SPINAL AND

EPIDURAL
ANESTHESIA

DEPARTMENT OF ANESTHESIA

OSPITAL NG MAYNILA MEDICAL CENTER

 GOOD
MORNING!!
!
 EPIDURAL AND SPINAL
ANESTHESIA
• No absolute indications

• Clinical situations, patient

physiology, surgical procedure:
makes central neuraxial block
the technique of choice
 EPIDURAL AND SPINAL
ANESTHESIA

• Blunt the “stress response” to

surgery
– decrease intraoperative blood loss
– lower the incidence of
postoperative thromboembolic
events
– decrease morbidity and mortality
in high-risk surgical patients
• extend analgesia into the
postoperative period
(provide better analgesia than
can be achieved with parenteral
opioids)

• provide analgesia to non-surgical

patients
ANATOMY
 VERTEBRAE
The spine consists
of 33 vertebrae
• 7 cervical
• 12 thoracic
• 5 lumbar
• 5 fused sacral
• 4 fused coccygeal
• Cervical (except C1),
thoracic, and lumbar
vertebrae: body
anteriorly, two pedicles
that project posteriorly
from the body, and two
laminae that connect
the pedicles ----form the
vertebral canal, which
contains the spinal
cord, spinal nerves, and
epidural space
• Lamina: give rise to the
transverse processes (laterally);
spinous process (posteriorly) ---
sites for muscle and ligament
attachments
• Pedicles: contain a superior and
inferior vertebral notch through
which the spinal nerves exit the
vertebral canal
5 sacral
vertebrae fused
to form the
wedge-shaped
sacrum (connects
the spine with the
iliac wings of the
pelvis)
 • 5th sacral vertebra
(not fused posteriorly)
give rise to a
variably shaped
opening ---- sacral
hiatus opening
into the sacral
canal (caudal
termination of the
epidural space)

Sacral cornu
• bony prominences on either side of the hiatus
• aid in identification of sacral hiatus
Coccyx
• fused 4 rudimentary coccygeal vertebrae
• a narrow triangular bone that abuts the
sacral hiatus
• Tip of the coccyx
can often be
palpated in the
proximal gluteal
cleft and by running
one’s finger
cephalad along its
smooth surface, the
sacral cornu can be
identified at the 1st
bony prominence
encountered
 C7 : 1st prominent
spinous process
encountered while
running the hand down
the back of the neck
T1 : most prominent
spinous process
T12 : can be
identified by
palpating the 12th
rib and tracing it
Line drawn between back to its
the iliac crests: attachement to
•body of L5 or the 4-5 T12
interspace
LIGAMENTS
• Vertebral
bodies are
stabilized
by 5
ligaments
that
increase
in size
between
the
cervical
and
lumbar
vertebrae
 EPIDURAL SPACE
• Space that lies between the spinal
meninges and the sides of the
vertebral canal
• Boundaries:
– Cranially: foramen magnum
– Caudally: sacrococcygeal ligament
covering the sacral hiatus
– Anteriorly: posterior longitudinal ligament
– Laterally: vertebral pedicles
– Posteriorly: ligamentum flavum and
vertebral lamina
• Not a closed space but
communicates with the
paravertebral space by way of the
intervertebral foramina
• Shallowest anteriorly where the dura
may in some places fuse with the
posterior longitudinal ligament
• Deepest posteriorly
• Composed of a series of
discontinuous compartments that
become continuous when the
potential space separating the
compartments is opened up by
injection of air or liquid
 MENINGES
• Spinal meninges consist of 3
protective membranes :
– Dura mater
– Arachnoid mater
– Pia mater
Dura mater
• Outermost and thickest meningeal
tissue
• Begins at the foramen magnum;
ends at approx S2 where it fuses
with the filum terminale
• Inner surface abuts the arachnoid
mater
Arachnoid mater
• Delicate, avascular membrane
composed of overlapping layers of
flattened cells with connective
tissue fibers running between the
cellular layers
• Specialized connections (tight
junctions and occluding junctions)
account for the fact that it is the
physiologic barrier for drugs moving
between the epidural space and the
spinal cord
• Subarachnoid space lies between the
arachnoid mater and the pia mater
and contains the CSF
• Spinal CSF is in continuity with the
cranial CSF and provides an avenue
for drugs in the spinal CSF to reach
the brain
• Spinal nerve roots and rootlets run in
the subarachnoid space
Pia mater
• Adherent to the spinal cord and is
composed of a thin layer of
connective tissue cells interspersed
with collagen
• Extends to the tip of the spinal cord
where it becomes the filum
terminale, which anchors the spinal
cord to the sacrum
• Gives rise to the dentate ligaments
TECHNIQUE
NEEDLES
NEEDLES
Spinal Needles
Whitacre and
Sprotte:
• “pencil-point” tip
• needle hole on the
side of the shaft

