The combined spinal-epidural technique

Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. The CSE technique is used routinely at many institutions, particularly for major orthopedic surgery and in obstetrics. It has been used in tens of thousands of patients without any reports of major problems. Although at first sight the CSE technique appears to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single-space, needle-through-needle method. Concerns about the epidural catheter entering the theca via the small puncture hole are now considered to be unfounded, but as with all epidural catheter techniques, vigilant monitoring of the patient during and after any injection is paramount. CSE is an effective way to reduce the total drug dosage required for anesthesia or analgesia. The intrathecal injection achieves rapid onset with minimal doses of local anesthetics and opioids, and the block can be prolonged with low-dose epidural maintenance administration. In addition, the sequential CSE method can be used to extend the dermatomal block with minimal additional drugs or even saline. Reduction in total drug dosage has made truly selective blockade possible. Many studies have confirmed that low-dose CSE with local anesthetic and opioid, or low-dose epidural block alone, will provide effective analgesia with minimal motor and proprioceptive block. Such neurologic selective blockade has made it possible for most patients to walk and bear down normally in labor or postoperatively. There remains concern about the risk of infection being increased when the CSE technique is used in place of epidural block alone. Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.     

Risk management in epidural anesthesia

Epidural anesthesia has many advantages, including block of surgical stress, postoperative pain management and prevention of postoperative complications. Therefore, we should use epidural anesthesia when indicated. However, patients with preexisting spinal stenosis or lumbar radiculopathy have higher incidence of neurologic complications after epidural anesthesia. Epidural abscesses caused by epidural anesthesia are rare. However, epidural abscesses are serious complications in patients. Knowing the risk factor of epidural abscesses is important to prevent epidural abscesses, and early diagnosis and early treatment are needed when suspected. It is important to have measures for safety in performing epidural anesthesia at every hospital. Recently, we have many anesthetic techniques, including epidural anesthesia, remifentanil infusion, ultrasound-guided peripheral nerve blocks and intravenous PCA. Therefore, we should choose an anesthesia method based on the careful evaluation of the benefit and risk balance for the patient's safety to reduce the incidence of complications.     

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.     

Techniques of epidural block

Epidural blocks are used for relief of chronic pain, labour pain and postoperative pain as well as for surgical anaesthesia. Effect can be targeted at the insertion level which can be from cervical spine level all the way to the sacral hiatus in the case of a caudal epidural block. Catheter insertion means doses can be repeated and the effect maintained. This contrasts with the typical single-shot spinal/subarachnoid injection primarily used for surgical anaesthesia. Specifically avoiding dural puncture also contrasts with the spinal's simple endpoint of detecting CSF. Accurate epidural needle insertion is therefore technically more difficult. The variety of methods available to identify if the needle tip is in the epidural space highlights this much less certain endpoint. With epidural injections, drug solutions need to physically spread to access each intended nerve root. This makes epidurals less reliable than spinals, where simply depositing the solution in the CSF rapidly enables it to bathe all the nerve roots encountered. Serious risks such as direct damage to nerve tissue, infection and epidural haematoma are shared with spinal anaesthesia but may be more likely with epidural techniques. Epidural needles are wider bore and more likely to damage tissue and vessels. They are sometimes directed close to the spinal cord itself. In-dwelling catheters can move and traumatize vessels and act as a focus for infection. Despite these potential drawbacks, careful selection, skilled placement and management mean patients can safely derive the intended benefits and epidurals and caudal blocks continue to be popular.     

