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Combined Spinal / Epidural

If you have a private operation planned, it may involve an anaesthetic procedure, in this instance a combined spinal / epidural. You may wish to know what this involves.
 
The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

 

What is the problem?

You need an operation on the lower half of your body. This type of anaesthetic may be suitable for any operations involving the lower half of the body. An epidural is most commonly used for pain relief for women in labour.

 

A combined spinal / epidural can be used instead of going to sleep (general anaesthetic). Some illnesses like bad lung disease may make a general anaesthetic unsuitable or more risky.

 

You may prefer to have a combined spinal / epidural, instead of going to sleep with a general anaesthetic.

 

What is a combined spinal / epidural?

A combined spinal / epidural is a type of anaesthetic. It is used to make part of the body pain-free without you going to sleep. It is in two parts. First there is the spinal, which produces numbness and pain relief very quickly. The second half is an epidural. The anaesthetist leaves a plastic tube (catheter) near the spinal nerves. This is very useful for keeping you pain free after an operation.

 

This anaesthetic was developed for women in labour and this is by far its most common use. However, any operations involving the lower half of the body may be suitable for a combined spinal / epidural.

 

We inject drugs to stop the spinal cord and nerves sending pain signals to your brain. You will not feel any pain on either side of your body, below a certain level. The level will depend on how far up the spinal cord the anaesthetic is placed.

Combined Spinal_epidural
Combined Spinal Epidural 2

 

The drugs will block other feelings apart from pain. They also block signals to the muscles. Your lower body will be numb and your legs will feel weak and clumsy.

 

Sometimes the epidural catheter can be left for a day or two after the operation, if you are likely to be in pain for that long.

 

You will be awake during the operation. We can give sedative drugs into your arm vein drip to make you feel more relaxed.

 

Why use both a spinal and an epidural?

Combining the two procedures is useful because both have advantages, which can be added together. This gives you the best pain control during AND after your operation.

 

The spinal, gives strong and almost immediate pain relief of a very high quality. The anaesthetist leaves an epidural catheter in place. This allows you to have on-going pain control, in the two to three days after your operation.

 

During the procedure the spinal injection is done first. The epidural catheter is put in place before the needle is removed.

 

The aims

The aim is to allow you to have a pain free operation without the risks of a general anaesthetic. The epidural may also be used to provide pain-relief after your operation.

 

The benefits

You can avoid the risks of a general anaesthetic, where you are asleep for the operation. Compared with a general anaesthetic, a combined spinal / epidural causes less sickness. It also allows you to keep a clear head so that you feel normal again more quickly. This allows you to eat, drink and be up and about as soon as possible.

 

You can have the combined spinal / epidural simply for preference if your surgery is suitable. Some patients prefer to be awake during their surgery.

 

The most useful benefit is the several days of pain relief that the epidural can give after an operation. When the surgical wound has settled and the pain is reduced, the epidural is removed. Then simple painkilling tablets or injections are used instead.

 

Smokers benefit from a combined spinal / epidural, as they do not need to breath the irritant gases of a general anaesthetic. They may upset the lungs and cause coughing after the operation.

 

Are there any alternatives?

There are several alternatives to a combined spinal / epidural.

 

General anaesthetic

You can have a general anaesthetic, where you are completely asleep throughout. Other strong painkillers, such as morphine, can be given to keep you comfortable when you wake up. There may be a medical reason why this is not suitable and this should be discussed with your anaesthetic doctor.

 

Regional anaesthetic

Another method is to make individual nerves go numb temporarily. This could be your whole leg. This makes a small region of the body numb, hence the name ‘regional anaesthetic’. 

 

Local anaesthetic

Sometimes, if the surgery is minor, local anaesthetic injections can be used to numb the operation area only.

 

Hypnosis

More recently, some patients have used hypnosis to help them during an operation. Very few people can tolerate operations with hypnosis alone, but it may assist with the relief of anxiety, when used with other nerve blocking methods.

 

Whether any of these alternatives are suitable, depends on the part of the body to be operated on. The length of the procedure is also important. All of these methods can be used with sedation into a vein to help relieve anxiety.

 

If you are to have one of these procedures there is another information leaflet that will tell you more about it.

 

Who should have it done?

There are general reasons for having a combined spinal / epidural, instead of a general anaesthetic. These are:

 

  • If you have had a previous problem with a general anaesthetic.

  • If you have moderate to severe lung disease.

  • If you have any other disease that may be made worse by a general anaesthetic, such as bad asthma or kidney disease.

  • If you are having an operation where an epidural can be used to control pain afterwards.

 

There are some specific reasons for having a combined spinal / epidural. The most common reason is when a baby is delivered by caesarean section. The mother can bond with the child immediately after the operation, because they are both awake. Also, the drugs given to the mother do not affect the baby, as in a general anaesthetic.

 

Another reason for using a combined spinal / epidural is when there is a definite history of allergy to general anaesthetic gases. There is a rare but serious condition, which runs in families, called malignant hyperpyrexia. Anaesthetic gases and other drugs used in a general anaesthetic can cause an increase in body temperature in patients who suffer from this condition. A combined spinal / epidural would avoid this.

           

Who should not have it done?

If you are unwilling to have a combined spinal / epidural and a general anaesthetic would be safe, then a combined spinal / epidural need not be performed. 

There are also specific medical situations when an epidural should not be done and these are:

 

  • Medication that prevents your blood from clotting, such as Warfarin; this would lead to more bleeding than normal. Bleeding around the spine is a serious problem and must be avoided.

  • An illness that prevents your blood from clotting, such as haemophilia; this would lead to more bleeding around the spine.

  • Infection of the skin over the site where the needle needs to be put in; this could lead to further infection in the deeper tissues and possibly blood poisoning. This could also cause infection around the spine.

  • Unusual or difficult spinal anatomy; this would make it difficult to put the needle in the correct place.

  • A combined spinal / epidural cannot safely give pain relief above the upper part of the chest. Here an epidural causes a fall in blood pressure and breathing difficulty.

 

Author: Dr Sean White FRCA. Consultant in pain and anaesthesia

© Dumas Ltd 2006

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