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Epidurals for surgery and pain relief

An epidural is the injection of local anaesthetic or other pain-relieving medicines into a space that surrounds your spinal cord. It temporarily numbs your nerves.

Your anaesthetist will discuss your care with you before your procedure, including what the epidural involves. There may be some differences from what we’ve described here depending on your individual needs and particular operation.

This page covers epidural injections during surgery. We have a separate page about epidural injections for lower back and leg pain.

Epidural anaesthesia (also called regional anaesthesia) stops you feeling pain without putting you to sleep.

Epidural anaesthesia can be used alone as an alternative to general anaesthesia for some types of surgery, usually in your pelvic area or legs. This means you won’t have the risks and side-effects of general anaesthesia, such as feeling sick and vomiting, or dental damage. Also, you will be able to stay awake during the operation and are more likely to recover faster.

Alternatively, an epidural may be combined with general anaesthesia for major upper abdominal surgery. It can be left in for a few days after the operation to provide you with continuing pain relief.

An epidural may not be suitable for you if you’ve had previous back surgery or have a blood-clotting problem. You must tell your anaesthetist if you're taking blood-thinning medicines, such as aspirin, warfarin or clopidogrel.

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Details

  • How does an epidural work? How does an epidural work?

    Your spinal cord is the main nerve pathway of your body and runs through a protective channel within your vertebrae (the bones in your spine). It’s surrounded by three layers of tissue called the meninges. The cerebrospinal fluid lies between the inner two of these tissue layers, cushioning your spinal cord. Just outside the third tissue layer (or dura) is the epidural space, which is very close to the nerves.

    Your spinal cord carries signals, in the form of electrical messages, between your brain and your body. At each level of your spine, nerves leave your spinal cord to go to specific parts of your body. For example, nerves from the lower part of your body join your spinal cord in your lower back.

    Injecting anaesthetic through a small plastic catheter into the epidural space in your lower back temporarily blocks the feelings in your pelvic area and legs. Your anaesthetist can control how much feeling is lost, depending on the amount, strength and type of medicines used.

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  • Injections and infusions Injections and infusions

    A single injection of local anaesthetic into your epidural space can be used for short-term pain relief. The effect wears off within a few hours and feeling in the affected area returns.

    More often, a continuous flow of pain-relief medicine is given through a catheter placed into the epidural space and attached to a pump. This is known as an epidural infusion and is useful for longer operations, and for providing pain relief over several days.

    After some operations, you may be given control of the infusion by pressing a button on an epidural pump. This is called patient-controlled epidural analgesia or PCEA.

  • Alternatives What are the alternatives to having an epidural?

    Alternatives to epidural anaesthesia that are used for surgery include spinal anaesthesia and general anaesthesia. Spinal anaesthesia is related to epidural anaesthesia. It involves your anaesthetist injecting local anaesthetic directly into the cerebrospinal fluid that surrounds the spinal nerves in your lower back. General anaesthesia means you're asleep during the operation. Sometimes the two are combined.

    Instead of having epidural pain relief, you can be given other painkilling medicines, such as morphine, immediately after surgery. You may be given morphine into a vein through an intravenous (IV) drip. This method can also be controlled by you. This is called patient controlled analgesia or PCA.

  • Preparation Preparing for an epidural

    Your anaesthetist will discuss with you what will happen before, during and after your procedure. Feel free to ask as many questions as you need to. This is your opportunity to understand what will happen and find out about the risks, benefits and any alternatives. You will need to give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

    If you’re having an epidural without general anaesthesia, you can stay awake during the procedure. However, you may be offered a sedative to help you relax.

  • The procedure What happens during an epidural?

    Your anaesthetist will ask you to lie on your side, with your knees drawn up to your abdomen and your chin tucked in. Alternatively you may be asked to sit up on the bed and lean forward. Both positions open up the space between your vertebrae making it easier and quicker for your anaesthetist to place the epidural.

    Your anaesthetist will carefully select a point to inject by feeling for specific bones in your spine and hips. Your anaesthetist will clean the skin on your back with a sterilising solution and give you an injection of local anaesthetic to numb the area. They will also cover your back in a sterile drape, with a square hole around the site of the epidural.

    When your skin is numb, your anaesthetist will pass a larger, hollow epidural needle into the epidural space. When the needle reaches the correct spot, they will insert a catheter tube through the needle. Your anaesthetist will then remove the needle and the catheter will be left in place. It will be held in place with adhesive tape.

