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62 E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82
Fig. 1. Horse with a rectal prolapse which was treated presurgically with 5 ml lidocaine (2%)
and 0.17 mg/kg xylazine by epidural catheter, followed in 12 hours by 5 ml lidocaine (2%) with
0.1 mg/kg morphine for prolonged pain and tenesmus control.
Fig. 2. Horse with bilateral ruptured annular ligament of the fetlock joint which received IV
flunixin meglumine and, through an epidural catheter, 1.0 mg/kg tramadol with 5 microgram/kg
fentanyl for two days, then 0.1 mg/kg morphine with 10–20 micrograms/kg detomidine daily for
4 weeks.
E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82 65
Fig. 3. Horse with visible cellulites of the left hind limb. Pain was managed by placing an
epidural catheter and administering 0.1 mg/kg morphine with 10–20 micrograms/kg detomidine
daily for three weeks.
although regular 20-gauge 1.5-inch (3.75 cm) hypodermic needles have also
been used [18,44,49]. The needle is placed in the first intercoccygeal space
with the horse held in stocks. The skin over the region is clipped and surgi-
cally prepared. After location of the first intercoccygeal vertebral space, the
skin and subcutaneous tissue above the space is desensitized by administra-
tion of 2–3 ml of 2% lidocaine or 2% mepivacaine, using a 5/8-inch (16 mm)
25-gauge needle. A fenestrated adhesive clear plastic dressing (Bioclusiv
transparent dressing, Johnson & Johnson, Arlington, TX) can be placed
over the site to prevent contamination. In thick skinned horses making a
small skin incision with a #15 scalpel blade or an 18-gauge needle helps nee-
dle insertion. The spinal needle is introduced perpendicularly to the skin
with the bevel directed cranially, and pushed down in the median plane until
the ligamentum flavum is penetrated. Often a ÔpoppingÕ sensation is detected
when the ligament is crossed and even a hissing sound as the epidural space
is entered. A drop of sterile water or saline placed in the hub of the needle is
aspirated when the needle enters the epidural space (Ôhanging dropÕ tech-
nique). If the needle is inserted down to the bony floor of the vertebral canal
it should be withdrawn about 0.5 cm to avoid injection into the interverteb-
ral disc. Before injection, correct placement of the needle in the epidural
space is verified by the hanging-drop technique and negligible resistance
to air or sterile-water injection [44,49]. Aspiration should always be per-
formed to ensure that a venous sinus was not penetrated.
Alternatively, a spinal needle can be inserted at the first intercoccygeal
space by angling the needle ventrocranially at an angle of 10–30° to the spinal
canal. Studies have shown the tip of the needle in the epidural space is gener-
ally at Co1 to S5 vertebral space [51]. The length of needle used should be
slightly longer and either an 18-gauge 8.75 cm or 15 cm spinal needle (Mono-
ject, Sherwood Medical, St. Louis, MO) has been recommended [50,51]. This
approach to the epidural space can be useful in horses that have developed fi-
brous tissue over the intercoccygeal space after previous epidural injections.
The amount of anesthetic injected depends on the type of drug, the size
and the conformation of the horse. If local anesthetic solution is used usually
<10 mls is injected in adult horses to avoid paralysis of the lumbosacral
nerves to the hind legs [18,44]. For single injections of analgesic solutions
total volumes of 10–20 ml can be used in adult horses to produce cranial
migration of the solution 6 to 10 vertebral spaces [21].
