged the sacrococcygeal ligament.
Figure 5. The 17-gauge needle has been advanced from the skin into the sacral
hiatus through the sacrococcygeal ligament. Usually, when fluoroscopy is not
available to verify correct needle placement, a syringe loaded with air or saline is
attached to the needle and the loss-of-resistance technique is employed to identify
the epidural space, as for conventional lumbar or cervical epidural injections.

Figure 6. Skeletal specimen demonstrating the needle introducer from the 17-gauge
extracatheter device situated correctly in the caudal epidural space, traversing the
sacrococcygeal ligament (removed) and entering the sacral hiatus (lateral view).

Figure 7. Caudocranial view of the 17-gauge extra catheter device situated

correctly through the sacrococcygeal ligament into the sacral hiatus.
 Epidural Blockade

Epidural blockade is becoming one of the most useful and versatile

procedures in modern anesthesiology. It is unique in that it can be
placed at virtually any level of the spinal spine, allowing more
flexibility in its application to clinical practice.
 Table 2. Common Applications for Epidural Blockade
Orthopedic surgery Major hip/knee surgery, pelvic fractures
Obstetrics Cesarean section, labor analgesia
Gynecologic surgery Procedures involving female pelvic organs
Urologic surgery Prostate, bladder procedures
General surgery Upper and lower abdominal proceduresa

Penile procedures, inguinal hernia repair, anal surgery,

Pediatric procedures orthopedic procedures on the feet; supplement to GA,
postoperative pain relief, orthopedic procedures on feetb

Vascular reconstruction of the lower limbs, amputations

Vascular surgery
involving the lower extremities

Postoperative analgesia, combination with GA to reduce

Thoracic surgery
GA requirements

Medical conditions Known/suspected malignant hyperthermia

Diagnosis and management of chronic pain Chronic pain

a Height of block with side effects required for upper abdominal procedures, may make it difficult to avoid
patient discomfort and increased risk.[22]
b Usually through a caudal epidural approach.
 Contraindications

Table 3. Contraindications: Epidural Blockade

Absolute Relative Controversial
Coagulopathy Inadequate
Patient refusal
Platelet count <100,000 training/experience
Elaborate tattoos at the
Uncorrected hypovolemia Uncooperative patient
needle insertion site
Positioning that
Severe anatomic
Increased ICP compromises respiratory
abnormalities of spine
status
Anesthetized patient
Infection at site Sepsis
(cervical/thoracic)
Allergic to amide/ester LA Hypertension Previous back surgery
ICP = intracranial pressure; LA = local anesthetic.
Epidural SpaceEpidural Space

Figure 7. Epidural space: 1. Anterior epidural space, 2. Posterior

epidural space, 3. Ligamentum flavum, 4. Blood vessels in the
epidural space, 5. Pedicles, 6. Nerve roots, 7. Transverse process,
8. Vertebral body, 9. Spinal cord.

Figure 8. Blood vessels in the epidural space and their

communication with systemic vessels.
Figure . Needle angulation required to accomplish thoracic blockade in the
high thoracic/low thoracic/lumbar regions. A: High thoracic region.
B: Low thoracic region. C: Lumbar region
Tabel 4. Anatomic Landmarks to Identify Vertebral Levels Before Epidural
Injection
Anatomic Landmark Features
Vertebral prominence, the most prominent
C7
process in the neck
T3 Root of the spine of the scapula
T7 Inferior angle of the scapula
L4 Line connecting iliac crests
Line connecting the posterior inferior iliac
S2
spines

Groove or depression just above or

Sacral hiatus
between the gluteal clefts above the coccyx
 Table 5. Local Anesthetics for Epidural Blockade

Duration Plain /+
Drug Concentration (%) Onset (min)
Epinephrine (min)
2-Chloroprocaine 3 10–15 45–60/60–90
Lidocaine 2 10–15 80–120/120–180
1 15 90–160/160–200
Mepivacaine
2 15 Same
0.25
Bupivacaine 15–20 160–220/180+
0.375–0.5
Etidocaine 1 15–20 120–200/150+
0.5
Ropivacaine 15–20 140–180/150+
0.6–0.75
Levobupivacaine 0.5 15–20 160–220/180+
Figure A. Lumbar epidural block through the
paramedian approach: The needle entry site is
marked approximately 1.5–2 cm lateral and
caudal to the desired level of blockade.

