ANATOMY OF EPIDURAL SPACE

Dr. M.Suguna
Dept. of Anesthesia
GTMC-Theni
 INTRODUCTION
• Epidural space or Peridural space or Extradural space is the
space that lies between the spinal meninges and the sides of the
vertebral canal.
 HISTORY
• 1885: Corning first performed epidural analgesia.
• 1901: Sicard and Cathelin first used cadual approach, Tuffier
attempted epidural analgesia by lumbar approach in the same
year.
• 1921: Fidel Pages first used epidural anaesthesia in his surgical
practice.
• Tuohy introduced the needle used in Epidural Anaesthesia in
1945.
• 1951: Crawford used epidural anesthesia for thoracic surgery
• The epidural space is the potential space between periosteum
lining the vertebral canal and the spinal dura mater.
• It extends from the foramen magnum to the sacral hiatus, and
surrounds the dura mater anteriorly, laterally, and posteriorly
Cont…

•Within the cranium the endosteal and meningeal layers of dura

mater are closely united, but below the foramen magnum the

two layers separate,the outer becoming the periosteal lining of

the spinal canal and the inner forming the spinal dura mater
 BOUNDARIES
• Above: the foramen magnum.

• Below: the sacrococcygeal ligament. (sacral hiatus)

• Anterior: the posterior longitudinal ligament covering the

posterior aspect of the vertebral bodies and the intervetrtebral

discs

• Lateral: the vertebral pedicles & intervertebral foramina.

• Posterior: the ligamentum flavum and the laminae.

Dr.M. Suguna, Dept. of Anesthesia, GTMC
Dr.M. Suguna, Dept. of Anesthesia, GTMC
Cont..

• The space is more extensive and easily distensible posteriorly

while anteriorly the dura adheres closely to the periosteum of

vertebral bodies.

• Laterally the space accompany the spinal nerves through the

intervertebral foramina.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

 CONTENTS
• Areolar connective tissue
• Fat
• Spinal nerve roots with their dural sleeves
• Blood vessels-spinal arteries and venous plexus (Batson’s
plexus)
• Lymphatics

Dr.M. Suguna, Dept. of Anesthesia, GTMC

 AREOLAR CONNECTIVE TISSUE
• It is present in significant amounts ventrally forming strong
connections between duramater and anterior longitudinal
ligament in the vertebral canal.
• The existence of fibrous connections in the posterior epidural
space called as PLICA MEDIANA DORSALIS of the
duramater extending longitudinally in the midline connecting
the dura and ligamentum flavum is also noted.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

 EPIDURAL FAT
• The contents of the spinal canal lie cushioned in a packing of
semi-fluid lobulated fat. It is principally present in posterior
and lateral space.
• Epidural fat is highly vascular,
• The epidural fat constitutes an important pharmacological
space and depot for injected local anesthetic agents
• Increased lipid solubility leads to sequestration of drugs in fat,
thereby reducing bioavailability of drug.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Dr.M. Suguna, Dept. of Anesthesia, GTMC
Dr.M. Suguna, Dept. of Anesthesia, GTMC
 BLOOD VESSELS
• The epidural arteries arise from the vertebral, the ascending
cervical, deep cervical, intercostal, lumbar, ilio-lumbar arteries.
• These arteries are found in the lateral region of the space and
therefore not threatened by an advancing epidural needle.
• The internal vertebral venous plexus, draining both cord and
canal, lies mainly in the anterolateral parts of the epidural
space.
• It has rich segmental connections at all levels and opens into
the intervertebral veins which pass out through the intervebral
foramina, and end in vertebral, posterior intercostal, lumbar,and
Cont..
• These veins communicate with the segmental veins of the neck,
the intercostal, azygos and lumbar veins. With the veins of
bones of the vertebral column, the internal and external
vertebral plexuses form Batson’s plexus.
• These veins are predominantly in the antero-lateral part of the
epidural space, and ultimately drain into the azygous system of
veins.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Cont..
• Through this venous network increased intra-abdominal and
intra thoracic pressures as in coughing and straining are
transmitted to the epidural space.
• Under the stress of these pressures the valveless epidural veins
distend and diminish the effective volume of epidural space, so
the solutions tend to spread more widely.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Dr.M. Suguna, Dept. of Anesthesia, GTMC
 LYMPHATICS

