[ANESTHESIOLOGY] Regional Anesthesia, Peripheral Nerve Blocks

Lecturer: Ernest M. Dela Cerna, MD

Transcriber: Patrick Angelo R. Bautista September 2020


References and Legends
nd
• {💻} PPT and {📕} Chapter 6-7 - Anesthesiology Manual 2 Ed
• {📖} Morgan & Mikhail’s Clinical Anesthesiology 5 Ed
th

• {📌} Transcriber’s Note

Table of Contents
I. Anatomy of the Spine 1
II. Autonomic Blockade of Regional Anesthesia 2
III. Somatic Blockade of Regional Anesthesia 3
IV. Regional Anesthesia Technique 3
V. Spinal Anesthesia 5
VI. Epidural Anesthesia 6
VII. Peripheral Nerve Blocks 8
VIII. Samplex 8
Figure: Posterior and sagittal views of the sacrum and coccyx.

I. ANATOMY OF THE SPINE Ligamentous Layers

• The Spine is composed of: • The vertebral bodies and intervertebral disks are joined together
9 Ligamentous layers by the anterior and posterior longitudinal ligaments ventrally.
9 33 vertebrae • Supraspinous ligament (outer most layer)
§ 7 cervical § 5 sacral (fused) • Interspinous ligament (middle layer)
§ 12 thoracic § 4 coccygeal • Ligamentum flavum (innermost layer)
§ 5 lumbar
• Function: structural security and support for the spinal cord.

Figure: Sagittal section through lumbar vertebrae

Spinal Cord
• The spinal cord with its covering is enclosed in the spinal canal.
Figure: Divisions of spinal column • Adult’s spinal cord:
9 Begins at the foramen magnum
• A spinal canal is formed: 9 Ends at the level of the L1 vertebra
9 Anteriorly: vertebral body • Newborn and children:
9 Laterally: pedicles and transverse processes 9 Ends at the level of the L3 and eventually moves up.
9 Posteriorly: lamina and spinous processes

Figure: Superior view of the common vertebra

• Sacral hiatus
9 Caudal opening to the spinal canal due to the lamina of the S5
and/or part of the S4 vertebra usually not uniting.
• Normal curvature of the spinal column:
9 Follows a double C shape convexity anteriorly specifically in
the cervical and lumbar area.
• Spinal column in a lateral view:
9 Highest points: C5 and L5
9 Lowest points: T5 and S2 Figure: Sagittal view through the lumbar vertebrae and sacrum.
9 These points entail the anesthetic level and local anesthetic Note the end of the spinal cord rises with development from
spread after spinal anesthetic injection. approximately L3 to L1. The dural sac normally ends at S2.

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Spinal Nerve Roots

• The principal site of action for neuraxial blockade is believed to
be the nerve root.
• The paired anterior and posterior nerve roots from each vertebral
level exits the CNS via the intervertebral foramen forming
cervical (C1) to sacral (S5) spinal nerve roots.
9 Cervical vertebra level: nerves appear above the
corresponding vertebrae level
9 Starting at the T1: the nerves leave below their vertebra.
9 Consequently, they form 8 cervical nerve roots with only
7 cervical vertebras in place.
• Conus medullaris
9 Spinal cord bulbous terminal end
• Filum terminale
9 Tapering end of conus medullaris
9 Usually anchors in the sacral region
• Cauda equina
9 Horse-tail appearance; some lower spinal nerve roots courses
down before leaving the intervertebral foramen creating a
horse-tail appearance

