What is the role of extradural or epidural blockade in pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Extradural or epidural blockade can be varied to suit the spinal segmental level of the patient's symptoms. Blockade can be achieved with a single injection of LA through a needle placed at the appropriate segmental level or by introduction of a catheter through a thin-walled 18- or 17-gauge needle placed at the spinal level, which is considered clinically to be the optimum site for injection. Injections into the lumbar epidural space can be accomplished through either a caudal or lumbar approach.

The lumbar approach involves passing the needle through the intralaminar space along the midline through the interspinous ligament or slightly to the side of the ligament, then penetrating through ligamentum flavum to enter the epidural space. Perceived advantages of the lumbar route are (1) the needle is directed more closely to the assumed site of pathology, (2) the drug to be injected can be delivered directly to its target (ie, more target specific), and (3) lesser volumes of the injected solution can be used.

Continuous epidural block often is used to eliminate chronic persistent pain secondary to somatic, visceral, or sympathetic etiologies. This procedure can be used for relieving the severe pain associated with pancreatitis, biliary colic, renal or ureteral colic, multiple fractures of the ribs, and severe posttraumatic pain. Postoperative pain of the thorax, abdomen, pelvis, and/or lower limbs is also a common indication. In all these acute conditions, blockade provides not only analgesia by interruption of nociceptive pathways from somatic structures and viscera, but also blocks reflex muscle spasm, sympathetically induced ileus, and neural endocrine responses that may codevelop with acute injury and disease. Continuous epidural anesthesia also can be achieved using minute doses of soluble opioids.

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