• Lymphatic networks surrounding and draining the dural cul-de-

sacs of the dural root sleeves run anteriorly from each

intervertebral foramen and empty into longitudinal channels in

front of the vertebral column.

• These share a vital sanitation role with the arachnoid villi in

eliminating debris from subarachnoid space.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

 SIZE OF EPIDURAL SPACE
• In the anterior region it is almost nonexistent while it can be
measured in posterior region, the average values are;
1. Cervical: 1mm-1.5mm
2. Upper thoracic: 2.5mm-3mm
3. Lower thoracic: 4mm-5mm
4. Lumbar: 5mm-6mm

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Epidural pressure:

There is a negative pressure in the epidural space.

•The communication between the epidural and paravertebral spaces
explains this phenomenon.
• The paravertebral spaces in the thoracic region are only separated
from the pleural cavities by the parietal pleura; pressure changes
within the pleural cavity are thus transmitted to the paravertebral
spaces in the thorax and thence to the epidural space.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Cont..
• Deep breathing increases the negative epidural pressure but coughing
will produce a positive pressure within this space.
•Pressure changes are most pronounced in the thoracic region but are
elsewhere progressively dissipated by the buffering of the epidural fat,
so that a negative pressure is no longer recorded within the cervical or
sacral limits of the space.
• However, it has been argued that the negative pressure in the epidural
space is produced, at least in part, by the tenting of the dura produced
when a blunt epidural needle presses against the dura during insertion.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

 How to reach?

• To reach epidural space in midline these structures have to be

penetrated:

1. Skin and subcutaneous tissues

2. Supraspinous ligaments

3. Interspinous ligaments

4. Ligamentum flavum

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Dr.M. Suguna, Dept. of Anesthesia, GTMC
IDENTIFICATION OF EPIDURAL SPACE

•The epidural space can be identified with either

the hanging drop or loss of resistance technique.
• With the hanging drop technique, place a drop
of saline at the hub of the epidural needle.
•As the needle enters the epidural space, the drop
of liquid will be pulled into the needle.
•This technique relies on negative pressure
within the epidural space.
• It is more reliable for thoracic than lumbar
needle insertion

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Dr.M. Suguna, Dept. of Anesthesia, GTMC
Dr.M. Suguna, Dept. of Anesthesia, GTMC
• A loss of resistance technique to identify the epidural space.
•When the tip of the epidural needle lies within the
ligamentum flavum, there is resistance to injection.
•As the tip of the needle enters the epidural space, this
resistance disappears.
• the loss of resistance technique use air or saline in the loss of
resistance syringe.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

MCINTOSH BALLOON TECHNIQUE
 a small air filled balloon is mounted on a adaptor.
 The needle placed in the spinal ligaments and the balloon
attached and infleted by injecting 2ml of air.
 On entering the epidural space the balloon deflates.

Dr.M. Suguna, Dept. of Anesthesia, GTMC

SONOGRAPHIC IMAGE

Dr.M. Suguna, Dept. of Anesthesia, GTMC

REFERRENCES

1,Anatomy for anesthetists- Harold Ellis, 9th edition

2, Miller’s basics of Anesthesia, 7th edition
3, Morgan & Mikhail’s clinical Anesthesia, 5th edition
4, Epidural Analgesia- Philip R Bromage
5,Clinical Anesthesia- Barash, cullen, stoelting, 8th edition

Dr.M. Suguna, Dept. of Anesthesia, GTMC

Dr.M. Suguna, Dept. of Anesthesia, GTMC