● Patient refusal ● Sepsis ● Prior back

● Infection at the ● Uncooperative surgery at the site D. SPINAL ANESTHESIA

site of injection patient of injection ● Spinal anesthesia is a neuraxial anesthesia technique in which
● Coagulopathy ● Pre-existing ● Complicated local anesthetic is placed directly in the intrathecal space
● Other bleeding neurological surgery (subarachnoid space).
diathesis deficits ● Prolonged ● The subarachnoid space houses sterile cerebrospinal fluid
● Severe ● Demyelinating operation (CSF), the clear fluid that bathes the brain and spinal cord.
hypovolemia lesions ● Major blood loss → The spinal subarachnoid space is the space between the
● Increased ● Stenotic valvular ● Maneuvers that arachnoid mater and pia mater in the spine and is continuous
Intracranial disease compromise with the intracranial subarachnoid space.
pressure ● Left ventricular respiratory → Extends from the foramen magnum to the S2 in adults and
● Severe aortic outflow function S3 in children.
stenosis obstruction ● Initially after injection, spinal anesthetic solutions inhibit
● Severe mitral ● Severe spinal conduction in nerve roots as they course through the
stenosis deformity subarachnoid space.
● Over time, the local anesthetic permeates the spinal cord and
2. AWAKE OR ASLEEP likely interacts with other targets located therein.
● There is controversy in whether regional blockade should be ● Injection of local anesthetic below L1 in adults and L3 (below
performed before or after induction of general anesthesia or the termination of the conus medullaris) in children helps to
heavy sedation. avoid direct trauma to the spinal cord.
● The major arguments for having the patient asleep are that: ● Spinal anesthesia is commonly used for surgical procedures
→ Most patients, if given a choice, would prefer to be asleep involving the lower abdomen, pelvis and lower extremities.
→ The possibility of sudden patient movement during block
administration causing injury is markedly diminished
● The major argument for having the patient awake is that:
→ The patient can alert the clinician to paresthesias and pain
on injection, both of which have been associated with
postoperative neurologic deficits
● Use of general anesthesia or heavy sedation removes all
opportunity for the patient and the clinician to report and
respond to problems that may arise during block administration

Notes from Doc So:

● Conscious sedation may be performed instead
→ Patient does not necessarily have to be heavily
sedated prior to block administration
→ Anxiolytics or sedatives may be given but only to a
●
level that the patient will still be able to respond to the
clinician’s questions Figure 3. Spinal Anesthesia vs Epidural Anesthesia
→ The patient must still be able to report to the clinician
whenever he/she experiences pain or paresthesias
→ Clinicians should be especially wary when the patient
complains of pain because there is probably already 1. EQUIPMENT
nerve fiber impingement ● Since the performance of neuraxial procedures is under aseptic
→ When introducing the spinal needle, make sure that the technique, the clinician is expected to maintain a sterile
bevel is facing upwards so that in case the clinician environment.
accidentally hits a nerve, it will not be transected → Cap, masks, handwash, sterile gloves are required.
→ It is really difficult to administer neuraxial block in an
asleep patient as it requires a certain degree of patient Spinal Needle
cooperation such as in proper positioning
● Commercially available in an array of sizes, lengths, bevel and
4. TECHNICAL CONSIDERATIONS tip designs.
● Neuraxial blocks should only be performed in a facility in which ● Spinal needles generally used today are 22 to 27 G, but sizes
all the equipment and drugs needed for intubation, ranging from 19 to 30 G are available. (Doc So: They usually
resuscitation, and general anesthesia are immediately use 26G needle).
available ● All should have a tightly fitting removable stylet that completely
● Ensure adequate premedication occludes the lumen to avoid tracking epithelial cells into the
● Non-pharmacologic interventions to minimize anxiety and/or subarachnoid space
pain are equally as important
● Can be divided into either sharp (cutting)-tipped or blunt-
● Supplemental Oxygen via face mask or cannula may be
tipped needles.
required to avoid hypoxemia
→ Quincke needle is a cutting needle with end injection.
● General monitoring requirements for regional anesthesia are the
→ The introduction of blunt tip (pencil-point) needles has
same as that in general anesthesia
markedly decreased the incidence of postdural puncture

Surg 2 Title of Lecture 1 of 5

 headache.
→ Whitacre needle and other pencil-point needles have
rounded points and side injection.
→ The Sprotte needle is a side-injection needle with a long
opening.
▪ It has the advantage of more vigorous CSF flow compared
with similar gauge needles.
▪ However, this can lead to a failed block if the distal part of
the opening is subarachnoid (with free flow CSF), the
proximal part is not past the dura, and the full dose of
medication is not delivered.
▪ In general, the smaller the gauge needle, the lower the
incidence of headache. (Doc So: Size of the needle does
not have any effect. Pahihirapan mo lang sarili mo pag
masyado maliit)
▪ (Doc So: Usually they use cutting-type needles (Quincke)
since mahirap ipasok yung blunt needles kasi mapurol).

