Combined spinal-epidural technique: Single-space vs double distant space technique

Abstract

Background/Aim. Several combined spinal-epidural (CSE) anesthesia techniques have been described. This study was designed to compare the single space (?needle-throughneedle?) technique (SST) and the double distant space technique (DDS) with regards to the time needed for the procedure, patient discomfort during the procedure and patient's preference technique. Methods. This prospective, randomized single-blind study included 156 patients undergoing colorectal surgery under general anesthesia and CSE. All neuraxial blocks were performed before general anesthesia induction. DDS group of patients had thoracic epidural catheter placed at T6-7 or T7-8, followed by subarachnoid injection at the L2-3 interspace. The SST group of patients had a single injection using the needle-through-needle technique (Espocan? needle) at L2-3. The epidural catheter was used for postoperative analgesia for 72 hours. Body habitus, spinal anatomy and spinal landmarks were assessed preoperatively. The number of epidural and spinal punctures, the feeling that the dura is perforated (dural perforation click) and the time needed to perform CSE were also recorded. Complications during epidural catheter placement and perioperative and postoperative epidural catheter function and patient preference for the anesthetic procedure were recorded. Results. Epidural and subarachnoid spaces were successfully identified in all the patients. Duration of CSE procedure, the number of spinal punctures, dural click feeling and the effects of test dose did not differ between the groups. The patients in both groups (90% of DDS and 87% of SST) would choose CSE as preferred method in the future. The CSE procedure was painful for 16% of DDS vs 20% of SST patients. A significant correlation between time needed for CSE technique performance and body habitus (r = 0.338, p < 0.01), spinal landmarks (r = 0.452, p < 0.001) and anatomy (r = 0.265, p < 0.05) was found in the SST group. There was no correlation between the number of epidural/spinal punctures and epidural bacteriological findings. There was no correlation between the patients? choice of the CSE technique and the number of spinal punctures, duration of CSE procedure and epidural catheter stay. Conclusion. The two CSE techniques did not differ with regards to the procedure time and patient's preference. Procedure time correlated with body habitus, spinal landmarks and the anatomy in the SST group.Uvod/Cilj. Opisano je vise tehnika izvodjenja kombinovane spinalno-epiduralne anestezije (KSE). Ova studija je sprovedena sa ciljem da se uporede tehnike u jednom prostoru ?igla-kroz-iglu? (SST) i tehnika dva udaljena prostora (DDS) u smislu duzine trajanja procedure, bolnosti i izbora tehnike od strane bolesnika. Metode. Ova prospektivna, randomizovana, jednostruko slepa studija obuhvatila je 156 bolesnika koji su planirani za kolorektalnu hirurgiju. Svi neuroaksijalni blokovi su izvodjeni pre uvoda u anesteziju. Ukoliko je izvodjena DDS tehnika, prvo je postavljan epiduralni kateter (T6- 7 ili T7-8), a nakon toga izvedena subarahnoidna punkcija na nivou L2-3 (spinalna igla 25G). SST je izvodjena upotrebom Espocan? igle specijalno konstruisane za izvodjenje KSE u nivou L2-3. Nakon identifikacije epiduralnog prostora, vrsena je subarahnoidana punkcija. Epiduralni kateter koriscen je za terapiju postoperativnog bola u periodu od 72 casa. Preoperativno, ispitana je telesna gradja bolesnika, spinalna anatomija i spinalni anatomski znaci. Belezeni su broj spinalnih i epiduralnih punkcija, postojanje osecaja probijanja dure i vreme neophodno za izvodjenje KSE, pojava parestezija kao i problemi tumacenja epiduralne test doze. Belezene su komplikacije u toku postavljanja epiduralnog katetera, perioperativno i postoperativno funkcionisanje epiduralnog katetera i misljenje bolesnika da li bi prihvatio koriscenje iste tehnike za sledeci hirurski zahvat. Rezultati. Epiduralni i subarahnoidni prostori su uspesno indentifikovani kod svih bolesnika. Nije bilo razlika izmedju grupa u pogledu duzine trajanja KSE procedure, broja spinalnih punkcija, osecaja probijanja dure i tumacenja test doze. KSE tehnika bi bila procedura izbora za terapiju bola u obe grupe (DDS 90.4%, SST 87%). Izvodjenje KSE tehnike bilo je bolno kod 16% DDS i 20% SST bolesnika. U SST grupi ustanovljena je znacajna korelacija u vremenu neophodnom za izvodjenje KSE, telesnoj gradji (r = 0.338, p < 0.01), spinalnim znacima (r = 0.452, p < 0.001) i anatomiji (r = 0.265, p < 0.05). Nije nadjena korelacija izmedju broja epiduralnih/spinalnih punkcija i pozitivnih bakterioloskih kultura. Nije nadjena korelacija izmedju odluke za ponovni izbor tehnike i broja spinalnih punkcija, trajanja izvodjenja KSE i duzine stajanja epiduralnog katetera. Zakljucak. Nije nadjena razlika u duzini trajanja izmedju dve tehnike izvodjenja KSE. U tehnici izvodjenja KSE u jednom interspinalnom prostoru, duzina izvodjenja procedure KSE bila je u korelaciji sa telesnom gradjom, spinalnim znacima i spinalnom anatomijom.