Anaes · Regional anaesthesia
Combined spinal-epidural (CSE) anaesthesia
Also known as Combined spinal-epidural · CSE · Needle-through-needle technique · Dural puncture epidural · DPE
Exam-exhaustive CSE: needle-through-needle technique, single vs double space, labour and caesarean indications, DPE variant, hypotension anticipation, catheter migration/total spinal risk, PDPH, and failed-block rescue for ANZCA Final and equivalents.
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Target exams
Red flags
- No CSF through the spinal needle after loss of resistance — do not force; resite or convert to plain epidural.
- Epidural top-ups after CSE can be intrathecal if the catheter migrates through the dural hole — aspirate, test dose, fractionate every top-up.
- Spinal component causes rapid hypotension — vasopressor ready before the intrathecal dose.
- Use the finest reliable pencil-point spinal needle to limit PDPH risk.
- Confirm CSF and dose before withdrawing the spinal needle — 'dry tap CSE' is a failed spinal waiting to happen.
Meet the patient
A twenty-six-year-old primigravida is six centimetres dilated, contracting every two minutes, and asking for the epidural she was promised would be instant. The midwife tells you labour has been established for eight hours, the baby is occipito-posterior, and theatre conversion for a slow first stage is genuinely on the table tonight.[1]
The two questions that decide her block are the two that decide every CSE: how fast can I get her comfortable? (the spinal answers within minutes) and how do I keep her covered if this ends in theatre? (the catheter answers that). Hold those two questions and the technique below slots into place.[1]
References4ShowHide
- [1]Roofthooft E, Rawal N, Van de Velde M Current status of the combined spinal-epidural technique in obstetrics and surgery. Best Pract Res Clin Anaesthesiol, 2023.PMID 37321766
- [2]Chino K, Rollins MD, Warrick C, et al. Post-dural Puncture Headache in Dural Puncture Epidural and Combined Spinal-Epidural Using 24- and 25-Gauge Needles Versus Conventional Epidural Labor Analgesia: A Systematic Review and Meta-analysis. Anesth Analg, 2026.PMID 42155003
- [3]Basheer P, Brijesh GC, Kumar R, et al. A Clinical Comparison between Single-Space Technique and Double-Space Technique for Combined Spinal and Epidural Anesthesia. Anesth Essays Res, 2022.PMID 36249131
- [4]Vallejo MC, Lilly CL, Saracoglu A, et al. Factors Associated With Unintended Dural Puncture and Failed Neuraxial Anesthesia in Obstetric Anesthesia. Cureus, 2026.PMID 42199590