This document provides information on cervical epidural anesthesia. It discusses the history and uses of cervical epidural, including for bilateral upper limb surgery, mastectomy, thyroid surgery, and chronic pain management. Risks like spinal cord injury and neurological complications are addressed. Techniques to increase safety are covered, such as using fluoroscopy, avoiding levels above C6-7, and low injection volumes. Drugs commonly used include ropivacaine, lidocaine, and bupivacaine. Overall, the document outlines the applications and techniques of cervical epidural anesthesia while also discussing risks and safety considerations.

1. Welcome

2. Cervical Epidural;
How to play safe
Dr Ashok Jadon,
MD DNB MNAMS
Chief Consultant & HOD Anaesthesia
Tata Motors Hospital

3. Introduction
• Cervical epidural blockade was
first reported by Dogliotti in 1933
(for cancer pain)
• Other than chronic pain management of head,
neck and upper limbs newer indication have
been added……

4. Uses of cervical epidural
• If simultaneously both upper-limbs to be operated,
• An adjunct to manage CRPS of upper limb
• Mastectomy
• Thyroid surgery
– General anaesthesia is undesirable/ less blood loss
• Parathyroid surgery
– Conscious communicating patient, tissue implant
• Prolonged and vascular surgery
• Cardiac surgery

5. bilateral upper-limb surgery;
regional blocks
• Low-Dose Intravenous Regional
Anesthesia in a Case of Multi staged,
Bilateral Hand Surgery. Anesth
Analg1986;65:812-4.
• Bilateral ultrasound-guided supra-
clavicular block. María Isabel Vásquez,
Rev colomb anestesiol. 2012;40(4):304–
308.

6. Regional anaesthesia can be a suitable
option for bilateral upper limb surgery.
• LA toxicity, phrenic nerve block and pneumothorax
remain the main concerns
• Spacing blocks reduce toxicity issues, peak absorption rates
for each block should not coincide.
• Since phrenic nerve block remains an issue even with low
doses, bilateral interscalene blocks are still not recommended.
• Peripheral nerve blocks have excellent safety profiles and are
ideal for ultrasound guidance.

7. use of cervical epidural for upper limb surgery
• Michalek P . Cervical Epidural Anesthesia for Combined Neck
and Upper Extremity Procedure: A Pilot Study. Anesth Analg
2004;99:1833–6
– Total para-thyroidectomy with partial auto-graft
implantation into the forearm muscle.
• Marodkar K. Cervical epidural anaesthesia for shoulder
arthroscopy and effective postoperative physiotherapy for a
frozen shoulder. South Afr J Anaesth Analg 2012;18(3):172-175.
• Tsui & Ganapathy et al. Cervical epidural analgesia via a thoracic
approach using nerve-stimulation guidance in adult patients
undergoing total shoulder replacement surgery . Acta
Anaesthesiologica Scandinavica 2007 ;51 (2), 255-260.

8. CEA for other surgery
• Khanna & Singh. Cervical epidural anaesthesia for thyroid
surgery. Kathmandu University Medical Journal 2009;27, 242-
245
• Malti Agrawal. Cervical epidural anaesthesia for neck arm and
upper thoracic surgery. JACP 2010.
• Mamta G. Patel. Cervical Epidural Anaesthesia for Various Neck
Surgeries. J Anaesth Clin Pharmacol 2009; 25(3): 297-300.
• Kulkarni K, Namazi IJ, Deshpande S, Goel R. Cervical Epidural
Anaesthesia with Ropivacaine for Modified Radical Mastectomy.
Kathmandu Univ Med J2013;42(2):126-131.

9. Conclusions:
•safe and reliable,
•stable hemodynamic,
•effective post operative
pain relief

10. Evidences for Cervical Epidural in Pain Management
• Benyamin R. Systematic Review of the Effectiveness of Cervical Epidurals
in the Management of Chronic Neck Pain. Pain Physician 2009: 12:1:137-
157
– The indicated evidence is Level II-1 in managing chronic neck and upper
extremity pain.
• Diwan Sudhir A. Effectiveness of Cervical Epidural Injections in the
Management of Chronic Neck and Upper Extremity Pain. Pain Physician
2012; 15:E405-E434
– The evidence is good for radiculitis secondary to disc herniation with local
anesthetics and steroids, fair with local anesthetic only; whereas, it is fair for local
anesthetics with or without steroids, for axial or discogenic pain, pain of central
spinal stenosis, and pain of post surgery syndrome.
• Laxmaiah Manchikanti. Fluoroscopic Epidural Injections in Cervical Spinal
Stenosis: Preliminary Results of a Randomized, Double-Blind, Active
Control Trial. Pain Physician 2012; 15:E59-E70.
– Patients who have chronic function-limiting pain that is secondary to cervical
central stenosis might receive relief with cervical interlaminar epidurals of local
anesthetic, whether with or without steroids.