Figure 5. Patient Position

● A line drawn between the highest points of both iliac crests
(Tuffier’s line) usually crosses either the body of L4 or the
L4–L5 interspace.
→ Counting spinous processes up or down from these
reference points identifies other spinal levels.

Figure 4. Spinal Needles

Spinal Catheter
● Rarely used for spinal anesthesia since the procedure is only
“one-shot”.
● Very small subarachnoid catheters are currently no longer
approved by the US Food and Drug Administration.
● The withdrawal of these catheters was prompted by their
association with cauda equina syndrome (CES).
● Larger catheters designed for epidural use are associated with
relatively high complication rates when placed subarachnoid;
however, they are frequently used for continuous spinal
anesthesia following accidental dural puncture during
performance of epidural anesthesia.
● Mostly the catheter size used are 18G and 20G.

Figure 6. Tuffier’s Line

2. TECHNIQUE
● The procedure is usually carried out with the patient in the
● After the patient is in proper position, the access site is
sitting or lateral decubitus position.
identified by palpation.
● The goal of positioning is to help establish a straight path for
→ This is usually very difficult to achieve with obese patients
needle insertion between the spinal vertebrae.
because of the amount of subcutaneous fat between the skin
● The most commonly used position is the sitting position.
and spinous process.
→ This is because, in the lateral decubitus position, the spinal
→ The space between 2 palpable spinous processes is usually
anatomy is usually not laterally symmetrical as it is in the
the site of entry.
sitting position.
→ Local anesthetic (usually 1% lidocaine) is used for skin
infiltration, and a wheal is created at the site of access
chosen, either midline or paramedian.

Two Approaches for Spinal Anesthesia

● Median Approach
→ The spinal approach to the intrathecal space is midline with a
straight line shot.
→ The spinal needle is introduced into the skin, angled slightly
cephalad.

