Placement of an Epidural:
When ready to place the epidural and spinal, the patient must be properly positioned. The patient can be sitting or placed on their side. Either technique is acceptable but most anesthesiologists will be more comfortable with one or the other. The patient will be instructed to arch their back out "in a C shape" or "like a cat". This separates the vertebral bones (the bones that make up your spine) in the lower back as much as possible. This is important because the needle is actually placed between these bones, and the larger the space between these bones is, the easier the procedure will be.

Once positioned, the patient will be covered with some sterile drapes to keep the area as clean as possible and then the back prepared with antiseptic solution to render it sterile. This is to reduce the chance of infection to a minimum. Once the back has been cleaned in this way, the landmarks of the back are identified by pressing with the fingers. Here the anesthesiologist is looking for bones and the spaces between them so the needle can be placed in the proper location.

Some local anesthesia is used to numb the skin prior to the insertion of the actual epidural needle. This does involve a needle, but an extremely small needle is used to minimize the discomfort to the patient. As the local anesthesia used to numb the skin of the back is injected, it burns a bit until it begins to work. (I usually describe this to my patients as a "bee sting followed by some burning, like a sunburn, for about 4 or 5 seconds") Once the skin is numb, the actual epidural needle (click here to see a picture) is inserted. This needle is slightly larger to allow placement of a catheter (a small plastic tube used to deliver medication - click here to see a picture) but should not cause any pain since the skin is now numb.

Anesthesiologists use different techniques to identify when the needle is actually in the correct place - the epidural space (this is the space just outside a membrane called the dura which covers the spinal cord and the fluid surrounding it). This part of the procedure may take some time and requires that the patient remain still. It is very important that the needle be placed in the correct location.(click here to compare a spinal needle with an epidural needle)