When Did Epidurals Start? A History of the Technique

The epidural as we know it traces back to 1921, when a Spanish military surgeon named Fidel Pagés published the first description of injecting anesthetic into the lumbar epidural space. But the roots of the technique stretch further, to crude experiments in the 1880s and a caudal approach developed in 1901. The century-long journey from those early injections to today’s computerized pumps and ultrasound-guided needles is a surprisingly tangled story of independent discoveries, lost credit, and innovations born on battlefields and in maternity wards alike.

The First Injections Near the Spine

The story begins in 1885, just one year after cocaine’s anesthetic properties were recognized. An American neurologist named J. Leonard Corning injected cocaine between the spinous processes of the lower spine, first in a dog and then in a human volunteer.¹ Corning’s goal was to block nerve transmission in the spinal cord. Whether he actually reached the epidural space or the subarachnoid space (or neither consistently) has been debated ever since. His technique was imprecise, and he had no way to confirm where the drug ended up. Still, the experiment proved that injecting an anesthetic near the spinal cord could numb large regions of the body, and it planted the seed for everything that followed.

For the next fifteen years, researchers across Europe experimented with spinal injections, but the approach we now call “epidural” did not take distinct shape until 1901. That year, two French physicians, Jean-Anthanase Sicard and Fernand Cathelin, independently described injecting anesthetic through the sacral hiatus at the base of the spine, a route now called the caudal approach.² This was a genuine epidural injection: the drug stayed outside the membrane surrounding the spinal cord (the dura) and spread through the fatty tissue of the epidural space. It was safer than puncturing the dura, and it worked. Caudal epidurals remained the standard approach for the next two decades.

Fidel Pagés and the Lumbar Epidural

The real turning point came in 1921, when Fidel Pagés Miravé, a 35-year-old Spanish military surgeon, published a paper titled “Anestesia Metamérica” in a Spanish surgical journal. Pagés described inserting a needle into the lumbar spine and depositing anesthetic in the epidural space, the first account of human thoracolumbar epidural anesthesia.³ This was a leap beyond the caudal technique because it allowed the anesthetic to be placed closer to the nerves serving the trunk and lower body, making it useful for abdominal and thoracic surgery, not just procedures below the waist.

Pagés developed his technique out of necessity. His experiences treating wounded soldiers in forward military hospitals during conflicts in North Africa and Austria drove him to seek better pain control for battlefield surgery.⁴ His paper was remarkably detailed, covering different needle approaches, various anesthetic solutions, instrumentation, and a frank discussion of complications.⁵ For a first description, it was unusually complete, reflecting someone who had clearly performed the procedure many times and thought hard about what could go wrong.

Pagés died in a car accident in 1923, at just 37 years old, only two years after his landmark publication.³ His paper, written in Spanish in a journal that was not widely read internationally, languished in obscurity. Other physicians later independently developed similar techniques without knowing about his work, and for decades Pagés received little credit. It took years of historical detective work for the anesthesia community to recognize him as the originator.

From a Single Injection to a Continuous Catheter

Pagés’s original technique was a single-shot injection. You put the needle in, deposited the drug, pulled the needle out, and hoped the anesthesia lasted long enough to finish the surgery. For longer operations or for labor, which can last many hours, this was a serious limitation. The solution was to leave a thin tube in the epidural space so more drug could be delivered over time.

The first person to try this may have been Eugen Aburel, a Romanian obstetrician who in 1931 threaded a silk catheter into the lumbar epidural space to provide pain relief during childbirth.² Aburel’s work was ahead of its time, but the materials available to him were crude. Silk catheters were stiff, prone to kinking, and not ideal for staying safely inside the body.

