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Combined Spinal-Epidural (CSE)
for Labor Analgesia: The Walking Epidural
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Once this epidural needle is properly positioned, a spinal
needle is placed THROUGH the epidural needle. This is the "combined"
part which is not usually performed in a traditional epidural.
Note that this needle is extremely small because is does not need
to go through the skin and tissues of the back. It follows the
epidural needle directly to the dura. Rest assured that this needle
does not cause any pain, also because of the fact that it is inserted
through the previously placed epidural needle. This spinal needle
is inserted all the way through the dura (instead of stopping
just outside it like the epidural needle) and actually comes into
contact with the fluid which surrounds the spinal cord. Confirmation
of correct placement comes when some of that fluid is seen escaping
through the spinal needle.
Once the spinal needle is placed, a quick acting narcotic is
given through it. Sometimes a very small dose of a local anesthetic
is also given. When these medications are injected, the patient
should begin to feel pain relief begin within a minute or two.
The spinal needle is then removed. Note that the epidural needle
remains in the correct location and is not removed at this point.
After the spinal needle is removed, a catheter is placed through
the remaining epidural needle, the needle removed and the catheter
secured to the patient's back with tape. It is now possible to
administer additional medication as needed through this catheter.
The procedure is then complete.
Following the procedure, it is necessary to monitor the patient's
blood pressure for any severe decreases and to treat drops in
blood pressure promptly. This is not difficult to do and requires
only a period of careful monitoring after the completion of catheter
placement and injection of medication. Also it is important to
stress that the patient should not be allowed to walk without
first testing muscular strength - everyone reacts differently
to medication and not everyone can walk, even after receiving
a "walking" epidural.
ADVANTAGES
We've already discussed the obvious advantages of maintaining
muscular strength and a quick onset to the pain relief. Having
a catheter in place is an obvious advantage as well because should
the patient need additional medications for pain relief this can
be achieved easily. Additionally, if a patient with an epidural
catheter in place needs a caesarean section later, the epidural
can be used to provide excellent anesthesia for the surgery by
using a slightly different combination of medications at a higher
dosage.
DISADVANTAGES
There are some disadvantages to the combined spinal-epidural
technique when compared to a traditional epidural. For starters,
it is slightly more technically involved than an epidural without
a spinal component. In addition, there is a purposeful placement
of a hole in the dura and this hole can be the cause of a headache
after the spinal. While rarely more than bothersome, this headache
can be a major annoyance for the patient after labor and delivery
is completed. The good news is that since the spinal needle does
not need to penetrate any of the body (except the very thin dura
membrane), it can be a very small needle which causes a very small
hole. This decreases the chance of getting a headache to less
than one percent.
COMPLICATIONS
First let me say that there is every indication that a combined
spinal epidural technique is as safe as a conventional epidural.
Every study ever done has found no difference in the complication
rate. If you are going to consider a traditional epidural as one
of your options for pain relief during labor, you should consider
a combined technique as well. Please note however, that there
are other options not discussed here that are available for pain
relief during labor and some patients find that they do not need
any medication for pain relief at all.
The possible complication of headache was already mentioned
above. Note that there is also a chance of headache with an epidural
alone because, although a hole is not intentionally made in the
dura when an epidural is placed, sometimes the dura is punctured
by accident. Sometimes this can occur without anyone even being
aware of it. This can then lead to a headache.
The risk of hypotension (low blood pressure) has also been
mentioned. It is my firm belief that a watchful anesthesiologist
is all that is needed to minimize this complication. I say this
because the blood pressure is easily brought back to normal should
it drop with simple treatments such as intravenous fluids or medications.
There are some people in which epidurals do not work for some
reason (and the reasons vary) and in some people they only work
on one side of the body or the other. Sometimes this is due to
the catheter being positioned in a strange place and repositioning
the catheter or placing a new one can often resolve this problem.
Common side effects related to the narcotic medication used
include pruritis (itching), urinary retention, and nausea or vomiting.
These are usually easily treated with medications and not very
dangerous. Again, they can be very annoying if they happen to
you!
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