EPIDURAL ANATOMY &

PHYSIOLOGY

A ABRAHAM
INTRODUCTION
 Epidural anaesthesia is a central neuraxial block
technique
 The epidural space was first described by Corning in
1901, and Fidel Pages first used epidural anaesthesia
in humans in 1921.
 In 1945 -Tuohy needle
 Applications in surgery, obstetrics and pain control.
Both single injection and catheter techniques can be
used. Its versatility means it can be used as an
anaesthetic, as an analgesic adjuvant to general
anaesthesia, and for postoperative analgesia in
procedures involving the lower limbs, perineum,
pelvis, abdomen and thorax. 
Anatomy of the epidural space
 The epidural space is that part of the vertebral canal
not occupied by the dura mater and its contents. It is
a potential space that lies between the dura and the
periosteum lining the inside of the vertebral canal. It
extends from the foramen magnum to the sacral
hiatus. The anterior and posterior nerve roots in their
dural covering pass across this potential space to
unite in the intervertebral foramen to form segmental
nerves.
 The space contains venous plexuses and fatty tissue
which is continuous with the fat in the paravertebral
space.
Anatomy of the epidural space
 The anterior border consists of the posterior longitudinal
ligament covering the vertebral bodies, and the
intervertebral discs.

 Laterally, the epidural space is bordered by the

periosteum of the vertebral pedicles, and the
intervertebral foraminae.

 Posteriorly, the bordering stuctures are the

periosteum of the anterior surface of the laminae and
articular processes and their connecting ligaments,
the periosteum of the root of the spines, and the
interlaminar spaces filled by the ligamentum flavum.
Physiological Effects of Epidural
Blockade
 Cardiovascular system. Vasodilatation of resistance
and capacitance vessels occurs. Sympathetic outflow
extends from T1 - L2 and blockade of nerve roots
below this level, as with, for example, knee surgery,
is less likely to cause significant sympathetic
blockade, compared with procedures requiring
blockade above the umbilicus.
 Respiratory system. Usually unaffected unless
blockade is high enough to affect intercostal muscle
nerve supply (thoracic nerve roots) leading to reliance
on diaphragmatic breathing alone. This is likely to
cause distress to the patient, as they may feel unable
to breathe adequately.
Physiological Effects of Epidural
Blockade
 Gastrointestinal system. Blockade of sympathetic
outflow (T5-L1) to the GI tract leads to predominance
of parasympathetic (vagus and sacral
parasympathetic outflow), leading to active peristalsis
and relaxed sphincters, and a small, contracted gut,
which enhances surgical access. Splenic enlargement
(2-3 fold) occurs.
 Endocrine system. Nerve supply to the adrenals is
blocked leading to a reduction in the release of
catecholamines.
 Genitourinary tract. Urinary retention is a common
problem with epidural anaesthesia. A severe drop in
blood pressure may affect glomerular filtration in the
kidney if sympathetic blockade extends high enough
to cause significant vasodilatation.
THE CHOICE OF DRUGS
 Depends on the indication for the epidural:

 Surgical anaesthesia - requires dense sensory block and

usually moderate to dense motor [Link] used
local anaesthetics in this setting are 2% lignocaine l (with or
without adrenaline 1:200 000) or 0.5% bupivacaine . The
latter has a longer duration of action, but a slower onset
time, compared with lignocaine.