Spinal Meninges
• Coat the spinal cord
• Three layers:
9 Fibrous dura mater (outermost layer)
9 Avascular arachnoid layer (middle layer)
9 Highly vascular pia mater (innermost layer) which is closely
attached to the spinal cord.
• Subarachnoid space aka intrathecal space
9 Lies between the arachnoid and pia mater.
9 It is also where cerebrospinal fluid (CSF) is located wherein the
spinal anesthetic agent is injected.
• Epidural space
9 A potential space that surrounds the spinal meninges.
9 Bound by the dura and the ligamentum flavum posteriorly.
9 Widest at the level of L2 (5-6 mm)
9 Narrowest at the level of the C5 (1-1.5 mm)
Figure: Arterial supply to the spinal cord.
A: Anterior view showing principal sources of blood supply.
B: Cross-sectional view through the spinal cord showing paired posterior
spinal arteries and a single anterior spinal artery.
Anesthesia Pearls
• Local anesthetic target site of action is the spinal nerve roots.
• The endpoint in performing a subarachnoid block is the presence
of the free-flowing and clear cerebrospinal fluid.
• During lumbar needle insertion below L1 in adults (L3 in children),
potential cord needle trauma is avoided since these nerve roots
float in the dural sac below L1 and tend to be pushed away by
an advancing needle.
• Epidural anesthesia can be applied at any vertebral level while
spinal anesthesia should only be injected below the level of the
spinal cord.

II. AUTONOMIC BLOCKADE OF

Figure: Exit of the spinal nerves.
Blood Supply of the Spinal Cord
• Blood supply of the spinal cord and nerve roots is derived from:
9 Single anterior spinal artery – supplies anterior 2/3 of cord
9 Paired posterior spinal arteries – supplies posterior 1/3
9 Intercostal arteries (thorax) and lumbar arteries (abdomen)
§ Supplementary blood flow to the anterior and posterior
spinal arteries
9 Artery of Adamkiewicz
§ One of these radicular arteries; Unilateral and mostly arises
on the left side and is the major blood supply to the
anterior, lower 2/3 of the spinal cord.
§ A damage to this artery would result to anterior spinal
artery syndrome causing spinal ischemia to the anterior
portion of the spinal cord.
REGIONAL ANESTHESIA
1. Cardiovascular Effects
• Blockade of the sympathetic preganglionic neurons during
regional anesthesia sends signals to both arteries and veins in
which the predominant action is venodilation and thus, reduces
the following:
9 Blood pressure
9 Venous return
9 Stroke volume
9 Cardiac output
• High spinal blockade (above T4 level) or T1-T4 blockade,
9 Unopposed vagal stimulation wherein the bradycardia at this
level is due to the cardio-accelerator fibers blockade.
9 Hence, a decreased venous return to right atrium would lead to
a decreased stretch receptor response.
• Hypotension can be prevented or minimized by increasing the
cardiac preload → done by infusing large IV fluid (10-20 cc/kg)
before or during spinal anesthesia induction.
9 If hypotension still persists despite maximum infusion of IV
fluids, a pharmacologic treatment may be done by giving
Ephedrine or Phenylephrine.
2. Pulmonary Effects
• Appropriate regional blockade has a little effect on ventilation.
• Pulmonary physiology effects even in high thoracic levels are
minimal (slight decrease in vital capacity) since the diaphragm is
innervated by the phrenic nerve (C3-C5).
• However, in patients with severe chronic lung disease that rely
upon accessory respiration (intercostal and abdominal muscles)
these will significantly impair the muscles of inspiration and
expiration during a high level of blockade.

