Spinal Anaesthesia

Dr Anita Lega
Senior Resident
Dept of Anaesthesiology
MMIMSR
 History

• CSF Discovered – Domenico Catugno 1764

• CSF Circulation – F Magendie 1825
• First spinal analgesia - J Leonard Corning
1885
• First planned spinal analgesia – August Bier (16th
August 1898)
August Bier 1885
 Indications
Surgeries of lower limbs, perineum,
pelvis, abdomen
It is ideal in
• Renal failure – onset is rapid, spread is
greater by two or three segments,
duration is shorter
• Cardiac disease
• Liver disease
• Obstetric anaesthesia
 Indications
• Immunosuppressed patients – does not
impair cell mediated immunity
• Elderly patients
• Diabetes mellitus
 Contra-indications
Absolute
• Patient refusal
• Infection at the site of injection
• Increased intracranial pressure
• Hypovolemia
• Shock – haemorrhagic, septic
• Septicemia
• Severe aortic and mitral stenosis
• Coagulopathies
 Contra-indications
Relative
• Spinal cord and peripheral nerve diseases-
poliomyelitis, multiple sclerosis,
demyelinating diseases
• Brain tumors, CNS syphilis, meningitis
• Severe anemia
• Uncontrolled hypertension
• Valvular heart diseases
• Anticoagulant therapy
 Contraindications
Relative
• Spinal congenital anomalies
• Acquired spinal anomalies
• Post-traumatic vertebral injuries
• Prior back surgery at the site of injection
• Metastatic lesions in the vertebral column
• Intestinal obstruction
• Obstructed hernia
• Mentally disturbed patients
• Uncooperative and apprehensive patients
Anatomy
Anatomy
 Anatomy
Skin.
Subcutaneous fat
Supraspinous ligament.
Interspinous ligament.
Ligamentum flavum.
Epidural space.
Dura.
Subarachnoid
space.
Anatomy

The spinal cord usually ends at the level of L1

in adults and L3 in children.
Dural puncture above these levels is
associated with a slight risk of damaging the
spinal cord and is best avoided.
An important landmark to remember is that a
line joining the top of the iliac crests is at
L4 to L4/5
Where Spinal Cord Ends
Cauda
Equina
 Surface anatomy
• Spinous processes
are palpable over the
spine and help
define the midline
• In cervical area
First palpable
spinous
process is C2
Most prominent
spinous process is C7
 Surface anatomy
• Spinous process of
T7 – inferior angle of
scapula