Epidural catheterization
Epidural catheterization is performed using the same technique described
above for intercoccygeal epidural injection [1,17,49,55]. Many manufac-
turers produce epidural trays or kits that are suitable for use in the horse
[1,17]. An epidural Huber point (Tuohy) needle should be used instead of
a spinal needle. This needle design has a slight curve on the end which aids
in catheter directional placement and is more blunted at the end so less likely
E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82 67
to sever the catheter than a regular spinal needle. The skin should be
clipped, surgically prepared and covered with surgical sterile drapes or clear
plastic adhesive drape, (Bioclusiv transparent dressing) to avoid catheter
contamination. A disposable sterile or reusable 17 or 18-gauge 3" (7.5 cm)
epidural Tuohy needle is used to penetrate the epidural space. After confir-
mation of successful epidural puncture, a 19 or 20-gauge epidural catheter is
introduced through the needle up to the desired length. Generally for injec-
tions in the sacral area, 2–4 cm of catheter is advanced cranially from the
needle tip [49]. Catheters have length marks that are helpful to know how
far they are into the epidural space. Usually the catheter should be inserted
no more than 30 cm into the epidural space to avoid catheter kink. The
authors prefer using a spring-wire reinforced catheter, 19-gauge, 91.4 cm
(Arrow epidural anesthesia catheter, Arrow International, Reading, PA)
that facilitates introduction and rarely kinks, although a polyamide or a
plastic catheter can be used. After the needle is removed and the catheter
is placed it must be secured to the skin using a tape butterfly that is sutured
to the skin. A bacterial filter may be attached to the catheter connector. The
site of catheter penetration should be covered with iodine paste and the re-
gion covered with sterile dressings and gauze sponges and an adhesive clear
plastic dressing (Fig. 4). After each drug injection the catheter should be
flushed with 0.9% saline. Any presence of blood in the catheter suggests vas-
cular catheterization that should be ruled out before catheter use. Epidural
Fig. 4. An epidural catheter placed in the first intercoccygeal space, and covered with a sterile
dressing.
68 E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82
[44]. Segmental distribution of analgesia has been reported after epidural ad-
minstration of morphine to horses, in which dorsal dermatomes innervated
by lumbosacral nerves had superior analgesia to ventral dermatomes [40],
This would result in inadequate analgesia in ventral areas of the hindlimb
in some horses. Unilateral blockade with local anesthetics might be due to
presence of congenital membranes in the epidural space, or adhesions [41].
Incorrect epidural catheter placement due to ventral epidural placement,
or placement through an intervertebral foramen could also result in unilat-
eral blockade [41].
Neurotoxicity
Damage to the nerves and spinal cord by epidural solutions is a contro-
versial issue. Reports indicate that clinical doses of local anesthetics used in
horses cause no neurotoxicity, whereas in rodents solutions containing the
antioxidant sodium bisulphate have produced neuronal damage [44]. The
pH of solutions is another possible cause of neural injury, although local
anesthetics are only mildly acidic [19,44]. If possible, it is preferred to use
solutions that contain no preservatives. The number of commercially avail-
able preservative-free solutions at the correct concentrations and volumes
suitable for epidural injection in horses is limited. In one study comparing
opioid, kappa agonists and tramadol in horses, the authors had to use a
20-ml injectate volume as this was the volume dictated by the only available
solution of alfentanil [34]. Such large volumes may cause pain in the spinal
canal of horses due to compression of sacral and lumbar nerves [21]. One
study showed no histologic changes in the spinal cords of ponies after lido-
caine and xylazine epidural administration [15].
Other complications
Sweating is seen in the area effected by lidocaine or xylazine injection
[29,41]. Perineal edema has been observed after xylazine injection. Edema-
tous skin wheals in the perineal area have been seen in some horses after
morphine injection, and may be associated with local histamine release
[34,40]. Cardiovascular effects such as bradycardia and second-degree atrio-
ventricular block have followed xylazine or detomidine injection [46–48].