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3. Gastrointestinal Effects
• Sympathectomy allows vagal tone dominance which results to
small and contracted gut with active peristalsis.
• Use of epidural analgesia for post-operative management
improves the return of gastrointestinal function.
4. Urinary Tract Effects
• The loss of bladder tone results in urinary retention during
regional blockade.
• Placement of indwelling foley-catheter helps to drain urine
intraoperatively until the blocks wears off.
III. SOMATIC BLOCKADE OF
REGIONAL ANESTHESIA (LOCAL ANESTHETICS)
• Regional Anesthesia provides a profound sensory blockade that
interrupts both somatic and visceral painful stimuli.
• Local anesthetics effect on the nerve fibers varies on the size
and characteristics of the nerve fiber.
• Smaller and myelinated nerve fibers are easily blocked than larger
and unmyelinated fibers.
• Differential blockade
9 Occurs when the concentration of local anesthetic decreases
with increasing distance from the level of injection.
9 Temperature sensitivity (alcohol swab)
§ Two segments or more cephalad than sensory block
9 Pin prick test (pain and light touch)
§ Few segments more cephalad than the motor blockade.
Spread of Local Anesthetics
Local anesthetic solution will soak the cauda equine area
↓ 9 Epidural catheters should be removed 2 hours prior to the
LA solution moves cephalad to the spinal cord
↓ • in cases LMWH are already administered:
Diffusing laterally to the primary targets: nerve rootlets, nerve roots
1. Common Clinical Indications of Regional Anesthesia
• Lower abdominal surgeries
9 Urogenital surgery (Ob-Gyne procedures)
9 Rectal surgery
9 Lower extremities (hip, femur, knee and foot surgery)
• It is also advantageous to patients with:
9 Full stomach
9 Anatomic distortions of the upper airway
• Favorable to post-operative analgesia management through
continuous infusion.
2. Contraindications to Regional Anesthesia
• Absolute Contraindication
9 Patient refusal
• Relative Contraindication
9 Infection
9 Coagulopathy
9 Severe hypotension
9 Increased intracranial pressure
9 Severe Aortic or Mitral Stenosis
3. Regional Anesthesia in the Anticoagulated Patient
• The American Society of Regional Anesthesia (ASRA) continue
to update guidelines whether a block be performed in
anticoagulated patient.
3.1 Oral Anticoagulants
• In patients who are receiving warfarin therapy, a normal
prothrombin time and international normalized ratio should be
done prior to regional anesthesia.
• Coordination with the primary physician must be initiated prior
discontinuation of the anticoagulant. 
 9 Pulse oximeter
3.2 Antiplatelet Drugs
• Aspirin / NSAIDs do not increase the risk of spinal hematoma.
• Drugs needed to be stopped for a certain waiting period for which
regional anesthesia can be administered after the drug effects
worn off:
9 Ticlopidine (Ticlid) – 14 days
9 Clopidogrel (Plavix) – 7 days
9 Abciximab (Rheopro) – 48 hours
9 Eptifibatide (Integrilin) – 8 hours
3.3Standard (Unfractionated) Heparin
• Avoid regional anesthesia in patients:
9 On therapeutic doses of heparin
9 With elevated partial thromboplastin time
• If epidural catheter placement is done, removal must be done:
9 1 hour prior administration of heparin or
9 4 hours after administration of heparin
• For patients who receive a prophylactic “minidose” of
subcutaneous heparin:
9 Anesthesia is not contraindicated.
• For patients who are to receive IV heparin intraoperatively:
9 Regional anesthesia may be done ≥1 hour prior to regional
blockade.
3.4Low-Molecular-Weight Heparin (LMWH)
• Enoxaparin (Lovenox)
• If a bloody regional placement happens:
9 The use of LMWH should be postponed until 24 hours
postoperatively because this traumatic placement may
increase the risk of spinal hematoma.
• If LMWH thromboprophylaxis is necessary:
first dose
9 The catheter should be removed at least 10 hours after a
dose of LMWH and the next dose must be not given for
another 2 hours.
3.5 Fibrinolytic or Thrombolytic Therapy
• A regional anesthesia should not be done in a patient who has
received a fibrinolytic and thrombolytic therapy.
IV. REGIONAL ANESTHESIA TECHNIQUE
Regional Anesthesia encompasses:
• Spinal Anesthesia (Subarachnoid Block)
• Epidural Anesthesia
• Peripheral Nerve Blocks
• Regional anesthesia must be performed in a sterile facility with
complete equipment and drugs for general anesthesia in case
regional anesthesia fails.
• Preparation for regional anesthesia (spinal or epidural anesthesia)
requires a vigilant cardiac, sensory and motor monitoring prior,
during and after local anesthetic administration.
• Patient must be hooked to a cardiac monitor equipped with:
9 Electrocardiogram
9 Non-invasive blood pressure monitoring
• Proper hydration – to minimize hypotension perioperatively.
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1. Surface Anatomy Landmarks