    Image showing where the epidural is positioned

    Your anaesthetist uses the catheter to inject local anaesthetic and/or other pain-relieving medicines directly into the epidural space. Your anaesthetist may attach a pump to the catheter to give a continuous infusion of medicines.

    It's very important to stay still when the epidural needle is being inserted. You must say if it’s hurting you – especially if it hurts your legs. This helps your anaesthetist to carry out the procedure safely.

    When you no longer need epidural pain relief, the catheter will be carefully withdrawn and the area covered with a plaster. An epidural isn’t normally left in for longer than 72 hours.

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  • Aftercare What to expect afterwards

    After an epidural you will need to rest until the effects of the anaesthetic have passed. You may not be able to feel or move your legs properly for several hours afterwards. So don’t try to stand until your doctor or nurse says you can. However, you won't experience the drowsiness that usually follows general anaesthesia.

  • Risks What are the risks?

    Epidurals are commonly performed and generally safe. To make an informed decision you need to be aware of any possible side-effects and the risk of complications of the procedure.

    Side-effects

    These are unwanted, but mostly temporary effects of a successful procedure. Common side-effects are listed here.

    • Inability to pass urine because of the numbing of nerves to your bladder. You may have a temporary catheter inserted until the effects of the epidural wear off. This is a thin tube used to drain urine from your bladder into a bag outside your body.
    • Feeling sick and vomiting. However, this is less common than with general anaesthesia.
    • A drop in blood pressure. Your blood pressure will be checked regularly. If it drops, you may be given medicines to raise it up to normal.
    • Loss of strength or control of your muscles. You may not be able to move your legs or arms, depending on where you had the epidural. This wears off after your operation.
    • Pain. Sometimes the epidural doesn't relieve pain as expected. A top-up dose can often correct this. 
    • Itchy skin. This can be treated with medicines if you need them.
    • Redness or a bruise on your skin where the epidural needle was placed.

    Complications

    This is when problems occur during or after the procedure. Most people aren't affected. With any procedure involving anaesthesia, there’s a very small risk of an unexpected reaction to the anaesthetic. Complications specific to an epidural are uncommon, but can include the following.

    • Headache. The epidural injection may puncture the membrane covering your spinal cord and cerebrospinal fluid can leak out. This means there’s less fluid around your brain, causing headaches. You may have headaches for up to a week or sometimes longer, but they can be treated.
    • Infection. This is rare because your skin is cleaned before the sterile needle is inserted. If you develop an infection, you may need to have the infected area drained and you will also need to take antibiotics.
    • Bleeding. Very rarely, blood clots can form in the epidural space, which can cause permanent injury, if not detected. You will be monitored to reduce this risk to a minimum.
    • Nerve damage. Permanent nerve damage causing paralysis (loss of sensation and movement) or life-threatening problems is rare.

    As with every procedure, there are some risks associated with an epidural. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon or anaesthetist to explain how these risks apply to you.

  • FAQs FAQs

    Which types of painkillers are injected through an epidural?

    Answer

    As well as local anaesthetics that numb the nerves, medicines called opioids are usually given through an epidural. Opioids are commonly included in epidurals to relieve the pain of surgery.

    Explanation

    Pain-relief medicines, such as morphine, fentanyl and diamorphine, belong to the opioid group of medicines. For an epidural, they can be used alone or in combination with a low dose of local anaesthetic. An epidural allows medicines to be delivered directly into your spine. The medicines act on your spinal cord to block the way in which pain signals are sent from your body to your brain. Local anaesthetics and opioids work together so that lower doses of each can be used.

    The type of opioid medicine you have depends on how much pain you're feeling and on your medical condition.

    Does an epidural make you feel groggy?

    Answer

    This depends on the type of medicines you are given through the epidural. Sedatives that you have before your procedure and strong pain-relief medicines, such as morphine or diamorphine, can make you feel drowsy.

    Explanation

    An epidural allows medicines to be delivered directly around your spinal nerves. The types of medicines usually given through an epidural include:

    • local anaesthetic – this blocks pain in the affected areas
    • painkillers – these block the way in which pain signals are sent from your body to your brain

    If you have morphine or diamorphine (strong pain-relief medicines), you may feel drowsy. The medicines may also temporarily cause breathing problems and low blood pressure. However, these complications will be carefully and safely managed by the team caring for you. Speak to your anaesthetist if you have any concerns about the type of medicines you're given or their effects.