Techniques of epidural block

Epidural blocks are used for relief of chronic pain, labour pain and postoperative pain as well as for surgical anaesthesia. The effect can be targeted at the insertion level which can be from cervical spine level all the way to the sacral hiatus in the case of a caudal epidural block. Catheter insertion means doses can be repeated and the effect maintained. This contrasts with the typical single-shot spinal/subarachnoid injection primarily used for surgical anaesthesia. Specifically avoiding dural puncture also contrasts with the spinal’s simple endpoint of detecting CSF. Accurate epidural needle insertion is therefore technically more difficult. The variety of methods available to identify if the needle tip is in the epidural space highlights this much less certain endpoint. With epidural injections, drug solutions need to physically spread to access each intended nerve root. This makes epidurals less reliable than spinals, where simply depositing the solution in the CSF rapidly enables it to bathe all the nerve roots encountered. Serious risks such as direct damage to nerve tissue, infection and epidural haematoma are shared with spinal anaesthesia but may be more likely with epidural techniques. Epidural needles are wider bore and more likely to damage tissue and vessels. They are sometimes directed close to the spinal cord itself. In-dwelling catheters can move and traumatize vessels and act as a focus for infection. Despite these potential drawbacks, careful selection, skilled placement and management mean patients can safely derive the intended benefits and epidurals and caudal blocks continue to be popular.     

Epidural abscess after combined spinal-epidural block

Purpose

We report the first case of abscess formation after combined spinal-epidural block (CSE). Penetation of the dura in CSE may constitute an addtional risk of subarachnoid spread of bacteria when post-puncture epidural infection is present.

Clinical Features

The combination of a spinal and a continuous epidural bkxk(CSE) using needle through needle technique was used in a 72-yr-old ran far reconstructive vascular surgery of the lower limb. On the fourth postoperative day the patient demonstrated back pain, fever, and exudation of pus from trie CSE-puncture site. An epidural abscess was diagnosed by magnetic resonance imaging and subsequently an emergency hemiarrinectomy was performed. Physical examination and surgery did not show evidence of bacterial spread into the subarachnoid space.

Conclution

Epidural abscess formation after CSE may increase the risk of bacterial spread into the subarachnoid space. In this case spontaneous exudation and surgical drainage of abscess material may have prevented intrathecal infection. Rapid diagnosis and treatment of an epidural abscess appears particulalry essential after CSE to prevent neurological sequelae.     

Differentialindikation zentraler und peripherer Leitungsanästhesien

Serious neurological complications caused by spinal hematoma or abscess following central neuraxial block have been reported more often during the last years. In contrast, severe complications are extremely rare associated with peripheral nerve blocks. Concerned about the safety of spinal and epidural anesthesia, we encourage the use of peripheral regional techniques for procedures on the lower extremity and especially for postoperative regional analgesia. Motor block due to lumbar epidural anaesthesia using high concentrations of local anesthetic makes spinal hematoma or abscess difficult to recognize. Therefore, low concentrations of local anesthetic should be used for postoperative epidural analgesia. Any increase in motor block following neuraxial blockade should raise the suspicion of a spinal compression (e.g. hematoma or abscess). Other symptoms are back pain, radicular pain or paresthesia and incontinence. Disastrous neurological injuries can only be prevented by immediate diagnosis (MR, CT or myelography) and therapy (surgical decompression).     

The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital

BACKGROUND AND OBJECTIVES: This study examined the safety and efficacy of combined spinal and epidural (CSE) analgesia/anesthesia performed in a community hospital. METHODS: Labor and Surgical Anesthesia Quality Assessment Worksheets were completed by the responsible anesthesiologist for 7,893 general anesthetics and 7,931 regional anesthetics from January 1, 1994 to December 31, 1997. A retrospective computerized analysis of these data tabulated the number of regional anesthesia techniques and identified anesthesia effectiveness and complications associated with these procedures. The safety and efficacy of CSE analgesia/anesthesia (6,002 blocks) was assessed by comparing these results with reported complications and failure rates for spinal and epidural anesthesia. RESULTS: The CSE technique did not increase the risk of anesthesia complications, as compared with the reported prevalence associated with major regional anesthesia. It provided decreased failure rates for labor analgesia and comparable or decreased failure rates for surgical anesthesia, when compared with reported failure rates for epidural anesthesia. Apnea did not occur in parturients who received 4,164 CSE blocks with intrathecal sufentanil (ITS; 10, 15, or 20 microg) for labor pain relief. However, the prevalence of laboring patients requiring intravenous medication for side effects was related to the dose of ITS: 10 microg (1.1%), 15 microg (4.6%), and 20 microg (5.5%) (P < .001). Patients who received prior systemic narcotics less than 6 hours before ITS were twice as likely to require intravenous treatment for low oxygen saturation/drowsiness (21%) than were those who experienced dysphagia or pruritus (10%) (P < .001). CONCLUSIONS: This review of 6,002 CSE blocks performed in a community hospital has demonstrated that CSE labor analgesia, surgical anesthesia are safe and efficacious. We believe that patient observation and continuous pulse oximetry for 1-2 hours after administration of ITS and prompt treatment with intravenous naloxone for severe drowsiness, low oxygen saturation (PaO2 < 90% unresponsive to mask oxygen), or dysphagia should be used to minimize the risk of apnea.     

Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

BACKGROUND AND OBJECTIVES: Epidural injection has been known to enhance spinal anesthesia in combined spinal and epidural (CSE) anesthesia. Saline and local anesthetics have been reported to have a volume effect, elevating sensory level when supplementing a volume into the epidural space. We evaluated the effects of epidural injection when using the CSE technique for cesarean delivery. METHODS: Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24): epidural injections of 10 mL saline and 0.25% bupivacaine were given in groups S and B, respectively, 10 minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, and no injection was given in group C. The sensory level at 10 minutes, the maximal level and the time to reach it, and degree of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the postanesthesia care unit. RESULTS: Epidural injection raised the sensory level significantly in groups S and B, but the maximal height of sensory block and degree of muscle relaxation did not differ among the groups. Fewer patients complained of intraoperative pain in group B than in the other groups (P <.001). CONCLUSIONS: We could not achieve satisfactory surgical analgesia with 8 mg of hyperbaric bupivacaine injected into the subarachnoid space using the needle-through-needle technique in cesarean deliveries. An epidural saline injection elevated the sensory level, which did not improve the spinal block, whereas an epidural injection of 10 mL of 0.25% bupivacaine enhanced the spinal block and sustained the block postoperatively.     

Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery

In a controlled study a single segment combined spinal epidural (CSE) block was compared with spinal or epidural block for major orthopaedic surgery. Seventy-five patients, age 52–86 yr, were randomly assigned to receive one of the three blocks. Bupivacaine 0.5% was used for surgical analgesia. The postoperative pain relief after 4.0 mg epidural morphine was compared with the analgesic effect of 0.2 or 0.4 mg morphine administered intrathecally. With the spinal technique good or excellent surgical analgesia and muscle relaxation were achieved rapidly (11.8 ± 1.1 min). The time taken to provide an equally effective and reliable block with the CSE technique was no longer (14.9 ± 2.2 min). For epidural block with the catheter technique more time was required (35.9 ± 3.9 min) to provide acceptable surgical conditions (P < 0.05). Perioperative sedatives and concomitant analgesics were required more frequently and in larger doses by the patients undergoing surgery with epidural block (P < 0.05) than with CSE or spinal block. Our study demonstrated that the analgesia after surgery provided by 0.2 and 0.4 mg morphine administered intrathecally was comparable to that provided by 4.0 mg of epidural morphine. It is concluded that the analgesia and surgical conditions provided by the spinal and CSE blocks were similar and were superior to those provided by an epidural block.     

Inserción intrapleural involuntaria de un catéter epidural en cirugía torácica: ¿está fuera de juego la analgesia regional o existe otra salida?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia and paravertebral block are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication.Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery. There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications.It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.     

抗凝病人硬膜外麻醉——三年临床病例分析

目的评价抗凝病人硬膜外麻醉的安全性。方法回顾分析本院2003-2006年107例关节置换或血管成形手术病例。关节置换病人术前12 h应用低分子肝素抗凝,血管成形病人在术中应用肝素抗凝。总共50例病人接受硬膜外麻醉,20例病人接受全麻联合硬膜外麻醉,29例病人接受全麻。结果所有病人均没有发生与硬膜外血肿有关的并发症。发生其它并发症的有10例,其中2例（3．45％）发生在硬膜外组,5例（25％）发生在全麻联合硬膜外组,3例（10．34％）发生在全麻组。结论硬膜外麻醉不是抗凝病人的绝对禁忌。掌握好硬膜外穿刺置管的时机,可以避免发生硬膜外血肿的风险。硬膜外麻醉在多方面优于全麻。     