• When spinal and lumbar epidural anesthesia is to perform, the
surface landmark at the back would be an:
9 Imaginary line drawn between the highest points of both iliac
crests (Tuffier’s line) which usually crosses the L4 vertebral
body or the L4-L5 interspace.
• When performing a cervical epidural block:
9 First palpable spinous process – C2
9 Most prominent spinous process – C7 (vertebra prominens).
9 Needle is inserted with only a slight cephalad angle.
• When thoracic epidural anesthesia is contemplated
9 The surface landmark of the spinous process of T7 is usually
at the same level of the inferior angle of the scapulae.
9 Needle is inserted more cephalad to enter.

Cervical Epidural C7 (Vertebra Prominens)

Thoracic Epidural T7
Spinal and Lumbar Tuffier’s line (L4-L5 interspace)

Figure: The effect of flexion on adjacent vertebrae. A: Posterior view.

B: Lateral view. Note the target area (interlaminar foramen) for neuraxial
blocks increases in size with flexion.

2.2Sitting Position
• Obese and pregnant patients may benefit from this position since
these patients cannot tolerate the fetal position of lateral decubitus
because of their enlarged abdomen.
• Patients sit on the side of the operating table with knees pushed at
the edge of the bed with legs/feet resting in a chair or footstool and
the arms comfortably hugging a pillow.
• The flexion of the spine arching like a “mad cat” brings the target
area closer to the skin surface

Figure: Surface landmarks for identifying spinal levels.

2. Positioning
2.1 Lateral Decubitus
• Patients lie on their side (right or left) with their knees flexed pulled
high against the abdomen in which it assumes a “fetal position”

Figure: Sitting position for neuraxial blockade.

Note an assistant helps in obtaining maximal spinal flexion.

2.3Buie’s (Jackknife) Prone

• This position is best utilized among anorectal procedures with an
isobaric or hypobaric local anesthesia.
• The block is done in the same position as the operative procedure,
the patient does not have to be moved after spinal blockade.
Figure: Lateral decubitus position for neuraxial blockade.
• The CSF in this position will not freely flow so a CSF aspiration
Note the assistant helping to provide maximal spine flexion.
must be done to confirm placement of the needle.

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V. SPINAL ANESTHESIA
• aka Subarachnoid Block
9 Sensory function → analgesia
9 Autonomic function → sympathetic block
9 Motor function → paralysis
• Process:
9 Lumbar tap
9 Injection of the Local Anesthetic

1. Technique
• Spinal anesthesia or aka subarachnoid or intrathecal block can
be performed in a midline or paramedian/lateral approach in a
patient lying in a lateral decubitus, sitting or prone position.
Figure: The prone jackknife position often used for anorectal surgery • As needle traverses at the entry site:
can also be used for caudal anesthesia in adults. 9 First pop (resistance) – penetration of ligamentum flavum
9 Second pop – dura-arachnoid membrane in which upon
3. Anatomic Needle Approach withdrawing the needle stylet, a free-flowing CSF is
appreciated.
3.1 Midline Approach
1) The plane of the back is usually perpendicular to that of the floor. 1) Lateral decubitus; Tuffier’s line identified
2) Tuffier’s line (L4-L5 interspace) is identified → needle entry site 2) Asepsis and antisepsis
3) Asepsis and antisepsis: Prior to needle entry, a 10% betadine 3) Local anesthesia (2% Lidocaine)
will be applied on and around the needle site entry. 4) 1st pop → ligamentum flavum
4) Local anesthesia (2% Lidocaine) on the desired needle site entry 5) 2nd pop → dura-arachnoid membrane
5) After 2-3 minutes of local infiltration, a procedure needle is inserted 6) Free-flowing CSF
midline with slightly cephalad direction (spinous processes at this
level are more caudad) traversing the following layers:
9 Skin → subcutaneous → supraspinous → interspinous
ligament → ligamentum flavum
6) From this point, the techniques for spinal and epidural differ.

