July 25, 2002

Pioneers in Epidural Needle Design

Frölich MA, Caton D. Anesth Analg 2001;93:215-20.

Commentary by Katherine McGoldrick

Although it is sad, I suppose it is not surprising that the study of medical history has vanished from most medical schools in the United States. The explosive and relentless growth of knowledge in such fields as molecular biology, biochemistry, and medical technology competes for precious time in the curriculum. Surely, however, there is a case to be made for including medical history in the self-education of students, residents, and attending physicians. Our professional heritage is both rich and fascinating, as this gem of a manuscript by Drs. Frölich and Caton reveals.

The intentional administration of epidural anesthesia began in 1901, when radiologist Jean-Anthanase Sicard [1] described injecting dilute solutions of cocaine through the sacral hiatus to treat patients suffering from intractable sciatic pain. Working independently, Fernand Cathelin [2] reported similar work 3 weeks later, recognizing additionally that sacral cocaine might also be used for surgery.

Twenty years after the papers by Sicard and Cathelin, a Spanish surgeon, Fidel Pagés [3], outlined a lumbar approach to epidural anesthesia. Unfortunately, Pagés died shortly after his manuscript was published, and his concept of lumbar epidural anesthesia lay dormant until an Italian surgeon, Archile Mario Dogliotti [4] resurrected and promulgated the idea in 1933.

In 1931, a Romanian obstetrician, Eugene Aburel [5], injected chinocaine through a silk ureteral catheter to block the lumboaortic plexus of laboring women. Hence, Aburel deserves recognition not only for using a lumbosacral approach, but also for suggesting a method for achieving a continuous epidural block. In the United States, Hingson and Edwards [6] demonstrated the potential of continuous epidural anesthesia, albeit via a caudal approach, in 1942. Two years later, Hingson, in collaboration with the surgeon James Southworth [7], described a lumbar approach for continuous epidural anesthesia. Perhaps owing to suboptimal needle design, their method did not reliably produce satisfactory lumbar epidural anesthesia. However, eventually the technical difficulties were resolved by a Cuban anesthesiologist, Manuel Martinez Curbelo, after he visited the Mayo Clinic and observed the prominent anesthesiologist Edward B. Tuohy administer continuous spinal anesthesia with a needle having a directional tip. Recognizing how the directional needle might facilitate the proper placement of epidural catheters, Curbelo [8] published a paper in 1949 documenting how he used a 16-gauge Tuohy needle with a 3.5F silk ureteral catheter for continuous segmental lumbar peridural anesthesia. Since then several other iterations of epidural needles have appeared, and ardent regional anesthesiologists have their own personal favorites.

No less significant than the improvements in needle design were the advances (pun intended) in catheters. Perhaps the most important single innovation was the replacement of cumbersome silk catheters with plastic; plastic catheters facilitated placement, were more reliable, and less costly. (Because lacquered silk catheters had to be boiled rather than autoclaved to avoid heat damage, sterilization was difficult and sepsis was not uncommon during their early usage). Flowers [9] first described the use of plastic catheters in 1949. The first polymer (plastic) was polyethylene but, owing to its propensity to swell and become deformed with sterilization, it was soon replaced by polyvinyl chloride. More recent polymers include nylon, Teflon, polyurethane, and silicone. By using these materials, manufacturers are able to produce a thin yet kink-resistant catheter with appropriate stiffness and impressive tensile strength.

What an interesting saga the story of continuous epidural anesthesia represents! It exemplifies the advantages that can accrue to patients when physicians from a wide range of specialties and nations collaborate, and then partner with industry to improve both the state of their art and their science.

References:

1. Sicard A. Les injections medicamenteuses extra-durales par voie sacrococcygienne. Compt Rend Soc De Biol 1901;53:396-8.
2. Cathelin F. Une nouvelle voie d'injection rachidienne: methode des injections epidurales par le procede du canal sacre-applications a l'homme. Compt Rend Soc De Biol 1901;53:452-3.
3. Pagés F. Anesthesia metamerica. Rev Esp Chir 1921;3:3-30.
4. Dogliotti AM. A new method of block: segmental peridural spinal anesthesia. Am J Surg 1933;20:107-18.
5. Aburel E. L'anesthésie locale continue (prolongée) en obstétrique. Bull Soc Obstet Gynecol Paris 1931;20:35-9.
6. Hingson RA, Edwards WB. Continuous caudal anesthesia during labor and delivery. Curr Res Anesth Analg 1942;21:301-11.
7. Hingson RA, Southworth JL. Continuous peridural anesthesia. Curr Res Anesth Analg 1944;23:215-7.
8. Curbelo MM. Continuous peridural segmental anesthesia by means of a ureteral catheter. Curr Res Anesth Analg 1949;28:12-23.
9. Flowers CE. Continuous peridural anesthesia and analgesia for labor, delivery, and cesarean section. Curr Res Anesth Analg 1949;28:181-9.