What is the historical development of spinal and epidural anesthesia?

History of Spinal and Epidural Anaesthesia

Origins of Spinal Anaesthesia

The German surgeon August Bier deserves credit for introducing the first authentic spinal anesthesia in 1898, not the American neurologist Corning who performed what was likely an extradural injection in 1885. 1

• Corning injected cocaine between spinous processes in 1885 and published "Spinal Anaesthesia and Local Medication of the Cord," but his technique was extradural based on several key factors: he used eight times higher doses of cocaine than later spinal techniques, had slower onset of analgesia, achieved lower sensory levels, and never described cerebrospinal fluid 1
• Bier performed authentic spinal anesthesia in 1898, with two of his first six patients being children, marking the beginning of neuraxial anesthesia as we know it today 1, 2
• French surgeon Tuffier also described authentic spinal anesthesia techniques during the same period (1889-1900) 1, 3
• The discovery built upon cocaine's anesthetic properties, which were discovered in 1884, shortly after which nerve blocks were being attempted for surgical anesthesia 2

Development of Epidural Anaesthesia

Spanish military surgeon Fidel Pagés Miravé completed the first successful lumbar epidural approach in 1921, publishing his landmark article "Anestesia metamérica" which accurately described the technique that revolutionized regional anesthesia. 4, 3

Early Caudal Approaches

• In 1901, two Frenchmen—Jean-Anthanase Sicard and Fernand Cathelin—independently described the first epidural anesthesia via a caudal approach 4
• Spanish physician Gil Vernet developed sacral techniques between 1917-1918, which influenced Pagés' later work 3

Lumbar Epidural Development

• Pagés' extensive experience treating armed conflict casualties, combined with his proficiency in French and German and vast knowledge of anatomy, physiology, and pharmacology, enabled him to accurately describe different approaches, anesthetic solutions, instruments, and the indications, contraindications, and complications of epidural technique 3
• His work in 1921 marked the centenary milestone celebrated in 2021 for describing an anesthetic and analgesic technique that has improved countless patients' lives 3

Technical Refinements

Identification of the Epidural Space

Two fundamental techniques for identifying the epidural space—the "loss of resistance" and "hanging drop" methods—were developed simultaneously by Italian surgeon Achille Mario Dogliotti and Argentinean physician Alberto Gutierrez. 4

Catheter Techniques and Continuous Blocks

• Romanian obstetrician Eugene Aburel pioneered catheter-based epidural analgesia as early as 1931, injecting local anesthetics via a silk catheter to perform lumbar obstetric epidural analgesia 4
• Cuban physician Manuel Martinez Curbelo reported the first successful continuous lumbar epidural anaesthesia in 1949 4
• John J. Bonica published the paramedian approach to the epidural space in 1956, expanding technical options 4

Evolution of Local Anesthetics

The development of better local anesthetics drove the expansion of neuraxial techniques, with stovaine and procaine introduced in 1904-1905, lignocaine in 1943, and the longer-acting bupivacaine in 1963. 2

• These pharmacological advances, particularly bupivacaine, combined with increasing concern about postoperative analgesia in the 1970s-1980s, contributed significantly to increased use of regional blocks 2

Pediatric Applications

• Spinal anesthesia in children began with Bier's initial cases in 1898, though widespread pediatric use developed much later 2
• Caudals and epidurals came into use in children considerably later than in adults, with specific reports increasing as pediatric anesthesia developed as a subspecialty 2
• Initially performed by surgeons, these techniques were gradually taken over by anesthesiologists as the specialty evolved 2

Modern Era

Epidural anaesthesia evolved from an exclusively local anesthetic technique to a multimodal approach incorporating various drugs, combinations with general anaesthesia, and adaptation for pediatric patients, with continuous epidural analgesia becoming a cornerstone of postoperative pain management. 5

• The technique can be performed in sitting or lateral positions in all segments of the spinal column via median or paramedian approaches, though different off-axis angles pose challenges in learning 4
• Modern practice requires balancing individual risks and benefits, particularly in patients with comorbidities or those taking medications that modulate the clotting system 5