Figure: Spinal anesthesia

2. Factors Influencing Level of Spinal Block

Figure: Lumbar epidural anesthesia; midline approach. TABLE 45-2
Factors affecting the dermatomal spread of spinal anesthesia
3.2 Paramedian or Lateral Approach Most important factors
• Applicable in patients who cannot positioned easily Baricity of anesthetic solution
9 Severe arthritis, kyphoscoliosis or spine surgery Position of the patient
1) Tuffier’s line identified During injection
2) Asepsis and antisepsis Immediately after injection
3) Local anesthesia (2% Lidocaine) → 2 cm lateral to the inferior Drug dosage
aspect of the superior spinous process of the desired level. Site of injection
4) Needle is directed and advanced at a 10-25° angle toward midline. Other factors
5) Techniques for spinal and epidural applies Age
Cerebrospinal fluid
Curvature of the spine
Drug volume
Intraabdominal pressure
Needle direction
Patient height
Pregnancy

1.1Baricity of the Anesthetic Solution

• The migration of local anesthetic depends on its density relative to
CSF (baricity).
• The CSF specific gravity is 1.003-1.008 at 37°C.
9 Hyperbaric anesthetic solution is heavier (denser) than CSF
that tend to move to the most dependent area of the spine]
9 Hypobaric is lighter than CSF that tends to move to the most
independent area of the spine.
Figure: Paramedian approach.

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1.2 Position of the Patient 5. Failed Subarachnoid Block

• When in a head-down position
9 Hyperbaric solution will move to the cephalad area.
9 Hypobaric solution moves to the caudad area.
9 Isobaric solution tends to stay at the level of injection since it
has the same as CSF density.
1.3 Drug Dosage and Site of Injection
• The larger the dosage of local anesthetic solution or the more
cephalad the site of injection, overall, the more cephalad
distribution level of anesthesia is expected.
1.4 Patient’s Height and Vertebral Column Anatomy
• Spinal curvature affects the anesthesia level by changing the
contour or shape of the subarachnoid space.
1.5 Direction of the needle bevel
• Higher levels of anesthesia are attained if when the injection is
directed cephalad than if the point of injection is directed laterally
or caudad.
1.6 CSF volume
• Inversely correlates with dermatomal distribution
• In cases of increased abdominal pressure (obese and pregnant
women), epidural veins are engorged thus decreasing CSF volume
are more associated with greater dermatomal distribution for a
given volume of anesthetic solution.
1.7 Increasing Age
• Increasing age is associated with decrease CSF volume thus likely
responsible for the higher levels of anesthesia.
• Spinal anesthesia: one of the most reliable regional block methods.
9 The appearance of free-flowing CSF is a clear indicator that
the needle is in the correct space.
9 1% chance of failure even in the most skilled hands.
• Failure can be described as no block or a partial block leading
to inadequate block height, block duration or quality as
originally planned for the surgical procedure.
• Several mechanisms for the occurrence of failure:
1) Failed lumbar tap
2) Solution injection errors e.g. wrong or inadequate drug dose
3) Inadequate preoperative anxiety alleviation of the patient
• One mechanism by which there can be loss of injectate is during
needle tip displacement after locking the syringe with the drug
and the spinal needle.
9 Pencil tip needles need only a small amount of backward
displacement to result in an accidental epidural injection.
9 The needle may also be inserted just between the dura and
epidural space, resulting in inadequate block.
• Barbotage, or the admixing of local anesthetic and CSF thru
careful aspiration of the latter during before administration of spinal
anesthesia has been traditionally done to assure that the spinal
needle is still in the subarachnoid space after connecting it to the
syringe containing the local anesthetic.
9 However, this practice is being questioned.
9 It has been proposed that the dura or arachnoid matter may
act as a “flap valve” so that initial aspiration of CSF is evident,
but subsequent pushing of the local anesthetic pushes the flap
forward, causing a misplaced injection

