Epidural..Revisited ..Part 1..Median approach VS Paramedian

There have been few studies comparing the midline and paramedian approach on block success.

 In cadavers, using epiduroscopy, paramedian catheters were observed to cause less epidural tenting, and pass cephalad more reliably than midline catheters.

In patients, faster catheter insertion times were reported in the paramedian, and higher incidence of paraesthesia in the midline group.

Adequate local infiltration is a prerequisite for patient comfort during paramedian puncture.

The paramedian approach may be less dependent upon spine flexion.

The risk of vascular puncture during epidural catheter placement was not associated with lumbar midline or paramedian technique in parturients, while another study suggested more paraesthesia and bloody puncture in non-pregnant adults when the midline approach was used.



1-Blomberg RG. Technical advantages of the paramedian approach for lumbar epidural puncture and catheter introduction. A study using epiduroscopy in autopsy subjects. 
Anaesthesia 1988; 43: 837–43
2- Leeda M, Stienstra R, Arbous MS, et al. Lumbar epidural catheter insertion: the midline vs. the paramedian approach. Eur J Anaesthesiol 2005; 22: 839–42
3-Griffin RM, Scott RP. Forum. A comparison between the midline and paramedian approaches to the extradural space. Anaesthesia 1984; 39: 584–6
4- Podder S, Kumar N, Yaddanapudi LN, Chari P. Paramedian lumbar epidural catheter insertion with patients in the sittingposition is equally successful in the flexed and unflexed spine.
Anesth Analg 2004; 99: 1829–32
22 Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82