The Thoracic Epidural

For me, the thoracic epidural is one of the most challenging procedures. Although I feel quite proficient with lumbar epidurals in the low back used for labor, lower abdominal surgeries, and lower extremity procedures, the mid-back thoracic epidural is much more tricky. We use thoracic epidurals for surgeries involving the upper abdomen and chest. Although video-assisted thorascopic surgery is not too painful, open thoracotomies for large lung or mediastinal procedures have a tough post-operative course and the epidural helps a lot. Not only does an epidural reduce pain, allow patients to take deeper breaths, minimize IV opiates, and smooth the intraoperative anesthetic, but it also improves surgical outcomes for procedures like Ivor-Lewis esophagectomies. The problem is placing them. The spine anatomy at the thoracic level is more challenging than the spine at the lumbar level. The spaces to place the needle are smaller and the spinous processes are steeper so there is little room for error in the approach. Thus, there are several different techniques in entering the space which also makes it harder for residents to master. Out of all the routine procedures performed by an anesthesiologist, I find this the toughest.

Image is in the public domain, from Wikipedia.