3. Spinal Anesthesia Levels VI. EPIDURAL ANESTHESIA

Dermatome Application
C4 (Clavicle) Chest Surgery
T4-T5 (Nipples) Upper Abdominal Surgery
T6-T8 (Xiphoid) Intestinal Surgery, Appendectomy,
Gynecologic Pelvic Surgery, Ureter
and Rectal Pelvic Surgery
T8 (Lower border of ribcage) Abdominal Surgery
T10 (Umbilicus) Transurethral resection, Obstetric
vaginal Delivery and Hip Surgery
L1 (Inguinal ligament) Transurethral resection, If no
bladder distension, Thigh surgery,
Lower limb amputation
L2-L3 (Knee and below) Foot surgery
S2-S5 (Perineum) Perineal Surgery,
Hemorrhoidectomy, Anal Dilation
4. Pharmacology of Spinal Anesthetic Agents
1. Technique
• An epidural anesthesia can be done at cervical, thoracic, lumbar
and sacral (caudal) level.
• This technique can be performed in a single shot or a continuous
epidural anesthesia (intermittent boluses through an epidural
catheter).
• Midline or Paramedian Approach
9 Can be used in inserting the epidural needle.
9 As the needle traverses the skin, subcutaneous, supraspinous
ligaments and interspinous ligaments, the needle must stop
piercing the dura layer.
1) Lateral decubitus; Tuffier’s line identified
2) Asepsis and antisepsis
3) Local anesthesia (2% Lidocaine)
4) Epidural needle must stop piercing the dura layer
5) 2 techniques to identify epidural space
6) Loss of resistance technique / Hanging drop technique

• Hyperbaric bupivacaine and Tetracaine • Two techniques are used to identify the epidural space:
9 Most common spinal local anesthetic solutions. 1) Loss of resistance technique (most preferred by clinicians)
9 Onset of action: Slow (5-10 minutes) 2) Hanging drop technique
9 Duration of action: Long (90-120 minutes)
• Addition of vasoconstrictors to anesthetic solution 1.1 Loss of Resistance Technique
9 The use of vasoconstrictors like alpha-adrenergic agonists
1) Advance the needle until the interspinous ligament
and epinephrine during spinal anesthesia prolongs the 2) Stylet is removed after which a 2-ml syringe filled with saline or air
duration of anesthetic block by decreasing the rate of uptake of is attached to the hub of the epidural needle.
local anesthetics from the CSF. 3) Gentle application of pressure is done as the needle is advanced
to the potential space
Anesthesia Pearls 4) As the tip of the needle reaches the epidural space, a sudden loss
• Only preservative-free local anesthetic solutions are used in
of resistance will be felt and will be seen → saline or air will be
regional anesthesia.
pulled inside by the negative pressure of the potential space.
• Use of lidocaine in spinal anesthesia is no longer used because of
the phenomenon “transient neurological symptoms and cauda
equine syndrome”.
• Saddle block is attained by keeping the patient in sitting position
after local anesthetic injection soaking the lower lumbar nerves
and sacral nerves.

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1.2 Hanging Drop Technique 5. Caudal Anesthesia

• Almost the same technique with the loss of resistance except that
the hub of the needle will be filled with a solution.
9 The needle will be advanced forward until the drop of saline
gets sucked into the epidural space due to its relative negative
pressure.
• An epidural catheter will be inserted if a continuous (intermittent
bolus) epidural anesthesia is desired.
• This is a common technique among the pediatric population.
• Surface landmark:
9 Depression above the coccyx and between the sacral cornua.
• The needle placement is performed by penetrating the
sacrococcygeal ligament at 90° (covering the sacral hiatus created
by the unfused S4 and S5 laminae) then must be angle
downwards as it advanced to enter the sacral hiatus