Regionalanästhesie in der Orthopädie

Regional anesthesia has its place in the perioperative pain management of orthopedic patients. A reduction in postoperative mortality and morbidity with regional anesthesia is acknowledged for subsets of patient populations. Single shot and continuous applications are techniques for providing regional analgesia. Continuous infusion of local anesthetics with catheter techniques provides for uninterrupted postoperative analgesia. The combination of regional and general anesthesia reduces the consumption of systemic anesthetics. The side effects of opioid therapy are thereby reduced. The inhibition of intraoperative stress reaction, especially with epidural anesthesia, helps to prevent or lower unwanted metabolic changes. Patient contentment with analgesic quality differs with the technique with which the regional anesthesia is applied (PDA, PCEA, IVRA, peripheral block, i.a. injection), and the medication (LA, opioid) used.     

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

OBJECTIVE: To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures. SUMMARY BACKGROUND DATA: Even though many beneficial aspects of epidural anesthesia have been reported, clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results. METHODS: The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic, gastric, biliary, or colon operations. They were assigned randomly to receive either general anesthesia and postoperative analgesia with parenteral opioids (group 1) or epidural plus light general anesthesia and postoperative epidural morphine (group 2). The patients were monitored for death and major complications during and for 30 days after surgery, as well as for postoperative pain, time of ambulation, and length of hospital stay. RESULTS: Overall, there was no significant difference in the incidence of death and major complications between the two groups. For abdominal aortic surgical patients, unlike the other three types of surgical patients, the overall incidence of death and major complications was significantly lower in group 2 patients (22%) than in group 1 patients (37%), stemming from differences in the incidence of new myocardial infarction, stroke, and respiratory failure between the two groups. Overall, group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients. In group 2 aortic patients, endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter. CONCLUSIONS: The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief. Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations.     

Comparison of combined spinal epidural anesthesia and epidural anesthesia for cesarean section

BACKGROUND: Epidural anesthesia (EA) is popular for cesarean section, but has some drawbacks such as incomplete block, inadequate muscle relaxation and delayed onset. Combined spinal epidural anesthesia (CSEA) has gained increasing interest as it combines the reliability of a spinal block and the flexibility of an epidural block. We investigated the efficacy of CSEA that combines the main spinal and the supporting epidural anesthesia, comparing with pH-adjusted EA, for cesarean section. METHODS: Sixty-four pregnant women at full term were divided into two groups. Patients in the CSEA group (n=32) were given 1.5-1.6 ml of 0.5% hyperbaric bupivacaine intrathecally, followed by 10 ml of 0.25% plain bupivacaine through the epidural catheter 10 min later. Patients in the EA group (n=32) received 20-25 ml of 2% lidocaine which was already mixed with 0.1 ml of 0.1% epinephrine, 100 g of fentanyl and 1.5 ml of 8.4% sodium bicarbonate. The quality and side effects of surgical anesthesia, neonatal state, and postoperative course were compared between the two groups. RESULTS: In the EA group, 22% (7 cases) complained of intraoperative pain but none in the CSEA group (P=0.011). Muscle relaxation and motor block were much better in the CSEA group (P<0.001 and P=0.011 each). Significantly more women in the EA group had shivering (P=0.001). They also had more nausea and vomiting but the differences were not significant. Not only the time to T4 block (9.7 vs. 18.3 min, mean, P<0.001) but also the stay in the postanesthesia care unit, recovery of sensory and motor block and start of postoperative pain were all significantly shorter in the CSEA group. No one in either group had postdural puncture headache (PDPH). CONCLUSION: We can conclude that, when combining the main spinal and the supporting epidural anesthesia, CSEA has greater efficacy and fewer side effects than the pH-adjusted EA in cesarean sections.     

Fundamentals and innovations in regional anaesthesia for infants and children

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.     