• Tuffier’s line –
body of
L4 or
L4-L5
inters
pace
 Dermatomal levels
• T10 – umbilicus
• T6 – xiphoid
• T4 – nipples
• T12, L1 – inguinal
ligament , crest
of ileum
• S2-S4 –
perineum
 Procedure
• Preparation of the patient
• Pre-medication
Sedatives – benzodiazepines , opioids
To decrease acid secretions – H2
blockers, proton pump inhibitors
• Monitors
• Intravenous line – preloading with fluids
 Positions
• Lateral flexed position
-most commonly used
-back parallel to edge
of table
-hips and knees
flexed, neck and
shoulder flexed
towards knees
-nose to knees
 Positions
• Sitting position
-for saddle block
anaesthesia
-obese patients,
pregnant patients,
patients with
abnormal spinal
curvatures
 Positions
• Sitting position
-patient should sit on
the table with knees
resting on the edge,
legs hanging over the
side and feet
supported by a stool
below
 Positions
• Prone position
- suitable for
hypobaric techniques
-patient should be in
prone position with
OT table flexed under
his flanks, just above
the iliac crests
 Technique
• Hands and lower forearms scrubbed for at
least 3 minutes
• Sterile gloves should be applied
• A large area of L-S spine from lower
border of scapula to iliac crests should be
painted using antiseptic solution
• Excess antiseptics removed after waiting
for sufficient time for the antiseptic to act
 Technique
• Area is draped – view of T12 to S1 and
laterally of quadratus lumboram muscles
• Selection of space – tuffier’s line
• Raise a skin wheal with 2ml of 2%
lignocaine solution after negative
aspiration for blood
 Technique
• Insert an introducer in the
midline
Uses -prevents deflection of
spinal needle
-fine gauge needles can
be used
-decreases incidence of
postpuncture headache
-decreases infections
-avoids skin fragments
from entering
 Technique
• Spinal needle is inserted with the stylet
through the introducer
• Needle should be inserted in the midline
and directed cranially at an angle of less
than 50 degrees to the longitudinal axis of
the vertebral column
Bevel of the spinal needle should be kept
parallel to the longitudinal axis of the spine
Loss of resistances can be felt after
puncturing ligamentum flavum and the
duramater
 Layers traversed by the
spinal needle (posterior to
•Skinanterior)
• Subcutaneous tissue
• Supraspinous
ligament
• Interspinous
ligament
• Ligamentum
flavum
• Duramater
• Sub dural
space
 Technique
• Remove stylet to observe free flow of CSF
• Attach 5 ml Luer Lok syringe containing
anaesthetic mixture to the spinal
needle
• Stabilize the spinal needle and attach the
syringe by grasping the hub of spinal
needle with thumb and index finger while
propping the remaining fingers against the
patient’s back to provide support
(bromage grip)
 Technique
• Inject at the rate of 0.2ml/sec
• Aspirate small amount of spinal fluid to
determine if the needle is still placed
properly
• Remove spinal needle and introducer
quickly and simultaneously
 Technique
Paramedian approach
• 1.5 cm lateral to
midline
• Spinal needle is
inserted at an angle
of 25 degrees with the
midline and without
deviation cephalad or
caudad
 Technique
Paramedian approach
• Needle lies lateral to supraspinous and
interspinous ligaments and penetrates
ligamentum flavum and duramater in the
midline
• Useful in arthritis , deformed spine
Taylor technique
• A 12 cm spinal needle
is inserted 1 cm
medially and 1 cm
above the lowest
prominence of
posterior superior iliac
spine
• Needle is directed
upwards medially and
forwards at an angle of
50 degrees
 Technique
Taylor technique
Uses :
• Spinal fusion
• Arthritic spine
• Opisthotonus
• Skin infection
in lumbar
region
 Spinal needles
Three parts
– Hub
– Canula
– Stylet
• Point of the canula is beveled and has a
sharp edge
• Lumenal sizes : 18 gauge to 30 gauge
• Length : 3.5 to 4 inches
 Spinal needles
• Quincke Babcock needle
 Spinal needles
• Whitacre needle
 Spinal needles
• Touhy needle
 Drugs used in
spinal
Lidocaine anaesthesia
• Rapid onset of action , intermediate
duration and low toxicity
• Disadvantages – Transient neurological
symptoms
 Drugs used in
spinal
Bupivacaine anaesthesia
• Amide local anaesthetic
• Exhibits sensory/motor split
• Dose of 7.5mg –
• ambulatory surgery
Low concentrations(0.1-0.125%) –
postoperative analgesia
 Drugs used in
spinal
Ropivacaine anaesthesia
Compared to bupivacaine
• Longer onset of block to T10 (5 min vs 2
min)
• Lower median maximal block height ( T7 vs
T5)
• Shorter regression of sensory block to T10
(55 min vs 110 min)
• Quicker mobilization (253 min vs 331 min )
• Less CNS and cardiac toxicity
 Drugs used in
spinal
anaesthesia
Levobupivacaine
• Isolated (S) entantiomer of bupivacaine
• Similar to bupivacaine
 Spinal anaesthetic agents
Drug preparation Perineum, Lower Upper Duration
lower limbs abdomen abdomen (min)
(mg) dose (mg)dos (mg)dos
e e
procaine 10% solution 75 125 200 45
tetracaine 1% solution 4-8 10-12 10-16 90-120
in 10%
glucose
lidocaine 5% in 7.5% 25-50 50-75 75-100 60-75
glucose
bupivacaine 0.75% in 4-10 12-14 12-18 90-120
8.25%
dextrose
0.5% in 8% 7.5 to 12.5 12.5-17.5 17.5-25 90-120
dextrose
ropivacaine 0.2-1% 8-12 12-16 16-18 90-120
solution
 Mechanism of action
• Local anaesthetic solution injected into the
subarachnoid space blocks conduction of impulses
along all nerves with which it comes in contact,
although some nerves are more easily blocked than
others.
• There are three classes of nerve: motor, sensory and
autonomic.
• Stimulation of the motor nerves causes muscles to
contract and when they are blocked, muscle paralysis
results.
 Mechanism of action
• Sensory nerves transmit sensations such
as touch and pain to the spinal cord and
from there to the brain, whilst autonomic
nerves control the calibre of blood vessels,
heart rate, gut contraction.
• Generally, autonomic and sensory fibres
are blocked before motor fibres. This has
several important consequences.
 Mechanism of action
• For example, vasodilation and a drop in blood
pressure may occur when the autonomic fibres
are blocked.
• Practical implications of physiological
changes. The patient should be well hydrated
before the local anaesthetic is injected and
should have an intravenous infusion in place so
that further fluids or vasoconstrictors can be
given if hypotension occurs.
 Mechanism of action of local
anaesthetics on nerve conduction
• Interacts with the receptor situated within
the voltage sensitive sodium channel and
raises the threshold of channel opening