2. Epidural Anesthesia Test Dose

• This test dose preparation is intended to detect both subarachnoid
and intravascular injection.
• Usual test dose:
9 3-ml of 1.5% Lidocaine with Epinephrine 1: 200,000 solution
(0.005 mg/ml)
• If the epidural catheter in placed is located intrathecally, the
45 mg of Lidocaine will produce spinal anesthesia rapidly
(motor and sensory blockade).
• if the epidural catheter in place is near or threaded intravascularly,
the 15 mcg of Epinephrine will increase the heart rate by 20% Figure: Positioning an anesthetized child for caudal block and palpation
from the baseline for the sacral hiatus. An assistant gently helps flex the spine.
9 If patient taking β-blockers, only an increase in BP is observed.

Anesthesia Pearls
• The onset of the epidural anesthesia is slower; the anesthetic
solution travels and soaks first (entry site level) the surrounding the
dura mater posteriorly, laterally and anteriorly where the nerve
roots are also located.
• Epidural anesthesia block may be differential or segmental block
(anesthetic solution confined near to the injection site). It is
described as a well-defined band of anesthesia at a certain
nerve roots while sparing other nerve roots.
• The lumbar epidural space contains fatty connective tissue,
lymphatics and a rich venous (Batson’s) plexus.

• In some patients where intravascular epinephrine is not prudent,

Fentanyl 100 mcg in the intravascular space will result in
dizziness or drowsiness.
• Care should be given to prevent accidental IV injection of local
anesthetics to prevent Local Anesthetic Systemic Toxicity
(LAST) – done by:
9 Aspirating for blood before administering doses
9 Intermittent dosing
9 Using dilute solutions, especially during labor analgesia
9 Maintaining verbal contact with the patient during giving of the
anesthetic
9 Recognition of the initial signs of LAST is important
3. Factors Affecting Blockade of Epidural Anesthesia
• Epidural anesthesia is not as predictable as spinal anesthesia.
• Dermatomal spread of epidural anesthesia is only partially
affected by gravity.
9 However, patient positioning through lateral decubitus and
Trendelenburg can be applied to attain desired level or block.
• Distribution of local anesthetic is computed according to the
desired level.
9 In adults: a 1-2 ml per segment (vertebra) is accepted.
9 An attempt to block the T4 sensory level requires 12-24-ml
of local anesthetic given at intermittent boluses.
9 Taller patients: require a higher dose at least 2 ml/segment
9 Shorter patients: may only require 1 ml/segment
4. Epidural Anesthetic Agents
• Common epidural anesthetic agents are:
9 Lidocaine (short acting – 30 minutes)
9 Mepivacaine (intermediate acting – 1 hour)
9 Levobupivacaine / Bupivacaine (long acting – 90 min-2 hrs)
• Addition of vasoconstrictors (Epinephrine 5 mcg/ml)
9 Can also prolong the effect of epidural lidocaine by delaying
vascular absorption.
• Addition of opioids (fentanyl and morphine)
9 Can enhance the quality of epidural anesthesia rather than the
duration of block.
Figure: Caudal block. Note the sacrococcygeal ligament is penetrated
with the needle almost at 90° and then must be angled down and
advanced to enter the sacral hiatus.
6. Complications assoc. with Needle / Catheter Insertion
• The most common complication of regional anesthesia is back
pain followed by inadequate anesthesia or failed block and post-
dural puncture headache.
6.1Post-Dural Puncture Headache (PDPH/Spinal Headache)
• The onset of the headache is usually 12-72 hours prior injection.
• It is described to be bilateral, frontal, retro-orbital or occipital that
extends into the nape area.
• Hallmark of PDPH: its association with body position
9 Pain is aggravated with sitting or standing and pain is relieved
by lying down.
9 This is explained from the leaking CSF from the dural defect
causing increased traction on structures that support the brain.
• Treatment:
9 Treatment is aimed at reducing the symptoms until the point of
leakage seals itself.
§ Flat on bed, application of abdominal binder, analgesic
administration and infusion of IV fluids and/or oral fluids to
promote adequate hydration are some of the methods to
alleviate PDPH.
9 Caffeine can also help by vasoconstricting intracranial vessels.
9 However, in cases where headache persists despite
conservative treatment, an epidural blood patch is effective
(90% of patients improve from a single blood patch).
9 Epidural blood patch works by sealing the dural defect by
placing 10-20 ml of autologous blood in the epidural space.

