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Background and Aims Combined spinal-epidural (CSE) is a neuraxial technique where injection of local anaesthetic into the subarachnoid space and placement of an epidural catheter is performed in the same procedure.
Methods Case 1 is a 69-year-old female who underwent total knee arthroplasty. CSE was performed using a needle-through-needle technique with the B.Braun Espocan®. 18G Tuohy needle was inserted at L3/L4 in the midline in sitting position and advanced until loss of resistance to saline obtained. 27G spinal needle was inserted through Tuohy needle up to the maximal protrusion length, however no CSF was obtained. Epidural catheter was inserted and epidural anaesthesia initiated with 15mls 0.5% bupivacaine. Case 2 is a 63-year-old male who underwent total hip arthroplasty. CSE was performed with the same technique. Intrathecal component was not given as CSF was not flowing freely. Epidural catheter was inserted and epidural anaesthesia initiated with 18mls 0.5% bupivacaine.
Results Both patients underwent total knee and hip arthroplasty uneventfully under epidural anaesthesia in an operative time of 4 and 5 hours respectively.
Conclusions Failure of the spinal component in CSE in these cases are likely due to deviation from midline resulting in the spinal needle missing the subarachnoid space laterally or in the dural-arachnoid side wall. In both cases, after removal of the spinal needle, epidural anaesthesia was administered. Alternative rescue techniques would include threading the epidural catheter and performing subarachnoid block using a separate spinal needle at a different interspace; or repeating the CSE technique at the same or different interspace with direction of needle medially.
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