Table 1
Recommended regimens (single injection) for epidural anesthesia and analgesia in horses reported in research studies and in clinical practicea
Duration
Onset of anesthesia
Drug or combination Doses of action or analgesia Adverse effectsb References
Lidocaine 0.22–0.35 mg/kg 5–15 minutes 60–90 minutes Ataxia or recumbency [1,15,18,19,32,41,43,44,49]
at higher doses
Lidocaine (2%) 5–8 mL per 450 kg
Mepivacaine (2%) 5–7 mL per 450 kg 10–30 minutes 90–120 minutes [42,43,49]
Ropivacaine (0.5%) 8 mL per 500 kg 5–15 minutes 2.5–4 hours Inadequate perineal analgesia [32,51]
Xylazine 0.17 mg/kg 10–30 minutes 2.5–4 hours Perineal edema and sweating [12,29,30,31,44,49]
Xylazine 0.35 mg/kg 10–20 minutes 3–5 hours Mild ataxia [15,26]
Detomidine 30–60 lg/kg 10–15 minutes 2–3 hours Sedation, ataxia, [45,46,48,49,59]
cardiovascular depression,
second-degree
atrioventricular block,
diuresis
Romifidine 80 lg/kg 10–20 minutes ? Inadequate perineal [25]
analgesia, bradycardia
Lidocaine and xylazine 0.22 mg/kg 5–15 minutes 5.5 hours Ataxia or recumbency, [4,19]
and 0.17 mg/kg perineal sweating
Morphine 0.1 mg/kg 4–6 hours 8–18 hours Skin wheals, sedation [11,34,35,40,54,58]
Morphine 0.1 mg/kg 20–30 minutes 20–24 hours Sedation, ataxia [54]
and detomidine and 10 lg/kg
E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82
Local anesthetics
Lidocaine, mepivacaine
Local anesthetics have the potential to produce sensory, motor and sym-
pathetic neuronal blockade by depressing axonal conduction of nerves. Cau-
dal epidural local anesthesia in horses does not progress cranial enough to
produce sympathetic blockade cranial to the hind limb. Onset of local anes-
thetic effects is marked by relaxation of the tail and the anus. Standard vol-
umes of lidocaine and mepivacaine produce up to 90 to 120 minutes
respectively of local anesthesia in horses (Table 1) [1,43,44,49]. The longer
durations given can be achieved by adding a vasoconstrictor to the solution
such as epinephrine (0.05 ml of 1:1000 solution to 10 ml of local anesthetic
solution ¼ 1:200,000). After this time, if an epidural catheter is in place,
anesthesia can be prolonged by injecting half the original volume of local
anesthetic. Mild ataxia is common even when doses as low as 0.22 mg/kg
lidocaine are used [19]. Carbonated lidocaine has been studied in horses in
the hope of producing a more reliable and consistent sensory block after epi-
dural administration, with a faster onset than lidocaine alone, however, in
horses carbonated lidocaine offered no advantages over lidocaine alone [41].
Ropivacaine, bupivacaine
In humans, ropivacaine is a longer duration local anesthetic which pro-
duces less motor block than traditional local anesthetics like lidocaine.
Results of epidural administration of ropivacaine, (8–9 ml, 0.5% solution)
has been studied in standing mares [51]. Prolonged bilateral analgesia between
the coccyx and sacral dermatomes S2-4 was produced, with minimal seda-
tion, ataxia and circulatory and respiratory changes. In 5 of the 10 mares
studied, inadequate analgesia was thought to be due to incorrect needle place-
ment [51]. In another study in horses, in which the effects of lidocaine and
ropivacaine given epidurally were compared, ropivacaine (5.8 ml, 1% solu-
tion) combined with epinephrine 1:200,000, produced 285 minutes of
perineal analgesia, compared to 163 minutes with lidocaine (5.8 ml, 2% solu-
tion [32]. One mare receiving a combination of lidocaine and ropivacaine
became recumbent [32]. Some of the newer local anesthetics (dilute solutions
of bupivacaine and ropivacaine) are being investigated in humans for prefer-
ential sensory block after epidural or subarachnoid injection, but this
concept has not yet been studied in horses. There are no current reports
of the use of bupivacaine for epidural analgesia in horses.
analgesic effect spreads cranially into the lumbar and thoracic area. How-
ever, ataxia and recumbency are still possible complications of this group
of drugs in individual horses [59]. Compared to local anesthetics, but similar
to opioids, detailed studies have shown that alpha-2 agonists tend to pro-
duce variable or patchy segmental effects [46,47]. For this reason, xylazine,
other alpha-2 agonists, and the opiods are often combined with other drugs,
such as local anesthetics, for caudal epidural analgesia in horses [19].
Agonists of alpha-2 adrenergic receptors produce analgesia by their action
on receptors in the substantia gelatinosa of the dorsal horn of the spinal
cord. Xylazine may also have a local anesthetic-like action on spinal nerves.
Any adverse effects of epidurally administered alpha-2 agonists can be
reversed in horses by drugs such as atipamezole (40 micrograms/kg IV) or
yohimbine (50 micrograms/kg IV) [49,50].
