History of Neuraxial Anaesthesia

Neuraxial anaesthesia (neuraxial blockade) refers to local anaesthetic techniques delivered around the spinal cord and nerve roots, principally spinal anaesthesia (intrathecal/subarachnoid) and epidural anaesthesia (extradural/peridural, including caudal). Modern practice relies on distinct confirmation endpoints: intrathecal placement is confirmed by free cerebrospinal fluid (CSF) flow, whereas epidural placement is inferred from loss-of-resistance and related indirect signs (including hanging-drop and pressure-based methods).

Historically, neuraxial techniques advanced alongside innovations in needle design, catheter placement, and reproducible methods for identifying anatomical planes. The eponym landscape reflects this. Some terms remain precise (e.g. Quincke and lumbar puncture), while others have drifted into generic usage (e.g. “Tuohy” often used as shorthand for many epidural needle designs despite later modification and variation).

Clinically, neuraxial blockade remains central to obstetrics, perioperative analgesia, and pain medicine. Its evolution is a recurring story of practical problems such as block reliability, post-dural puncture headache (PDPH), catheter direction and dosing control. These drive successive solutions from early caudal injections to continuous catheter epidurals and directional needle tips designed to guide catheters.

1844 – Francis Rynd introduces hypodermic (subcutaneous) perineural morphine instillation for neuralgia at the Meath Hospital in May 1844. A practical precursor to regional injection-based analgesia. He later provided a formal description of his instrument in ( 1861 ).

On the 13th of November [1844] the fluid was introduced, ten grains acetate morphia to the drachm of creo­sote, one punture behind the trochanter, and one half-way down the thigh. He was instantly relieved from pain, and walked steadily through the ward without any pain or difficulty

1853 – Development of syringe and hollow needle technology. Charles Gabriel Pravaz (1791–1853) described a screw-driven syringe with a fine trocar for intravascular injection of ferric chloride into naevi (published in 1853 ). Alexander Wood performed therapeutic injections and published ( 1855 ) the first widely reproducible clinical account of hypodermic morphine for neuralgia.

On November 28th [1853] I attended an old lady, who had suffered severely for four days from cervico-brachial neuralgia…I inserted the syringe within the angle formed by the clavicle and acromion, and injected twenty drops of a solution of muriate of morphia…in half an hour the pain had subsided, and I left her in the anticipation of a refreshing sleep.

1884 – Cocaine becomes the first practical local anaesthetic in clinical use. Ophthalmologist Carl Koller (1857–1944) introduces cocaine as the first practical local anaesthetic for clinical use. Koller’s clinical demonstration of topical cocaine in ophthalmology triggered rapid uptake of injection-based regional techniques, underpinning subsequent experiments in nerve block and early neuraxial cocaine injection work.

1885 – James Leonard Corning (1855–1923) conducted a series of experiments injecting hydrochlorate of cocaine between the lumbar spinous processes in dogs and later in a human subject. He observed segmental sensory changes and motor effects in the lower limbs, publishing his findings in Spinal anaesthesia and local medication of the cord . These experiments constitute the first published description of the principle of neuraxial blockade. Long regarded as “first spinal blockade”, but later reviews consider the injection intrathecal and likely extradural.

1891 – Heinrich Irenäus Quincke (1842–1922) is credited with the development and standardisation of lumbar puncture as a repeatable, minimally invasive method for CSF pressure relief and fluid sampling. Diagnostic lumbar puncture becomes the technical gateway for intrathecal anaesthesia. The “Quincke needle” becomes archetypal cutting bevel needle for neuraxial access.

The fluid was withdrawn via a fine needle between the third and fourth lumbar vertebrae. Pressure readings were taken before and after drainage… and samples analysed for protein, sugar, cells, and bacteria.

1891 – In parallel, Walter Essex Wynter (1860-1945) attempts therapeutic CSF pressure relief in paediatric meningitis via incision-based thecal puncture and drainage tubing, a more surgical decompression approach than Quincke’s needle puncture.

1898 – On August 16, August Bier performed the first spinal anaesthetic using cocaine on a 34 year old man undergoing a partial amputation of the leg. His vivid description of post-dural puncture headache (PDPH) becomes a key driver for later needle refinement.

1900 – Oskar Kreis (1872-1958) applies spinal anaesthesia to obstetrics (labour and operative delivery). In Über Medullarnarkose bei Gebärenden Kreis demonstrates the feasibility of spinal (subarachnoid) cocaine analgesia feasibility and highlights the burden of side effects in early intrathecal practice.

1901 – Jean-Athanase Sicard and Fernand Cathelin independently describe caudal epidural injection via the sacral hiatus “ dans le canal sacré, en dehors des méninge s”. Initially used for minor durgical and urological operations.

1909 – Walter Stoekel introduces caudal epidural for labour pain relief. He publishes Über sakrale Anästhesie detailing 141 cases of obstetric epidural analgesia via the caudal route, the first large obstetric series of caudal (sacral) epidural analgesia.

1921 – Fidel Pagés publishes Anestesia Metamérica , the first clear clinical description of thoracolumbar epidural (“metameric”) anaesthesia with segmental blockade in humans. One of the earliest clear presentations of epidural anaesthesia as a surgical technique distinct from spinal anaesthesia

1922 – Sicard and Jacques Forestier introduce intrathecal lipiodol myelography, demonstrating contrast mapping of the subarachnoid space for neuraxial diagnosis rather than analgesia.