Greene and Quincke:

beveled tips with
cutting edges
Spinal Needles
• * pencil-point needles
require more force to
insert than the bevel-
tip needles but provide
better tactile “feel”;
not deflected
* Size: 22-29 gauge larger
gauge smaller diameter
Epidural Needles
• Touhy: curved tip to
help control the
direction that the
catheter moves in
the epidural space
• Hustead: less
curved tip
• Crawford: straight;
less suitable for
catheter insertion

*sizes: 16-19 gauge

 SEDATION
• Light sedation before placement of block
– Successful spinal and epidural anesthesia
requires patient participation to:
• maintain good position
• evaluate block height
• indicate paresthesias if needle
contacts neural elements
• properly evaluate an epidural test

• Once the block is placed and adequate

block height assured, patient can be
sedated as deemed appropriate
 SPINAL ANESTHESIA
POSITION
Patient positioning is critical to
successful spinal puncture
• lateral decubitus
• sitting position
• prone jackknife position
POSITION
Lateral decubitus
• patient lies with the operative side
down (hyperbaric LA)
• or with operative side up (hypobaric
LA) ---most dense block occurs on
the operative side
POSITION

– back at the edge of the table

– patient’s shoulders and hips positioned
perpendicular to the bed
– knees drawn to the chest; neck flexed;
patient instructed to curve the back outward
MIDLINE APPROACH
• Skin overlying the desired
interspace is infiltrated with a small
amount of LA (1-2 ml) to a depth of
1-2 inches to prevent pain when
inserting the spinal needle
• Slight cephalad angulation (10-15
degrees)
MIDLINE APPROACH
Needle is then advanced
• subcutaneous tissue
• supraspinous ligament
• interspinous ligament
• ligamentum flavum
• epidural space
• dura mater
• arachnoid mater
MIDLINE APPROACH
MIDLINE APPROACH
Penetration of the dura mater produces
a subtle “pop”
– detection of dural penetration
• prevent inserting the needle all the way
through the subarachnoid space and
contacting the vertebral body;
– insert spinal needle quickly without
having to stop every few mm and remove
the stylet to look for CSF at the needle
MIDLINE APPROACH
Once the needle tip is believed to be in
the subarachnoid space, stylet is
removed to see if CSF appears at the
needle hub
– Small diameter needles (26-29 gauge)
requires 5-10 sec or >/= 1 minute
• Failure to obtain CSF suggests that
the needle orifice is not in the
subarachnoid space and must be
reinserted
MIDLINE APPROACH
Once the needle is correctly inserted
into the subarachnoid space, it is
fixed in position and the syringe
containing LA is attached
CSF is gently aspirated to confirm that
the needle tip remained in the
subarachnoid space and LA slowly
injected (</=0.5 ml/s-1)
MIDLINE APPROACH
After completing the injection, a
small volume of CSF is again
aspirated to confirm that the needle
tip remained in the subarachnoid
space while the LA was deposited
This CSF is then reinjected and the
needle, syringe, and any introducer
removed together as a unit
MIDLINE APPROACH
strict attention to patient’s hemodynamic
status with BP and/or HR supported
block height should also be assessed early
– pin prick
– temperature sensation