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VII. PERIPHERAL NERVE BLOCKS 2.4Sural Nerve

• A branch of posterior tibial nerve.
1. Upper Extremity Nerve Block • Supplies sensory to the posterior lateral half of the calf and
lateral side of the foot and 5th toe.
Brachial Plexus
• A local anesthetic solution must be injected posterior to the lateral
• As the brachial plexus emerges below the clavicle, the local
malleolus.
anesthetic solution can be deposited at any point depending on the
desired block effects.
2.5Deep Peroneal Nerve
9 Musculocutaneous, Median, Ulnar, Radial, Axillary
• The continuation of the common peroneal nerve.
• This nerve can be block by identifying the depression between the
extensor hallucis longus and extensor digitorum longus tendon in
which the dorsalis pedis artery is appreciated.
• A local infiltration is injected lateral to the pulse.

Figure: Cutaneous innervation of the foot

Figure: The location of local anesthetic deposition along the brachial

plexus depends on the desired effects of the block.

1.1 Axillary Nerve Block

• Position:
9 Patient is in a supine position
9 Head turned away from the arm being blocked
9 Arm is abducted to 90°
9 Forearm is flexed to 90° Figure: Needle placement for ankle block.
9 Brachial artery pulse is palpated
• Tourniquet band is usually applied in the arm to allow the local
VIII. SAMPLEX
anesthetic concentration to soak the axilla area.
• This block provides anesthesia to distal forearm and wrist, but it 1. What is the principal site of action for neuraxial blockade?
has no block to the musculocutaneous nerve because it lies A. CSF C. Spinal cord
outside the sheath and this must be blocked separately. B. Nerve root D. Epidural space

2. Which of the following statement is true regarding hyperbaric

2. Lower Extremity Nerve Block anesthetic solution during spinal anesthesia?
• Ankle Block – A complete ankle block requires 5 separate A. The solution is not dependent on positioning.
injections that provides anesthesia for surgical procedures of the B. The solution will spread cephalad in head-up position.
foot and these nerves are the following: C. The solution will spread caudad in head-down position.
D. The solution will have a greater effect in the dependent side in a
2.1 Tibial Nerve lateral position.

• The largest nerve to block. 3. The adult spinal cord ends at the level of:
• Supplies sensory to the heel and medial side sole of the foot. A. L1 C. L3
• Local infiltration can be injected by identifying first the posterior B. L2 D. L4
tibial artery pulse behind the medial malleolus, thereafter the local 4. In which level is epidural space widest?
anesthetic solution is deposited posterior to the artery in the deep A. L1 C. L3
pocket to the flexor retinaculum. B. L2 D. L4

2.2 Superficial Peroneal Nerve 5. What dermatomal level is needed in doing spinal anesthesia for
appendectomy?
• A branch of common peroneal nerve. A. T4 (answer key) C. T6 (proposed answers)
• Supplies sensory to the dorsal (top) portion of the foot. B. T5 D. T7
• A local infiltration is injected near the lateral malleolus.
6. Which layer of the back is NOT traversed by the spinal needle in a
2.3 Saphenous Nerve paramedian approach?
A. Supraspinous C. Dura
• A branch of femoral nerve
B. Intraspinous D. Ligamentum flavum
• Supplies sensory to the medial side of the leg, ankle and foot.
• This can be block by injecting a local anesthetic solution toward 7. The vascular spinal meningeal layer that coats the spinal cord:
the medial malleolus. A. Dura C. Subarachnoid
B. Arachnoid D. Pia

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