• Decreases the entry of sodium ions during

upstroke of action potential
Mechanism ……..

• Local depolarization fails to reach the

threshold potential and conduction
block ensues

• Onset time of blockade is related to the

pKa of the LA
• Lower pKa – fast acting
 Adjuvants used
Opioids
• Addition of opioids improves analgesic
quality, prolongs sensory block, reduces
local anaesthetic requirements, reduces
duration of motor blockade and improves
haemodynamic stability
• Fentanyl – 12.5 mcg
• Sufentanyl – 2.5 – 5 mcg
• Diamorphine – 0.3 mg
• Morphine – 0.1 – 0.2 mg
 Adjuvants used
Epinephrine
• Dose - 0.2 mg
•Decreases blood flow
Clonidine
• Dose – 15 – 45 mcg
•Prolongs duration of sensory analgesia
Neostigmine
• Dose – 5-100 mcg
• Inhibits breakdown of acetylcholine
 Baricity
Density of a solution in relation to density
of CSF
• Hypobaric solutions : raise against
gravity
• Isobaric solutions : tend to remain in the
same sight where they are injected
• Hyperbaric solutions : tend to follow
gravity
 Factors affecting block height
(postulated)
• Patient characteristics
– Age
– Height
– Weight
– Gender
– Intra abdominal pressure
– Anatomic configuration of spinal column
– Position
 Factors affecting block height
(postulated)
• Technique of injection
– Site of injection
– Direction of injection
– Direction of the bevel
– Use of barbotage
– Rate of injection
 Factors affecting block height
(postulated)
• Characteristics of anaesthetic solution
– Density
– Amount
– Concentration
– Temperature
– Volume
– Vasoconstrictors
 Factors affecting block height
(postulated)
• Characteristics of spinal fluid
– Volume
– Pressure
– Density
Factors influencing block height
Controllable factors
• Dose ( volume x concentration)
• Site of injection
• Baricity of local anaesthetic solution
• Posture of patient
Factors influencing block height
Factors not controllable
• Volume of CSF
• Density of CSF
Levels of block
Sympathetic paralysis

Sensory block

Motor nerve blockade

 Sequence of nerve modality block
1. Vasomotor block – dilatation of
cutaneous vessels and increased
cutaneous blood flow
2. Block of cold temperature fibres
3. Sensation of warmth felt by the
patient
4. Temperature discrimination is lost
5. Los of slow pain
6. Loss of fast pain
 Sequence of nerve modality block
7. Tactile sensation is lost
8. Motor paralysis
9. Pressure sense abolished
10. Proprioception and joint sense is lost
 Testing for levels of block
Sympathetic block
• Skin temperature sensation
• Changes in the skin temperature
 Testing for levels of block
Sensory level
• Pin prick using sterile needle
• Loss of touch is two dermatomes lower
than pin prick
 Testing for levels of block
Motor block
• Modified Bromage scale of onset of motor
block
 Indirect effects of SA drugs

