What is a Combined Spinal Epidural?

A combined spinal epidural (CSE) is a form of spinal anesthesia combining both the spinal block and epidural. The spinal block will kick in first, providing powerful pain relief but leaving muscles unaffected. The patient is still able to move around during this time, so the combined spinal epidural is sometimes called a walking epidural. After an hour or two, the epidural kicks in, providing lasting relief. This is often used on women who are in labor.

In preparation for an epidural, the patient's back is first cleaned and swabbed with an antiseptic solution. A numbing injection is given, and then the epidural needle is inserted. The needle will stop in the epidural space, just before the dura, which surrounds the spinal column. A thin catheter is passed through the needle, and the needle is removed.

The catheter is then thoroughly taped to the patient's body to keep it from being dislodged. Anesthetic medication continually drips through the catheter, providing lasting, effective relief. The body is very numb from the waist down, although movement is still possible and pressure is still felt. Patients who have gotten a regular epidural can not get out of bed.

The preparation for a spinal block is the same, although numbing medicine might not be used. A spinal block is a single injection, rather than being continuously administered. The needle passes through the dura, so the medication mixes with the spinal fluid for almost instant relief. It is only a small amount of medication, so it wears off fairly quickly.

The combined spinal epidural starts with the placement of an epidural needle. The smaller spinal block needle is then inserted through the epidural needle and into the dura. The spinal needle is withdrawn, followed by the epidural. The epidural catheter is left in place. The spinal kicks in after just a few minutes, providing relief while still allowing the patient to walk and move about.

There are several disadvantages to getting a spinal, an epidural or combined spinal epidural. There is a small chance that spinal fluid will leak out through the hole in the dura created by the needle. This might cause a headache, called a spinal headache, that might be very bad. A spinal headache will be worse when the patient is sitting or standing, but not bad while he or she is lying down. It is usually treated with a blood patch, where blood is taken from the patient, clotted and then injected into the hole to patch it.

Spinal headaches occur more often after a spinal block or combined spinal epidural, because they actually puncture the dura. An anesthetist may accidentally nick the dura with an epidural needle, causing a fluid leak and headache. Other side effects of all forms of spinal anesthesia are shaking, nausea and vomiting, generalized itchiness and increased likelihood of fever. Patients who receive an epidural cannot walk, so a catheter must be placed. Sometimes a bed pan is used instead, if the patient is not too embarrassed to use one.