11. Physiological effects
• (Fear) of a bilateral phrenic nerve block and
respiratory distress. phrenic nerve activities
show a suppression of 72% and 57% of control
• No significant effect on PO2 , significant
increase in PCO2
• decreases in heart rate and blood pressure.
There is also a blunted response to atropine
and atropine-like drugs

12. Risks & Complications
• The risk of spinal cord injury (most serious complication) Only
highly experienced physicians should perform these
procedures.
– Bose B. Quadriparesis following cervical epidural steroid injections: case report and review of the
literature. Spine J 2005;5:558–63
– Ziai WC, Ardelt AA, Llinas RH. Brainstem stroke following uncomplicated cervical epidural steroid
injection. Arch Neurol 2006;63:1643–6
• Cervical epidural injection complicated by syrinx formation: a
case report. Khan S, Pioro EP. Spine (Phila Pa 1976). 2010 Jun
1;35(13):E614-6
• Iatrogenic cervical epidural hematoma: case report and
review of the literature. Neurocirugia (Astur). 2011
Aug;22(4):332-6.

13. Complications
 Yatin Mehta. Headache and seizures after
cervical epidural. Annals of Cardiac
Anaesthesia,2012
• Hankey G J. Polyneuropathy cranialis following
cervical epidural anaesthesia
• Roussier M. Patient-controlled cervical
epidural fentanyl compared with patient-
controlled i.v. fentanyl for pain after
pharyngolaryngeal surgery. Br J Anaesth 2006;
96: 492–6.

14. •How to increase safety
of cervical epidural?
•Technical know-how or
tips

15. Newer techniques..
• Sonographic Estimation of Needle Depth for
Cervical Epidural Blocks. Soo Hwan Kim,
Anesth Analg May 2008;106 (5): 1542-1547
•Clinical Judgment
•Fluoroscopy use

16. • Avoid epidural needle
placement above C6-7.
– ligamentum flavum: Incidence of
midline gaps. Lirk P. BJA 94 (6):
852–5 (2005), and
Anesthesiology 2003;99:1387–90
– epidural fat
• Low volume cervical injections
– often spread upward several
segments.
– If higher levels is indicated,
introduce an epidural catheter
• Do not use the hanging drop
technique

17. Use of fluoroscopy
• The “3-D technique,”
• direction, followed by depth, and last,
direction again.
• difficult at the lower cervical levels because of the
superimposed shoulder joints, particularly in thick-
necked patients.
• A “swimmer’s view
• Oblique views

18. Fluoroscopy use
• Stojanovic MP. The role of fluoroscopy in cervical epidural
steroid injections: an analysis of contrast dispersal patterns.
Spine 2002 Mar 1;27(5):509-14.
– 53% rate of false LOR during the first attempt to enter the epidural space.
Unilateral epidural contrast spread was found in 51% and ventral epidural
spread was found in 28% of cases.
• Recommendation: The loss of resistance technique
may not be an adequate method for ensuring
accurate needle placement in blindly performed
cervical epidural

20. Swimmer’s View

22. Original Research Article On the Geometry of Fluoroscopy
Views for Cervical Interlaminar Epidural Injections by Milton H
Landers Pain Medicine 2012; 13: 58–65

23. Original Research Article On the Geometry of Fluoroscopy Views
for Cervical Interlaminar Epidural Injections by Milton H
Landers Pain Medicine 2012; 13: 58–65

24. catheter

26. Cervical epidural in sitting postion

27. Cervical epidural in prone possition

32. Thyroid surgery in cervical epidural

33. Drugs @ Safety
• Ropivacaine 0.5% to 0.75%, 5 to 15ml
• Lidocaine with adrenaline 1.5% to 2%, 5ml to
15ml
• Bupivacaine 0.25% to 0.5% , 5ml to 15ml
• Adjunct During surgery: Fentanyl 20-25 mic
• Postoperative Analgesia: Morphine 2.4mg to
3.2mg with 0.2% Rpivacaine or 0.125%
Bupivacaine, 3ml to 4ml SOS

34. Thank You
Catheter Tunneling