 Cardiovascular effects
Due to sympathetic blockade there is
vasodilatation of both resistance
and capacitance vessels

Fall in peripheral vascular resistance

Posture dependent fall in cardiac output

Fall in BP
 Indirect effects of SA drugs

 Cardiovascular effects

• Marey’s law :baroreceptors in the carotid

sinus and the aortic arch normally respond
to a fall in blood pressure by producing a
compensatory tachycardia
 Indirect effects of SA drugs

 Cardiovascular effects
• Bain bridge reflex predominates during
spinal anaesthesia : venous pooling in the
periphery reduces stimulation of volume
receptors - diminishes the action of
cardiac sympathetic nerves- vagal
preponderance - bradycardia
• Oxygen consumption is reduced due to
hypotension and muscle relaxation
 Indirect effects of SA drugs

 R es pir at or y effects
• High spinal may cause paralysis of
intercostal nerves
• Bronchodilatation secondary to
hypotension or to reduced pulmonary
blood volume
 Indirect effects of SA drugs

 Gastro-intestinal effects
• Contracted bowel and relaxed sphincters
due to sympathetic blockade
• In the absence of vagal block – increase
in peristalsis and intraluminal pressure
 B l a d d e r and urogenital dysfunction
 Spinal anaesthesia in pregnancy
Decreased dose requirement due to
• Mechanical factor : compression of IVC
causes shunting of blood to the venous
plexus in the vertebral canal- decreased
vertebral canal space and CSF volume
• Hormonal factor – higher progesterone
levels
 Complications
1. Immediate complications
- Hypotension
- Bradycardia and Cardiac arrest.
-High and Total spinal block leading to
respiratory arrest.
- Urinary retention.
- Epidural hematoma, Bleeding.
 Complications

2. Late complications
- Post dural puncture headache (PDPH)
- Backache
- Nausea
- Focal neurological deficit
- Bacterial meningitis
- Sixth Cranial nerve palsy
- Urinary retention
 Treatment of complications
Hypotension is due to vasodilation and a
functional decrease in the effective
circulating volume.
1. Vasoconstrictor drugs
2. All hypotensive patients should be given
OXYGEN by mask until the blood pressure is
restored.
3. Raising their legs thus increasing the
return of venous blood to the heart.
 Treatment of complications

4.Increase the speed of the intravenous

infusion to maximum until the blood pressure is
restored to acceptable levels.

5. Treatment of bradycardia- give

atropine
intravenously.
 Pregnancy & Spinal
• Aortocaval • Pre loading with IV
Occlusion Fluids
• Left lateral
Position
• Vasopressors
• Oxygen therapy
 How to prevent Delayed
Complication

• Use Thin Spinal needles

• Sterile Precaution
It is widely considered that pencil-point needles
(Whiteacre or Sprotte) make a smaller hole in the
dura and are associated with a lower incidence of
headache (1%) than conventional cutting-edged
n eedles (Quincke)
 Treatment of spinal headache

 Remain lying flat in bed as this relieves the pain

 They should be encouraged to drink freely or, if

necessary, be given intravenous fluids to maintain
adequate hydration.
 Treatment of spinal headache

 Simple analgesics such as paracetamol,

aspirin or codeine may be helpful,

 Caffeine containing drinks such as tea,

coffee are often helpful.
 Treatment of spinal headache

 P r o l o n g e d or severe headaches may

be treated with
• epidural blood patch performed by aseptically
injecting 15-20ml of the patient's own blood
into the epidural space.
• This then clots and seals the hole and
prevents further leakage of CSF.
Thank You