Combined spinal-epidural anesthesia for cesarean section; needle-through-needle approach

Purpose The Portex “Spinal/Epidural Set” is designed for combined spinal-epidural (CSE) anesthesia by the needle-through-needle approach. We evaluated the technical and clinical usefulness of CSE with this needle set, and also isobaric tetracaine, for cesarean section. Methods Thirty patients for cesarean section were included. In the left decubitus position, a 16-gauge epidural needle was introduced by the loss-of-resistance method into the lumbar intervertebral space. A 26-gauge spinal needle was threaded through the epidural needle into the subarachnoid space. Tetracaine dissolved in saline was injected. A 17-gauge catheter was advanced into the epidural space. The analgesic level was checked by the pin-prick method. Results The insertion in the first attempt was successful in 21 cases (70%) of the patients, and difficulty in insertion was not experienced. Inadvertent dural puncture occurred in one case, but no accidental subarachnoid catheterization was observed. Spinal anesthesia with tetracaine (11.1±0.5 mg) reached the level of Th₆ on average, with a relatively wide range. Five cases (13%) were supplemented by epidural anesthesia. No postspinal headache was noted. Conclusion CSE technique by the needle-through-needle approach is easy to handle, and provides a speedy, reliable, and flexible analgesia as well as postoperative pain relief for patients undergoing cesarean section.     

Epidural anesthesia in a patient with myasthenia gravis

We present a patient with myasthenia gravis who was safely managed by epidural anesthesia during and after thymectomy. An epidural catheter was inserted via the C7-T1 intervertebral space and 2% lidocaine was used during the surgery. The level of analgesia as determined by pinprick extending from C5 to T6. Epidural morphine or morphine and bupivacaine were used for postoperative pain relief. We evaluated ventilatory responses to CO₂ and hypoxia after epidural anesthesia with lidocaine or morphine, and during continuous epidural infusion of the mixture of morphine and bupivacaine. Ventilatory responses to CO₂ and hypoxia were both depressed following epidural injection of morphine. However, depression of ventilatory responses was not demonstrated following continuous epidural infusion of a mixture of morphine and bupivacaine. This case report suggests that epidural anesthesia is useful as a primary anesthetic and for postoperative pain control in patients with myasthenia gravis.     

Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot spinal technique

The extent of the intrathecal compartment depends on the balance between cerebrospinal fluid and subatmospheric epidural pressure. Epidural insertion disrupts this relationship, and the full impact of loss-of-resistance on the qualities of subarachnoid block is unknown. In this study we sought to determine if subarachnoid block, induced by combined spinal-epidural (CSE) using loss-of-resistance to air could render higher sensory anesthesia than single-shot spinal (SSS) when an identical mass of intrathecal anesthetic was injected. Sixty patients, scheduled for minor gynecological procedures, were randomly allocated into three groups all receiving 10 mg of 0.5% hyperbaric bupivacaine. In the SSS group, intrathecal administration was through a 27-gauge Whitacre spinal needle inserted at the L3-4 level. For the CSE group, the epidural space was identified with an 18-gauge Tuohy needle using loss-of-resistance to 4 mL of air. After intrathecal administration, a 20-gauge catheter was left in the epidural space. No further drug or saline was administered through the catheter. The procedure was repeated in group CSE ((no-catheter)) except without insertion of a catheter. Sensorimotor anesthesia was assessed at regular 2.5-min intervals until T10 was reached. In all aspects, there was no difference between CSE and CSE ((no-catheter)). Peak sensory level in SSS was lower than CSE and CSE ((no-catheter)) (median T5 [max T3-min T6] versus (T3 [T1-4] and (T3 [T2-5]) (P < 0.01). During the first 10 min postblock, dermatomal thoracic block was the lowest in SSS (P < 0.05). Time for regression of sensory level to T10 was also shortest in SSS. Hypotension, ephedrine use and period of motor recovery were more pronounced in CSE and CSE ((no-catheter)). We conclude that subarachnoid block induced by CSE produces greater sensorimotor anesthesia and prolonged recovery compared with SSS. There is also a more frequent incidence of hypotension and vasoconstrictor use despite using identical doses and baricity of local anesthetic. IMPLICATIONS: This study confirms that induction of subarachnoid block by a combined-spinal epidural technique produces a greater sensorimotor anesthesia and results in prolonged recovery when compared with a single-shot spinal technique. There is a more frequent incidence of hypotension and vasoconstrictor administration despite identical doses of intrathecally administered local anesthetic.