–Table may be tilted as appropriate to

influence further spread of local
anesthetics
PARAMEDIAN APPROACH
• useful in situations where the
patient’s anatomy does not favor
the midline approach
– inability to flex the spine
– heavily calcified interspinous ligaments
• Patient in any position; best
approach for the patient in the
prone jackknife position
PARAMEDIAN APPROACH
• Identify the spinous process forming
the lower border of the desired
interspace
• Needle inserted
– ~1 cm lateral
– directed toward middle of the interspace
~45 degrees cephalad
– medial angulation (~15 degrees) to
compensate for the lateral insertion point
PARAMEDIAN APPROACH

•Needle inserted ~1 cm lateral, directed toward middle of

the interspace ~45 degrees cephalad with just enough
medial angulation (~15 degrees) to compensate for the
PARAMEDIAN APPROACH
1st significant resistance encountered:
ligamentum flavum
Alternative method:
– insert needle perpendicular to the skin in all
planes until the lamina is contacted; needle is
then walked off the superior edge of the lamina
and into the subarachnoid space

**Lamina provides a valuable landmark that

facilitates correct needle placement
EPIDURAL ANESTHESIA
• May be performed at
any intervertebral
space
• LA skin wheal is
raised to the point of
needle insertion
• Pierce the skin with a
>/=18 G hypodermic
needle
• Epidural needle
inserted through
the subcutaneous
tissue and into the
interspinous
ligament “gritty
feel”

• Needle is advanced
slowly until an
increase in
resistance is felt :
Techniques to
identify epidural
space:
– Loss of resistance
technique
(fluid/air)
• Glass syringe: 2-3
ml saline + 0.1-0.3
ml air bubble
– Hanging drop
technique
After entering the epidural space, stop
advancing the needle
– heightens the risk of meningeal puncture
“wet tap”
• LA test dose should be administered to
help rule out undectected subarachoid
or IV needle placement
• After a negative test dose, desired
volume should be administered in small
increments
EPIDURAL TEST DOSE
– To identify epidural needles or
catheters that have entered an epidural
vein or the subarachnoid space
– Failure to perform: IV injection or total
spinal block
– 3 ml of LA + 1:200,000 epinephrine
• IV: epinephrine
– HR increases 20-40 sec after
– BP increase of >/=20 mmHg
• Subarachnoid: motor block ---LA
PHYSIOLOGY
• Spinal anesthesia interrupts sensory,
motor, and sympathetic nervous system
• Classic concept:
– Conduction blockade through small diameter
unmyelinated (sympathetic) fibers before
interrupting conduction via large myelinated
(sensory & motor) fibers
• Block of afferent impulses from the
surgical site leads to absence of
adrenocortical response to pain
Cardiovascular system
• Vasodilatation of resistance and capacitance
vessels occurs: hypovolaemia, tachycardia,
drop in blood pressure
– exacerbated by blockade of the sympathetic
nerve supply to the adrenal glands,
preventing the release of catecholamines.
• Bradycardia: If blockade is as high as T2,
sympathetic supply to the heart (T2-T5)
• overall result: inadequate perfusion of
vital organs
measures: restore blood pressure and
cardiac output (fluid administration,
vasoconstrictors)
• Sympathetic outflow extends from T1 - L2
(blockade of nerve roots below this level,
knee surgery, is less likely to cause
significant sympathetic blockade,
compared with procedures requiring
blockade above the umbilicus)
Respiratory system
• usually unaffected unless blockade is
high enough to affect intercostal muscle
nerve supply (thoracic nerve roots)
leading to reliance on diaphragmatic
breathing alone
• distress to the patient, as they may feel
unable to breathe adequately
• decreased ability to cough and expel
secretions
• if patients cannot breathe, ventilate (face
mask and bag
Gastrointestinal system
• Blockade of sympathetic outflow (T5-L1),
leads to predominance of
parasympathetic (vagus and sacral
parasympathetic outflow)
– leading to active peristalsis and relaxed
sphincters, and a small, contracted gut, which
enhances surgical access
– Splenic enlargement (2-3 fold) occurs
• If above T5, inhibits sympathetic
innervation to the GIT, resulting in
unopposed parasympathetic nervous
system activity
– Contracted intestines and relaxed sphincter;
if not on NPO, tendency to develop vomiting
Genitourinary tract
• urinary retention is a common problem
• severe drop in blood pressure may affect
glomerular filtration in the kidney (if
sympathetic blockade extends high
enough to cause significant
vasodilatation)
• ureters are contracted and ureterovesical
orifice is relaxed
• Decreased bleeding may be a
reflection of decreased BP
• Increased blood flow to lower
extremities ---- decreased incidence
of thromboembolism
• BLOCK HEIGHT
SURGICAL SUGGESTED TECHNIQUE
PROCEDURE BLOCK
HEIGHT
Perianal L1-2 Hyperbaric/sitting pos
Perirectal Hypobaric/jackknife pos
Lower extremity/ T10 Isobaric
Hip
TURP
Vaginal/ cervical
Herniorrhaphy T6-8 Hyperbaric/ horizontal
Pelvic procedures
Appendectomy
Abdominal T4-6 Hyperbaric/ horizontal
 FACTORS THAT AFFECT SPREAD OF
LOCAL ANESTHETIC SOLUTIONS
Characteristics of the local anesthetic solution
– Baricity: ratio of density (mass/vol) of LA div density of CSF
– Local anesthetic dose
– Local anesthetic concentration
– Volume injected