The technique did not become truly practical until the late 1940s, when better equipment arrived. The Tuohy needle, designed by Ralph Huber and refined by Edward Tuohy at the Mayo Clinic, had a curved tip that let a catheter be threaded through it and directed into the epidural space. This needle made continuous epidural anesthesia a realistic option.⁶ In 1949, Manuel Martinez Curbelo, a Cuban anesthesiologist, reported the first fully successful continuous lumbar epidural anesthesia using this approach.² With a catheter in place, anesthesiologists could top up the drug as needed, keeping a patient comfortable for hours without repeated needle insertions. The Tuohy needle, with minor modifications, is still the standard instrument used for epidurals today.

How Clinicians Know They Are in the Right Spot

One of the trickiest parts of placing an epidural has always been confirming that the needle tip is actually in the epidural space and not somewhere it should not be, like inside the dura or between the spinal ligaments. Since you cannot see the space from outside the body (at least not until ultrasound came along), clinicians developed several indirect methods.

The most widely used is the “loss of resistance” technique. As the needle advances through the tough ligaments of the spine, the clinician applies gentle pressure on a syringe filled with saline or air. The ligaments resist the pressure, but the moment the needle tip pops into the epidural space, resistance vanishes and the fluid or air flows freely. Other methods include detecting a slight negative pressure inside the epidural space or listening for a change in acoustic pitch as the needle enters the space.⁷ Loss of resistance remains the gold standard, a technique that is fundamentally the same as it was decades ago, relying on the clinician’s tactile skill.

The Drugs Changed Everything

The evolution of epidurals is not just a story about needles and catheters. It is equally a story about the drugs injected through them. The earliest epidurals used cocaine, the only local anesthetic available in the 1880s and 1890s. Cocaine worked, but it was toxic and addictive. The search for safer alternatives produced a long line of synthetic local anesthetics over the twentieth century, including procaine, lidocaine, mepivacaine, and eventually bupivacaine, which was synthesized in 1957 and introduced clinically in 1965.⁸

Bupivacaine became especially important for epidurals because it lasted a long time, making it well suited to labor and postoperative pain control. But reports of serious heart toxicity accumulated over the years, prompting restrictions on how it could be used. This safety concern pushed researchers to develop ropivacaine, a chemically related drug engineered to be less toxic to the heart and nervous system. Ropivacaine reached the market in 1996 and remains one of the most commonly used epidural drugs today.⁸

A separate breakthrough came in 1979, when two groups of researchers independently showed that opioids like morphine could be injected into the spinal space to treat pain. Behar and colleagues published the first report on epidural morphine, while Wang and colleagues described intrathecal morphine (injected inside the dura).⁹ The discovery that opioids worked directly on spinal cord receptors meant clinicians could now combine a local anesthetic with a small dose of opioid in the epidural, producing better pain relief at lower total drug doses. This combination approach is now standard practice in labor epidurals and postoperative pain management.

Epidurals in the Delivery Room

Although Aburel pioneered obstetric epidural analgesia in 1931, widespread use of epidurals for childbirth did not take off until the 1960s, once continuous catheter techniques and safer drugs made the procedure reliable enough for routine labor. From that point, uptake was rapid. The epidural became the most effective form of labor pain relief available, and in many hospitals it became the default option offered to laboring women.

The cultural response was not uniformly enthusiastic. The history of pain relief in childbirth has been shaped by waves of feminist thought that sometimes pulled in opposite directions. Early feminist activists in the first half of the twentieth century demanded access to pain relief as a woman’s right, championing methods like “twilight sleep” (a combination of morphine and scopolamine) before its dangerous side effects became clear. When epidurals grew popular in the 1960s and 1970s, a second wave of feminist critics pushed back, arguing that medicalized childbirth disempowered women and calling for a return to “natural” birth, sometimes framing the pain itself as an empowering experience. Then, from the 1990s onward, a third perspective emerged, reasserting that choosing a pain-free, technology-assisted birth is a legitimate feminist position.¹⁰ These debates are far from settled, and they explain much of the conflicting advice that expecting parents encounter today.