Xylazine
Original work with xylazine compared various dose rates and concluded
that 0.17 mg/kg was the optimal dose given epidurally to horses to produce
2.5 hours of perineal analgesia, with no hindlimb ataxia (Table 1) [29]. This
dose is one half to one fifth the dose commonly given systemically for seda-
tion of horses. Xylazine was diluted in 10 ml of 0.9% saline for injection. At
this dose rate no sedation nor cardiorespiratory side-effects were noted [31].
In combination with other drugs (e.g., lidocaine) this dose of xylazine is still
frequently used [4,19]. For perineal surgeries, using xylazine alone, higher
dose of 0.22–0.25 mg/kg have been recommended [30,47,48]. Ponies receiv-
ing xylazine at 0.35 mg/kg for caudal epidural analgesia had mild ataxia [15].
A recent report used a high dose rate of xylazine (0.5 mg/kg) when combined
with ketamine for perineal analgesia [26]. Cardiorespiratory changes have
been recorded in mares administered 0.25 mg/kg xylazine, diluted in 6 ml
of saline, for caudal epidural analgesia [47]. All mares were mildly sedated.
Heart rate and respiratory rate decreased significantly, and 2° atrioventricu-
lar block developed in 7 of 8 mares. Arterial blood pressure initially in-
creased then decreased below normal. Perineal sweating was seen in all
mares 30 minutes after injection and persisted for 3 hours. Distribution of
bilateral analgesia varied between mares, from the coccygeal to S3 dermato-
mal segments. Blockade of motor nerves in 2 mares produced tail flaccidity
and hindlimb ataxia. Blockade of parasympathetic nerves resulted in relaxa-
tion of the genitalia and dilation of the rectum [47].
Detomidine
Potent analgesic and sedative effects are produced when detomidine is in-
jected into the caudal epidural space of horses [45]. Detomidine is a lipophi-
lic drug and is rapidly absorbed systemically from the epidural space.
Sedation, ataxia, recumbency, and cardiovascular effects can occur with
doses as low as 20 micrograms/kg. Thus, low doses (20–40 micrograms/kg)
74 E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82
Romifidine
In a recent report, romifidine at 80 micrograms/kg diluted in saline to
8.0 ml, produced no analgesia in 5 of 8 horses studied, and insufficient anal-
gesia for surgery in the other 3 horses. Sedation, bradycardia, and decreased
respiratory rate were reported [25].
Butorphanol
Butorphanol is the most common Kappa opioid agonist used systemi-
cally in horses. For caudal epidural analgesia, butorphanol combined with
lidocaine has been shown to improve quality of analgesia and prolonged
duration in horses compared to lidocaine alone [9,14]. In the authorsÕ ex-
perience, butorphanol does not produce analgesia when used alone in clini-
cal cases. In a controlled study the authors showed that butorphanol at
76 E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82
U50488H
U50488H is a pure Kappa opioid agonist which has been shown to pro-
duce no CNS excitatory effects in horses when administered systemically
[23]. In a study in horses, U50488H, at 0.08 mg/kg, produced no analgesia
when given into the caudal epidural space [34].
Alfentanil, fentanyl
Highly lipid soluble Mu opioids such as alfentanil and fentanyl are
rapidly transferred from the epidural space to the subarachnoid space and
to plasma [8,42]. Cephalad movement of lipid-soluble opioids is limited by
uptake into the spinal cord after transferring into the subarachnoid space
[53]. In a controlled study in horses alfentanil at 0.02 mg/kg given into the
caudal epidural space produced a measurable but insignificant analgesic
effect in the perineal and sacral dermatomes [34]. We believe that the reason
why alfentanil produces an increase in the threshold for the noxious stimuli
only over the perineal and sacral regions and not over the lumbar and thor-
acic areas is due to its higher lipid solubility when compared to tramadol
and morphine. The epidural administration of highly lipophilic opioids
should be done immediately adjacent to spinal cord segmental binding sites
to improve selectivity of spinal analgesia [42]. This lack of epidural analgesic
effect observed with kappa opioid agonists and lipophilic mu agonists, such
as alfentanil, could be related to the number and distribution of opioid
receptors in the spinal cord in horses and to the high lipid solubility leading
to a rapid systemic absorption.