Patient characteristics
Age
Weight
Height
Gender
Pregnancy
Patient position
 FACTORS THAT AFFECT SPREAD OF
LOCAL ANESTHETIC SOLUTIONS
Speed of injection
Barbotage
Direction of needle bevel
Addition of vasoconstrictors

Technique
– Site of injection

Diffusion
 LOCAL ANESTHETIC
SOLUTION
• HYPERBARIC: solution more dense than
CSF; >/=1.0015
– Add glucose (5-8% dextrose) of increase the
density
– LA solution settles to dependent region
• HYPOBARIC: solution less dense than
CSF; <0.9990
– Add sterile/distilled water; floats up to the
nerves innervating surgical site
• ISOBARIC: same density; 1.0000
– Dilute with CSF or normosaline solution
COMPLICATIONS
• Hypotension
• Postdural puncture headache
• Hearing loss
• Total spinal
• Backache
• nausea
• Urinary retention
• Systemic toxicity
• Neurologic injury
• Spinal hematoma
• Hypotension
– Due to sympathetic nervous system
blockade
a.Decreased venous return to heart,
decreased cardiac output
b.Decreased systemic vascular resistance
c.Bradycardia due to blockade of
cardioaccelerator fibers (T1-3),
decreased cardiac output
• Hypotension
Treatment: restore venous return to
incrase cardiac output
– Position head-down: autotransfusion
– Hydration before spinal anesthesia
– Sympathomimetics
• Postdural puncture headache
– Frontal/occipital
– Worsened by sitting, improved by supine position
– Due to decreased CSF pressure and resulting
tension on meningeal vessels and nerves as a
result of leakage of CSF through the dural hole
– Diplopia due to traction on abducens nerve
– Treatment: bed rest, analgesics
• Hydration (>/= 3L/day) to increase CSF production
• Epidural patch (10-20 ml) to seal dura
• Caffeine-sodium benzoate (by vasoconstriction)
• Hearing loss
• High Spinal
– Undesired excessive level of sensory
and motor anesthesia associated with
difficulty of breathing or apnea ---
arterial hypoxemia or hypercarbia
– Apnea reflects ischemic paralysis of
medullary ventilatory centers due to
profound hypotension and associated
with decreased cerebral blood flow
• High Spinal
– Treatment: support breathing and circulation
a. Positive pressure ventilation with face mask
b. IVF and sympathomimetics
c. Head down to increase venous return
(head up will jeopardize cerebral blood
flow --- medullary ischemia
d. Intubation of trachea in those at risk
for aspiration
• Total spinal
– rare complication
– profound hypotension
– apnea
– unconsciousness
– dilated pupils as a result of the action
of local anesthetic on the brainstem
• Management
– Airway – secure, administer 100% oxygen
– Breathing - ventilate by facemask, intubate
– Circulation - treat with iv fluids and
vasopressor
– Continue to ventilate until the block wears off
(2 - 4 hours)
– As the block recedes the patient will begin
recovering consciousness followed by
breathing and then movement of the arms and
finally legs. Consider some sedation (diazepam
5 - 10mg i/v) when the patient begins to
recover consciousness but is still intubated
and requiring ventilation
• Backache
– May be related to position required for
surgery
– More likely due to ligamentous strain
when in an uncomfortable position
• Nausea
– May be due to hypotension --- cerebral
ischemia; tx sympathomimetics
