title: Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal and epidural anaesthesia.
abstract: BACKGROUND
  Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one.
  
  
  OBJECTIVE
  WE PERFORMED A STUDY TO COMPARE TWO POPULAR CSE TECHNIQUES: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT).
  
  
  METHODS
  After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared.
  
  
  RESULTS
  SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups.
  
  
  CONCLUSIONS
  SDT is an acceptable alternative to DST and SST.
authors.affiliation: Department of Anaesthesia and Intensive Care, GB Pant Hospital, New Delhi, India.
authors.forename: Deepti
authors.initials: D
authors.lastname: Saigal
authors.forename: Rama
authors.initials: R
authors.lastname: Wason
keywords: Combined spinal epidural; double segment; needle through needle; paramedian