Meanwhile, the technique itself kept improving for obstetric use. Epidural anesthesia today faces modern pressures in the operating room around efficiency and a low tolerance for failure, and obstetric settings are no exception.³ Anesthesiologists have responded with technical refinements aimed at faster onset, more even pain relief, and fewer side effects.

Combined Spinal-Epidural and the Modern Toolkit

One major refinement is the combined spinal-epidural, or CSE, technique. Instead of choosing between a spinal injection (fast onset but single-shot) and an epidural (slower onset but continuous), the CSE delivers a small spinal dose for immediate relief and then threads an epidural catheter for ongoing top-ups. The technique gained widespread popularity for surgeries below the waist that need prolonged postoperative pain control, and it has become standard in many institutions for cesarean deliveries and major orthopedic procedures.¹¹

Drug delivery has also become smarter. Traditional epidural infusions ran at a constant rate, like a slow drip. Newer pump systems use programmed intermittent epidural boluses, delivering a set volume of drug at regular intervals rather than as a trickle. Compared to continuous infusion, this approach spreads the drug more evenly through the epidural space and tends to provide better pain relief with less total medication.¹² Some systems also give patients a button to self-administer extra doses within safe limits, combining programmed boluses with patient-controlled top-ups.¹³

Ultrasound is another recent addition. For most of the epidural’s history, clinicians relied entirely on surface landmarks and their sense of touch to guide needle placement. Starting around 2009, researchers demonstrated that real-time ultrasound could be used to visualize the epidural space and guide needle insertion in adults.¹⁴ Ultrasound is especially helpful in patients where landmarks are hard to feel, such as those with obesity or spinal deformities. It is not yet universal, but its use is growing steadily.¹⁵

What Can Go Wrong and How Safety Has Improved

Epidurals are generally safe, but they are not risk-free, and understanding the complications has been part of the technique’s evolution. One of the most common problems is accidental puncture of the dura, which can cause a post-dural-puncture headache. This headache can be severe, worsening dramatically when the patient sits up. The standard treatment, developed over the twentieth century, is the epidural blood patch: a small amount of the patient’s own blood is injected into the epidural space, where it clots and seals the puncture. An initial blood patch provides lasting relief in roughly two-thirds to three-quarters of cases.¹⁶

Infection is another concern, though thankfully rare. Epidural abscesses can form around catheters left in place, and preventing them requires strict sterile technique. Modern protocols include alcoholic skin preparation, gowning and gloving for the clinician, masks for all nearby staff, transparent semi-permeable dressings over the catheter site, and discouraging unnecessary manipulation of the catheter after insertion.¹⁷ These protocols represent decades of incremental learning from adverse events.

Epidurals Beyond Labor and Surgery

Although most people associate epidurals with childbirth, the technique’s reach extends well beyond the delivery room. Epidural steroid injections for low-back pain with radiating leg symptoms have been in widespread use for over fifty years.¹⁸ In this application, a corticosteroid rather than a local anesthetic is injected into the epidural space to reduce inflammation around compressed nerve roots. The procedure is done as an outpatient visit, usually guided by fluoroscopy or CT imaging, and represents one of the most common pain-management interventions in the world.

Pediatric anesthesia has its own epidural tradition. Caudal epidural anesthesia in children was first described in 1933, originally as an alternative to general anesthesia for urological procedures. It has since become one of the most popular regional blocks in pediatric surgery, valued for its simplicity, speed, and safety profile.¹⁹ In children, the sacral hiatus is easier to locate and the epidural space is more accessible, which makes the caudal route practical in ways it sometimes is not in adults.

Epidural catheters also play a role in managing pain after major chest and abdominal surgeries, in palliative care for cancer patients, and in some chronic pain conditions. Each of these applications descends from the same core technique that Pagés described a century ago, adapted with better drugs, better equipment, and a far deeper understanding of spinal anatomy and pharmacology than anyone had in 1921.

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Pediatric Anesthesia Procedures. Caudal Epidural Anesthesia