Teaching Practices of Thoracic Epidural Anesthesia in the United States: Should Lumbar Epidurals Be Taught Before Thoracic Epidurals?

Objective: The purpose of this study was to determine the current teaching practice of thoracic epidural procedures in the United States and to determine the effect of the teaching sequence of thoracic and lumbar epidurals on technical difficulties and complications. Design and setting: The first part was a survey, which was distributed to all American Board of Anesthesiology-accredited programs. The second part was a noninterventional retrospective review of 2,007 epidural procedures in a university teaching program. Interventions: The survey questions were designed to determine the number of epidural procedures performed monthly on various services, teaching sequence, insertion technique, indications, and service provider. Results:The survey received 81 responses (60%) from 134 programs; 34% of the programs placed more thoracic than lumbar epidurals, 92% of the programs placed epidurals mainly for postoperative pain control, and 88% of programs mainly teach lumbar before thoracic epidurals, whereas only 10 programs (12%) mainly teach residents thoracic before lumbar epidurals. The authors' residents were divided into 2 groups: group 1 (42 residents, 70%) who learned thoracic before lumbar epidurals and group 2 (18 residents, 30%) who learned lumbar before thoracic epidurals during their earlier obstetric anesthesia training. There were no significant differences between the 2 groups in the degree of technical difficulties or the incidence of procedure-related complications. Conclusions: Thoracic epidurals are widely taught in the United States. Most programs teach lumbar before thoracic epidurals. Thoracic epidurals are safe to teach without prior experience with lumbar epidurals.