– May be due to predominance of
parasympathetic nervous system
activity; tx atropine 0.4 mg IV
• Urinary Retention
– Because spinal anesthesia interferes
with innervation of the bladder
– Administration of large amounts of fluid
--- bladder distention requiring catheter
drainage
• Systemic toxicity
• Neurologic injury
– Very rare due to small dose of LA employed
– In the absence of hematoma or abscess,
treatment is symptomatic
• Spinal hematoma
– Rare; present with numbness or LE
weakness
– Risk factor: coagulation defects
• Inadvertent high epidural block
– due to an excessively large dose of
local anesthetic
– hypotension, nausea, sensory loss or
paresthesia of high thoracic or even
cervical nerve roots (arms), or difficulty
breathing
– most severe cases may require
induction of GA with securing of the
airway, while treating hypotension
– If patient has a clear airway and is
breathing adequately: reassurance and
any hypotension immediately treated
– Difficulty in talking (small tidal volumes
due to phrenic block) and drowsiness
are signs that the block is becoming
excessively high and should be
managed as an emergency
• Local anesthetic toxicity
– excessive dose of local anaesthetic
– moderate dose of LA, injected directly
into a blood vessel
– epidural catheter is inadvertently
advanced into one of the many epidural
veins. It is therefore vital to aspirate
from the epidural catheter prior to
injecting local anaesthetic
– symptoms: light-headedness, tinnitus,
circumoral tingling or numbness and a
feeling of anxiety or "impending doom",
followed by confusion, tremor, convulsions,
coma and CPR arrest
– early recognition: discontinue further
administration of local anesthetic drugs
– treatment: supportive,
sedative/anticonvulsants, cardiopulmonary
resuscitation if required
CONTRAINDICATIONS
• Patient refusal: only absolute contraindication
• Conditions that increase the apparent risk of
central neuraxial block
- Hypovolemia or shock increase the risk of
hypotension
- Increased ICP increases the risk of brain herniation
when CSF is lost through the needle, or if a further
increase in ICP follows injection of large volumes of
solution into the epidural or subarachnoid spaces
- Coagulopathy or thrombocytopenia increase the
risk of epidural hematoma
- Sepsis increases the risk of meningitis
- Infection at the puncture site increases the risk of
meningitis
• Pre-existing neurologic disease
(multiple sclerosis) : considered CI
– No evidence to suggest that spinal or
epidural anesthesia alters the course of
any preexisting neurologic disease
– Recommendations to avoid RA stem
largely from a medicolegal concern
that the anesthetic may be incorrectly
blamed for any subsequent worsening
of the patient’s preexisting condition
 SPINAL OR EPIDURAL
ANESTHESIA?
• Spinal Anesthesia
– Less time to
perform
– Produces more
rapid onset of
better quality
sensorimotor
block
– Less pain during
surgery
 SPINAL OR EPIDURAL
ANESTHESIA?

• Epidural Anesthesia
– Lower risk of PDPH
– Less hypotension if epinephrine is not
added to the LA
– Ability to prolong or extend the block
via an indwelling catheter
– Option of using an epidural catheter to
provide postoperative analgesia