    Will I be able to see or hear what the surgeon is doing during an operation under epidural anaesthesia?

    Answer

    No, the area being operated on is shielded from you, so you won't be able to see what your surgeon is doing. You will be able to hear what’s going on. However, you may be able to listen to music distract yourself from any other sounds.

    Explanation

    If you have an operation under epidural anaesthesia you will remain awake. If you’re having or have had an operation on your legs, pelvis or lower abdomen the epidural will be placed in your lower back. You won't feel anything from your waist down, but you may get a sensation of pushing or pulling during the operation. Since you will be awake, you may be able to hear the sound of any instruments that are used during the operation. If you think it will help you during the operation, you may be able to listen to music using earphones.

    Your anaesthetist may offer you a sedative to take before the operation. This relieves anxiety, helps you to relax and can affect how much you remember about the operation.

    A surgical drape or shield is usually hung over your chest area to hide your lower body from your view. It also keeps the operation site sterile to reduce the risk of infection.

    For some procedures, you may be able to watch the operation on a video monitor if you want to.

    The raised sheet or shield is only removed after the operation is finished and the wound has been closed and covered with a dressing.

    Will an epidural give me backache in the long term?

    Answer

    No, there’s no evidence that epidurals lead to long-term backache.

    Explanation

    The effect of an epidural is short term and there’s no lasting injury to your back. So there’s no reason why you will have long-term backache. Studies of women during labour found no difference in the frequency of long-term backache between women who had an epidural and those who did not.

    Short-term backache after surgery is a common side-effect that happens to about one in 100 people. It may be caused by lying on a firm, flat operating table, but it isn’t caused by the type of anaesthesia you have.

    You may have some slight bruising or soreness where the needle was inserted. This usually settles without treatment, but your epidural catheter tube may need to be removed and re-inserted to make it more comfortable for you.

    If you have backache after your operation that gets worse, you need to contact your surgeon or the hospital where you had the operation. It’s very rare, but you may have an infection (this happens to less than one in 100,000 people). You would need to have the area drained and be treated with antibiotics.

    Before you have an epidural, you will have an opportunity to meet your anaesthetist and surgeon. They will explain how any risks and complications of your procedure relate to you.

  • Pros and cons Pros and cons

    Pros

    • Having epidural anaesthesia alone avoids the common side-effects of general anaesthesia. These include nausea, sore throat, damage to teeth and changes to your mental functioning.
    • Epidural anaesthesia seems to reduce blood loss during surgery compared to general anaesthesia.
    • You will stay awake during the operation.
    • There may be a lower risk of deep vein thrombosis (DVT) compared to general anaesthesia. 
    • It can give you better pain control which can begin immediately after your operation.

    Cons

    • There’s a risk of a headache.
    • There’s a risk of serious nerve damage, infection or bleeding in your spine, which can be life-threatening or cause permanent damage. However, these complications are rare.
    • You may prefer to be asleep for your operation.
    • There is a risk that an epidural may not block pain as well as expected. Around one in four people still have pain.
  • Resources Resources

    Further information

    Sources

    • Epidural nerve block. Medscape. www.emedicine.medscape.com, published 6 May 2013
    • Practical local anaesthesia. PatientPlus. www.patient.co.uk/patientplus.asp, published 19 October 2011
    • General anaesthesia. Medscape. www.emedicine.medscape.com, published 10 September 2013
    • Hole JW and Koos KA. Human Anatomy. 2nd ed. US: C Brown Publishing. 1994: 280
    • Local and regional anesthesia. Medscape. www.emedicine.medscape.com, published June 3 2013
    • Pain and pain relief. PatientPlus. www.patient.co.uk/patientplus.asp, published 18 February 2011
    • Regional Anesthesia for Postoperative Pain Control. Medscape. www.emedicine.medscape.coml, published 16 July 2013
    • Important complications of anaesthesia. PatientPlus. www.patient.co.uk/patientplus.asp, published 25 June 2014
    • Pain and its control. MaQuay, H. Bandolier. www.medicine.ox.ac.uk, accessed 1 September 2014
    • Anim-Somuah M, Smyth RMD, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD000331. DOI: 10.1002/14651858.CD000331.pub3
    • Cook TM, Counsell D, Wildsmith JAW on behalf of The Royal College of Anaesthetists Third National Audit Project. British Journal of Anaesthesia 102 (2): 179–90 (2009). doi:10.1093/bja/aen360.
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