Neuraxial anesthesia is a term that denotes all forms of central blocks, involving the spinal, epidural, and caudal spaces. Epidural anesthesia is a versatile technique widely used in anesthetic practice. Its potential to decrease postoperative morbidity and mortality has been demonstrated by numerous studies. To maximize its perioperative benefits while minimizing potential adverse outcomes, the knowledge of factors affecting successful block placement is essential. This paper will provide an overview of the pertinent anatomical, pharmacological, immunological, and technical aspects of epidural anesthesia in both adult and pediatric populations and will discuss the recent advances, the related rare but potentially devastating complications, and the current recommendations for the use of anticoagulants in the setting of neuraxial block placement. 1. Introduction Neuraxial anesthesia is the term for central blocks involving the spinal, epidural, and caudal spaces. While it is now an invaluable adjunct and even occasionally an alternative to general anesthesia, its use is not a new phenomenon. Physicians such as Corning published studies documenting success with neuraxial blocks as early as 1885 [1]. Even more ambitious physician-scientists such as Bier became knowledgeable about spinal anesthesia, in particular, through self-investigation [2]. It unfortunately was also through this type of dedication that he became all too familiar with postdural puncture headaches. Despite its early use, though, much of the gains we have with neuraxial blocks did not occur until the early 1900’s. Limitations in this particular area of anesthesia were limited to lack of drug diversity and a lack of adequate equipment. Prior to 1904, the only drug available for neuraxial use was cocaine, and development of epidural technology was still a ways off. With a larger drug base and equipment advancements came an expansion of the role of neuraxial anesthesia in anesthesia practice. Excluding the obvious fact that surgical conditions primarily dictate the type of anesthesia performed, most operations below the neck can be performed under neuraxial anesthesia. Various studies have shown a decrease in postoperative morbidity and even mortality when used either with general anesthesia or alone. Neuraxial blocks have even been shown to reduce the incidence of venous thrombosis and pulmonary embolism while also minimizing transfusion requirements and respiratory compromise following thoracic and upper abdominal surgery. A decreased stress response has also been noted which may have
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