Surg 2 Title of Lecture 2 of 5

 → The needle is advanced from skin through the deeper
structures until two “pops” are felt.
→ The first is penetration of the ligamentum flavum, and the
second is penetration of the dura–arachnoid membrane.
→ Successful dural puncture is confirmed by withdrawing the
stylet to verify free flow of CSF.
● Paramedian Approach
→ The paramedian technique may be selected if subarachnoid
block is difficult, particularly in patients who cannot be
positioned easily (eg, severe arthritis, kyphoscoliosis, or prior
spine surgery)
→ The skin wheal from the local anesthetic is placed about 2
cm from midline, and the spinal needle advances at an angle
toward the midline.
→ In this approach, the supraspinous and interspinous
ligaments are usually not encountered.
→ Hence, there is little resistance encountered until reaching
the ligamentum flavum.
Figure 7. Median and Paramedian Approach
Figure 8. Image highlighting the T4-T8 areas as the most dependent area of a
3. FACTORS AFFECTING LEVEL OF SPINAL BLOCK
Figure 7. Factors affecting the level of Spinal anesthesia
Surg 2 Title of Lecture
(Butterworth et al., 2015)
● The most important that affect the level of spinal anesthesia are:
Baricity, Position of the Patient and Drug Dosage
● In general, the larger the dose and the more cephalad the level
of injection, the more cephalad the level of block that will be
obtained.
Baricity of Anesthetic Solution
● Baricity refers to the degree of specific gravity of the anesthetic
solution relative to specific gravity of CSF.
→ The specific gravity of CSF is 1.003 – 1.008.
→ An anesthetic solution with a specific gravity GREATER
than CSF is HYPERBARIC
→ An anesthetic solution with a specific gravity LESSER than
CSF is HYPOBARIC
→ An anesthetic solution with a specific gravity EQUAL to
CSF is ISOBARIC
● Mixing certain compounds and solutions to the anesthetic can
increase or decrease its baricity, allowing a degree of control on
the level of block.
→ Addition of sugars such as glucose and dextrose
INCREASE BARICITY, thus more HYPERBARIC
→ Addition of sterile water and fentanyl make DECREASE
BARICITY, thus more HYPOBARIC
→ Addition of CSF makes anesthetic solutions ISOBARIC
● A more hyperbaric solution would settle at the most dependent
areas of the spine.
→ In a person with a normal spine anatomy this would be
located at the level of T4 – T8
normal spine. Hyperbaric solutions would tend to settle towards those
areas (Butterworth et al., 2015)
NTK: What happens to the level of block if CSF increases in
viscosity?
● Theoretically, a more viscous CSF means an increased
specific gravity
● The default level of block obtained from hyperbaric and
hypobaric would change as these were manufactured with the
default specific gravity of CSF as a reference
→ A hyperbaric solution would become less hyperbaric in
reference to a more viscous CSF
→ A hypobaric solution would become more hypobaric in
reference to a more viscous CSF
● In clinical practice however, a viscous CSF means that there
is an increased amount of protein in the CSF
→ Increased protein in the CSF is suggestive of an infection
in the spinal cord (e.g. meningitis)
● Remember that an infection in the spinal cord is an
ABSOLUTE CONTRAINDICATION in administering spinal
anesthesia!
Position of the Patient
3 of 5
● Depending on the position of the patient, the anesthetic solution
would migrate towards the dependent areas if hyperbaric,
and to the nondependent areas if hypobaric.
● An isobaric solution would tend to remain at the level of the
injection.
● Some examples include:
→ A heads-up position would cause a hyperbaric solution to
descend caudad and a hypobaric solution to ascend
cephalad.
→ A lateral position would cause a hyperbaric solution to
migrate downward while a hypobaric solution would migrate
upward
→ A sitting position would result in a higher concentration of a
hyperbaric solution in the lower lumbar and sacral areas
→ A prone jack knife position would result in a higher
concentration of hypobaric solution in the lower lumbar and
sacral areas
Dosage
● The higher the dose, the higher the blockade.
● Other factors related to dosage include
→ Concentration – the higher the concentration, the higher the
block
→ Temperature – considered a minor consideration but has it
effects nonetheless
▪ A cold solution would be more viscous limiting its spread
▪ A warm solution would spread more easily
→ Volume – the greater the volume, the greater the spread
Other Factors
● The direction of the needle bevel or port plays a role in the
level of blockade
→ Higher levels of blockade are achieved if the injection is
directed cephalad than if the point of injection is directed
laterally or caudad
● Patient’s height, age and spinal anatomy play a role as well
→ Abnormal curvatures of the spine (e.g. scoliosis and
kyphoscoliosis) make placing the block more difficult
▪ The paramedian approach to lumbar puncture may be
preferable in such cases
→ Taking a radiograph of the patient’s spine before
administering the anesthesia would therefore be helpful and
must be considered
● The size of the syringe used should be considered as well
→ According to Doc, a size of Gauge 26 is enough for routine
anesthesia.
→ The size is small enough to safely puncture structures and
large enough to not require an applicator, hence making
administration easier
4. AGENTS USED IN SPINAL ANESTHESIA
Posteriorly
Laterally
Anteriorly
Figure 9. Agents used in spinal anesthesia (Butterworth et al., 2015)
Surg 2 Title of Lecture
● In general, Bupivacaine and Tetracaine have a relatively slow
onset of action (5-10 min), but have a long duration of action
(90-120 min)
→ Duration of action of both drugs lengthen significantly when
mixed with a vasoconstrictor such as epinephrine
▪ Tetracaine’s duration of action lengthens by more than
50% when mixed with epinephrine.
▪ Phenylephrine lengthens tetracaine’s duration but doesn’t
lengthen bupivacaine’s duration.
→ Sensory blockade for both drugs is the same on an
equivalent dose
→ Motor blockade is greater for tetracaine than bupivacaine on
an equivalent dose
● In contrast, Procaine and Lidocaine have a relatively rapid onset
of action (3-5 min), but have a short duration of action (60 – 90
min)
→ Duration of action of both drugs do not lengthen significantly
when mixed with a vasoconstrictor
→ Lidocaine, in particular, has seen less use due to risk of
causing transient neurological symptoms and cauda equina
syndrome (CES)
▪ Therefore, repeat blockade, following a failed block, using
Lidocaine is NOT RECOMMENDED
NTK: What is Cauda Equina Syndrome (CES)?
● CES is a set of symptoms arising from an injury or damage to
the cauda equina, usually affecting the nerve roots L2 – S5.
● Symptoms include...
→ Lower back pain
→ Loss of sensation in a saddle distribution (buttocks,
perineum, superior thighs, etc)
→ Lower extremity weakness and paralysis
→ Loss of reflexes from the affected nerve roots (Achilles,
Patellar, Bulbocavernosus)
→ Bladder and bowel dysfunction
● Commonly caused by trauma or impingement due to a
growing mass in that region such as a tumor
● Rarely caused by anesthesia administration, particularly
Lidocaine
→ Repeat administration of Lidocaine causes it to accumulate
in neurotoxic amounts
→ Neurotoxicity destroys neurons causing the symptoms
E. EPIDURAL ANESTHESIA
● A type of neuraxial anesthesia wherein the local anesthetic
(LA) is injected into the epidural space to anesthetize the
spinal nerve roots that traverse the space
→ Epidural space: surrounds the dura mater circumferentially
and extends from the foramen magnum to the
sacrococcygeal ligament; contains adipose tissue, blood
vessels, nerve roots, loose connective tissue
→ Boundaries:
Ligamentum flavum
Pedicles, Intervertebral foramina
Posterior longitudinal ligament
● Offers a range of applications wider than the typical all-or-
nothing, single dose spinal anesthetics
● Widely utilized for surgical anesthesia, obstetric analgesia, post-
operative pain control, and chronic pain management. It is used
for anesthesia of abdominal, pelvic, and lower extremity
procedures and, less commonly, thoracic procedures
● May also be used to supplement general anesthesia for
thoracic, abdominal, and pelvic procedures and for
postoperative analgesia following these procedures
4 of 5