Figure B. Lumbar epidural block through the

paramedian approach: Epidural needle
angulation 45 degrees cephalad and very
slightly medial.

Figure C. Lumbar epidural block through the

paramedian approach:When (if) the bone (lamina)
is contacted during needle advancement, the
cephalad needle angle is lowered to walk off
the lamina.
Midthoracic Epidural Paramedian Approach. The
T4-5 interspace is the injection site.

Figure A. Thoracic paramedian approach:

Landmarks/initial needle insertion. Note
the approximately 45-degree cephalad
and medial needle angulation.

Figure B. Thoracic paramedian approach:

Needle angle 55–60 degrees to the skin
surface.
 INADEQUATE BLOCK: BREAKTHROUGH PAIN DESPITE
ADEQUATE BLOCK HEIGHT

This problem can be seen secondarily to inadequate

sacral blockade. The sacral segment is larger, dense,
and difficult to block.

Action. Raise the head of the bed and redose the

catheter with a higher concentration of local
anesthetic.
• Administration of 50 mcg of fentanyl to improve the
quality of the block.
 Complications Of Epidural Blockade

1. Drug-Related Complications
2. Procedure-Related Complications
3. Minor Back Pain
4. Postdural Puncture Headache
5. Major Subdural Injection
6. Subarachnoid Injection/High or Total Spinal
7. Meningitis
8. Chronic Adhesive Arachnoiditis
 Table 11. Neurologic Complications Associated with Epidural Anesthesia/Analgesia
Pathology Cause Onset Clinical Features Outcome
Pain with needle
insertion and
Spinal nerve
Needle trauma 0–2 days injection; paresthesia; Recovery 1–12 weeks
neuropathy
numbness over spinal
nerve distribution

Anterior spinal artery Hypotension Poor—painless

Immediate Painless paraplegia
syndrome Arteriosclerosis paraplegia persists

Pain on injection, back

pain, bilateral leg pain,
Trauma, surgery,
sensory abnormalities, Can progress to
infections
Adhesive arachnoiditis 0–7 days hyporeflexia, severe, permanent
Contaminants
progressive neurologic disability
Irritant injectate
deficit with pain,
paraplegia

Severe backache with

Epidural hematoma Coagulopathy 0–2 days progressive sensory– Immediate surgery
motor deficits

IVDA, nonspinal Fever, leukocytosis, >

infection; ESR Severe backache Antibiotic therapy and
Epidural abscess 0–2 days
neurosurgical with sensory–motor immediate surgery
procedures deficits
IVDA = intravenous drug abuse; ESR = erythrocyte sedimentation rate.
 Problems with Epidural Function

HYPOTENSION Adropinblood pressure is common and expected with

epidural anesthesia secondarily to the sympathectomy caused by local
anesthetic action. The blood pressure should be maintained to within 20%
of the patient’s resting baseline.

Action. Bolus the patient with 500 to 1000 mL of a balanced salt solution.
• If necessary, small doses of ephedrine (10–20 mg) can be used in the
pregnant or bradycardic patient after fluid bolus if the patient is still
hypotensive.
• Phenylephrine (40–120 mcg) can be used in the nonpregnant patient to
constrict peripheral blood vessels, thereby increasing venous return and
blood pressure.
 UNILATERAL BLOCK
After an epidural has been adequately dosed, the patient may
complain that one side is densely blocked, but pain and motor
function is still intact on the opposite side. Because of the
segmental and possibly septated nature of the epidural space,
unilateral blocks can occur. The more common explanation for a
unilateral block is incorrect catheter placement. If the catheter has
been inserted > 5 cm into the epidural space, the tip of the catheter
may have entered the intervertebral foramen, exited the epidural
space, or wrapped around a spinal nerve. The resultant block will be
inadequate or unilateral

Action. Pull the catheter back 1–2 cm, leaving 3–4 cm in the epidural
space.
• Turn the patient with the unblocked side down and redose the
catheter with 3 to 5 mL of local anesthetic.
• If no effect, replace the catheter.