Meperidine
A study in mares has shown that meperidine holds promise as a suitable
opioid for epidural adminstration in horses [52]. The effects of meperidine in
the mares; perineal analgesia, decreased tail muscle and anal sphincter tone,
were thought to resemble a local anesthetic action, rather the more typical
effects seen with the opioids [52]. There was mild sedation and ataxia and
no measurable cardiorespiratory side-effects seen in any mares [52].
Tramadol
Tramadol is a synthetic 4-phenyl-piperidine analgesic drug, an analogue
of codeine, with both opioid and non-opioid mechanisms of action [10,38].
At the time of writing, only the oral form is available in the United States.
Epidural administration has demonstrated a fast onset of analgesia in hu-
mans. In a recent study in horses all classes of opioids and tramadol were
comparatively evaluated after epidural administration [34]. Caudal epidural
administration of tramadol showed promise in management of perineal and
E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82 77
Dissociative anesthetics
Ketamine
Both epidural and subarachnoid injections of ketamine have been shown
to produce short-duration analgesia in horses [3,16]. Ketamine has been
used alone for caudal epidurals in horses producing 30 to 90 minutes of anal-
gesia, with mild sedation but no cardiorespiratory changes [16]. Superficial
and deep muscle pinpricks were used in the tail, perineal region and upper
hindlimb as noxious stimuli. This study did not evaluate whether the anal-
gesia produced was sufficient for surgery [16]. When epidurally administered
in horses ketamine, at 0.8 and 1.2 mg/kg, reduced the MAC of halothane to
stimulation of the pelvic limb [11].
Ketamine is thought to produce analgesia primarily by its noncompeti-
tive antagonism of NMDA receptors. Thus ketamine is more appropriate
to prevent secondary hyperalgesia which will occur when noxious painful
stimulation activates spinal cord neurons repetitively and intensively in cases
such as chronic laminitis and other orthopedic lesions. High concentration
of ketamine also may produce local anesthetic-like effects blocking Na+
channels [2,13]. Whether epidural ketamine will be useful alone for acute
surgical or traumatic pain in the horses is unknown at this time.
Ketamine may be indicated combined with more potent analgesics such
as morphine. Ketamine has also been studied in combination with xylazine.
Analgesia, tested by pin-prick, was produced in the tail, perineum, anus and
vulva, and extended to the flank in some horses [26]. The effects were longer
in duration than when ketamine was used alone and exceeded 120 minutes.
Mild sedation but no recumbency was produced, and there were significant
decreases in heart and respiratory rates [26].
It is not known at this time if epidurally administered ketamine will pro-
duce CNS stimulation in the awake horse, but clinicians should be aware of
this possibility.
Tiletamine
In an experimental study in horses, tiletamine–zolazepam combination
was injected epidurally in horses at 0.5 and 1.0 mg/kg [36]. No analgesia
was detected in 25% of the studies and only mild analgesia in the others.
No sedation was observed but ataxia was seen in all horses and one horse
showed CNS excitation [36].
Further studies with the dissociative agents, ketamine and tiletamine, are
warranted to evaluate their effectiveness and lack of side-effects, such as
CNS excitement, when used for caudal analgesia in horses.
Conclusions
Pain control and local anesthesia for perineal procedures have become
commonplace in horses with the increased knowledge of the techniques of
E.P. Robinson, C.C. Natalini / Vet Clin Equine 18 (2002) 61–82 79
epidural injection and of the effects of drugs which can be given epidurally.
Combinations of a variety of drugs have allowed the onset and duration of
effects to be more closely tailored to the needs of each horse. Long-duration
pain-control has become a reality with the availability of epidural kits suita-
ble for use in horses, and the knowledge of the effects of new and novel
analgesics. Although caudal epidural anesthesia was traditionally limited
to the sacral and perineal area in horses, to avoid recumbency, the advent
of the use of drugs such as opioids, alpha-2 adrenergic agonists and ketamine
has increased the possibilities for analgesia in more cranial parts of the body.
Many of these drugs which produce undesirable side-effects when given
systemically to horses, can be used epidurally with astoundingly good effect.
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