Segmental Block
● Characterized by a well-defined band of anesthesia at
certain nerve roots, leaving the nerve roots above and below
unblocked
● Can be made possible because the anesthetic can be confined
close to the level at which it was injected
● Usually used in labor and postoperative analgesia
1. EQUIPMENT
Epidural Needle
● Standard epidural needle is usually 17-18 gauge, 3 or 3.5
inches long, and has a blunt bevel with a gentle curve of 15-
30° at the tip
● TUOHY NEEDLE
→ Usually used
→ Blunt, curved tip
→ theoretically helps to push away the dura after passing
through the ligamentum flavum instead of penetrating it
→ Other modifications to needles used in epidural anesthesia
are winged tips and introducer devices set into the hub
designed for guiding catheter placement.
● CRAWFORD NEEDLE
→ Straight without a curved tip
→ May have a greater incidence of dural puncture but facilitate
the passage of an epidural catheter.
Figure 9. Epidural Needles.
Types of epidural needle (left), Tuohy needle (right)
Epidural Catheter
● Utilized when continuous infusion or intermittent bolus
techniques are employed
● 19- or 20-gauge catheter is introduced through a 17- or 18-
gauge epidural needle
● May be taped on the skin or tunneled under the skin (for
prolonged use of > 1 week)
Figure 10. Epidural Catheter
2. TECHNIQUE
● An epidural block can be performed at the lumbar, thoracic, or
cervical level
● Can be used as a single shot techniques or with a catheter
that allows intermittent boluses and/or continuous infusion as
indicated
● Epidural space can be accessed using the midline or the
paramedian approach
Surg 2 Title of Lecture
→ Epidural needle is passed through the skin and the
ligamentum flavum, with the needle stopping short of piercing
the dura
● To identify the potential (epidural) space, two techniques can be
used: (1) Loss of Resistance Technique, (2) Hanging Drop
Technique
Loss of Resistance Technique
● The needle is advanced through the subcutaneous tissues with
the stylet in place until the interspinous ligament is entered ⇨
indicated by an increase in tissue resistance
● Stylet or introducer is removed and a glass syringe filled with
approximately 2.0 mL of saline or air is attached to the hub of
the needle
→ A resistance is felt if the tip of the needle is within the
ligament and thus, injection is not possible.
● With a slow advancement of the needle, a sudden loss of
resistance and thus easier injection ⇨ needle is in the
epidural space
Figure 11. Loss of Resistance Technique
Notes from Doc So:
Loss of Resistenance Technique:
1. Use of air
− Don’t inject too much air because it may cause a
post-dural headache-like headache (BUT no
diplopia, tinnitus, not relieved by lying down)
− Pain due to air accumulating at foramen magnum
2. Use of saline – preferred and more recommended
Hanging Drop Technique
● Requires that the hub of the needle be filled with solution so that
a drop hangs from its outside opening once the
interspinous ligament has been entered and the stylet has
been removed
● As the tip of the needle enters the epidural space, the drop of
fluid is sucked into the needle due to the negative pressure
created
→ Artificial negative pressure is created in the epidural space
when the epidural needle comes in contact with the dura
mater and pushes it away ⇨ increase in epidural space
volume
→ Increase in epidural space volume ⇨ decrease in pressure ⇨
5 of 5