 Postoperative analgesia, weaker concentrations of

bupivacaine, e.g. 0.1-0.166% with or without added low
dose opioids, by bolus, continuous infusion or PCEA (patient
controlled epidural analgesia) has been shown to be safe
and efficient when given by via a syringe pump.
 he addition of opioids to local anaesthetic solutions has gained popularity; as the opioids
have a synergistic effect by acting directly on opioid receptors in the spinal cord. Various
opioids, such as morphine (2-5mg), fentanyl (50-100mcg) and diamorphine (2-4mg), have
been used successfully both alone and in combination with local anaesthetic drugs, during
labour, for intraoperative use and for postoperative analgesia. The combination of low-
concentration local anaesthetic and low-concentration mixtures of opioids, administered by
slow infusion rather than as intermittent boluses, has, in particular, been shown to be very
effective in the management of postoperative pain.
 The amount of opioid, e.g. diamorphine in the examples above, should be reduced where
there is an increased risk of respiratory depression, i.e. the elderly, the very frail or in
patients with significant chronic obstructive airway disease.
 Caution should be exercised when morphine is administered epidurally, as it is associated
with delayed respiratory depression. This is thought to be as a result of its low lipid
solubility, which means that instead of binding to opioid receptors in the spinal cord, some
of the drug remains in solution in the CSF, and the circulation of CSF transports the
remaining drug to the brainstem where it acts on the respiratory centre. This may occur
many hours (up to 24 hours) after morphine has been administered epidurally.
 Opioids have also been used on their own in the epidural space. Pethidine (meperidine)
25-75mg, in particular, has a structure similar to local anaesthetics and is effective in
providing surgical anaesthesia and postoperative analgesia.
 All opioids given by this route have the potential to cause respiratory depression, and this
should be borne in mind when the patient is discharged from the care of the anaesthetist.
Patients should be managed postoperatively in an area with a high nurse-to-patient ratio,
and should be monitored carefully with special attention to their respiratory rate and level
of consciousness. Epidural opioids should be avoided where there are inadequate resources
for such careful monitoring. Other drugs used successfully via the epidural route include
ketamine and alpha-2 receptor blockers such as clonidine. 
Complications and Side Effects
 Hypotension has been discussed and is the commonest side effect of
successful therapeutic blockade for procedures above the umbilicus. It is
especially common in pregnancy, both in labour and when used for
Caesarean Section, and should be corrected promptly using fluid and
vasopressors. The presenting symptom of hypotension is often nausea,
which may occur before a change in blood pressure has even been
detected.
 Inadvertent high epidural block due to an excessively large dose of local
anaesthetic in the epidural space may present with hypotension, nausea,
sensory loss or paraesthesia of high thoracic or even cervical nerve roots
(arms), or difficulty breathing due to blockade of nerve supply to the
intercostal muscles. These symptoms can be very distressing to the patient
and in the most severe cases may require induction of general anaesthesia
with securing of the airway, while treating hypotension. If the patient has a
clear airway and is breathing adequately they should be reassured and any
hypotension immediately treated. Difficulty in talking (small tidal volumes
due to phrenic block) and drowsiness are signs that the block is becoming
excessively high and should be managed as an emergency - see total
spinal.
Complications and Side Effects
 Local anaesthetic toxicity can also occur as a result of an excessive dose of local
anaesthetic in the epidural space. Even a moderate dose of local anaesthetic, when
injected directly into a blood vessel, can cause toxicity. This is especially possible when
an epidural catheter is inadvertently advanced into one of the many epidural veins. It is
therefore vital to aspirate from the epidural catheter prior to injecting local anaesthetic.
Symptoms usually follow a sequence of light-headedness, tinnitus, circumoral tingling
or numbness and a feeling of anxiety or "impending doom", followed by confusion,
tremor, convulsions, coma and cardio-respiratory arrest. It is important to recognise
these symptoms early, and discontinue the further administration of local anaesthetic
drugs. Treatment should be supportive, with the use of sedative/anticonvulsants
(thiopentone, diazepam) where necessary, and cardiopulmonary resuscitation if
required.
 Total spinal is a rare complication occurring when the epidural needle, or epidural
catheter, is advanced into the subarachnoid space without the operator's knowledge,
and an "epidural dose" e.g. 10-20 ml of local anaesthetic is injected directly into the
CSF. The result is profound hypotension, apnoea, unconsciousness and dilated pupils as
a result of the action of local anaesthetic on the brainstem. The use of a test dose
should prevent most cases of total spinal, but cases have been described where the
epidural initially appeared to be correctly sited, but subsequent top-up doses caused the
symptoms of total spinal. This has been ascribed to migration of the epidural catheter
into the subarachnoid space, although the precise mechanism is uncertain.
 Accidental dural puncture is usually easily recognised by the
immediate loss of CSF through the epidural needle. This
complication occurs in 1-2% of epidural blocks, although it is more
common in inexperienced hands. It leads to a high incidence of
post dural puncture headache, which is severe and associated with
a number of characteristic features. The headache is typically
frontal, exacerbated by movement or sitting upright, associated
with photophobia, nausea and vomiting, and relieved when lying
flat. Young patients, especially obstetric patients, are more
susceptible than the elderly. The headache is thought to be due to
the leakage of CSF through the puncture site. Basic measures,
such as simple analgesics, caffeine, bed rest, fluid rehydration and
reassurance are indicated in the first instance, and are often
sufficient to treat the headache. Where the headache is severe, or
unresponsive to conservative measures, an epidural blood patch
may be used to treat the headache. This procedure is effective in
treating approximately 90% of post dural puncture headaches. If
unsuccessful, the blood patch may be repeated, and the success
rate increases to 96% on the second attempt. The blood injected
into the epidural space is thought to seal the hole in the dura.
 Epidural haematoma is a rare but potentially catastrophic complication of
epidural anaesthesia. The epidural space is filled with a rich network of
venous plexuses, and puncture of these veins, with bleeding into the
confined epidural space, may lead to the rapid development of a
haematoma which may lead to compression of the spinal cord, and can
have disastrous consequences for the patient including paraplegia. For this
reason, coagulopathy or therapeutic anticoagulation with heparin or oral
anticoagulants has long been an absolute contraindication to epidural
blockade.
 Infection is another rare but potentially serious complication. Pathogenic
organisms can be introduced into the epidural space if strict asepsis is not
observed during the performance of the block. The commonest pathogens
are Staphylococcus aureus and streptococci. Meningitis has been described,
as has epidural abscess. In addition to the symptoms of spinal cord
compression described above, the patient may exhibit signs of infection
such as pyrexia and a raised white cell count. Once again, a high index of
suspicion is needed, and surgical decompression of an abscess should be
performed without delay.
 Failure of block can occur as a result of many factors, the most
important being the experience of the operator. False loss of
resistance during performance of the block may lead to insertion of
the epidural catheter into an area other than the epidural space,
with failure to establish anaesthesia. Segmental sparing occurs
occasionally for reasons that are unclear, but are assumed to be
the result of anatomic variation of the epidural space, so that local
anaesthetic fails to spread evenly throughout the space. The result
is that some nerve roots are inadequately soaked with local
anaesthetic, leaving the dermatomes of these nerve roots poorly
anaesthetised. Unilateral blockade occurs occasionally, and this is
thought to be the result of a septated epidural space, with failure
of the local anaesthetic solution to spread to one half of the
epidural space. Positioning the patient on his side with the
unblocked side down is sometimes successful in allowing spread of
the local anaesthetic to the dependent side, giving bilateral
anaesthesia.