TECHNICAL SKILLS
Spinal anaesthesia
Amy LK Sadler
Paul DW Fettes
Abstract
Spinal anaesthesia involves the injection of local anaesthetic solution
into the intrathecal space. It is a widely practiced anaesthetic tech-
nique that can provide surgical anaesthesia for procedures below
the umbilicus. Due to the proximity of the central nervous system,
safe practice is of paramount importance and requires a good under-
standing of relevant anatomy, physiology and pharmacology. Compli-
cations are rare but need to be recognized and managed rapidly and
appropriately.
Keywords Local anaesthetics; regional anaesthesia; spinal anaes-
thesia; spinal cord; subarachnoid space
Royal College of Anaesthetists CPD Matrix: 2G01, 2G02, 2G04
Spinal anaesthesia is a form of regional anaesthesia involving the
injection of local anaesthetic into the intrathecal space. First
pioneered over 100 years ago, it remains an important anaes-
thetic technique utilized in a variety of clinical situations.
Spinal anatomy and landmarks
Spinal anaesthesia should be performed below the level of
termination of the spinal cord to minimize the possibility of
direct injection into and trauma to the cord. The cord terminates
at approximately L1 vertebral level in adults, and as low as L3 in
neonates. The line joining the highest points of the iliac crests
(Tuffier’s line) lies at approximately L4 level and can be used to
estimate lumbar interspace position. In adults, the L3eL4 and
L4eL5 interspaces are most commonly used. However, clinical
estimation of vertebral level is known to be inaccurate and
although these interspace levels should be below the termina-
tion of the spinal cord, appropriate care must be taken when
performing dural puncture to avoid inadvertent nerve damage.
When performing a spinal injection using the midline approach,
the anatomical layers encountered from posterior to anterior
are: skin, subcutaneous tissue, supraspinous ligament, inter-
spinous ligament, ligamentum flavum, epidural space, dura
mater, arachnoid mater and finally the subarachnoid space
containing cerebrospinal fluid (CSF). Although currently not
routine practice, ultrasound imaging can be used to aid identi-
fication of vertebral anatomy and neuraxial block placement,1
especially in patients with significant spinal deformity or
morbid obesity.
Amy LK Sadler FRCA is a Specialty Registrar in Anaesthesia at
Ninewells Hospital, Dundee, UK. Conflicts of Interest: none declared.
Paul DW Fettes FRCA is a Consultant Anaesthetist at Ninewells
Hospital, Dundee, UK. Conflicts of Interest: none declared.
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Learning objectives
After reading this article, you should be able to:
C discuss spinal anatomy and landmarks relevant to spinal
anaesthesia
C describe indications and contra-indications for spinal
anaesthesia
C discuss spinal needle and drug choices available for spinal
anaesthesia
C describe the technique of spinal anaesthesia
C understand the physiological effects and potential complica-
tions associated with spinal anaesthesia
Indications
Spinal anaesthesia may be considered for surgery below the
umbilicus anticipated to be of less than 3 hours’ duration. This
can include lower abdominal and pelvic procedures (e.g.
inguinal hernia repair, Caesarean section, transurethral resection
of the prostate), as well as lower limb procedures. Contra-
indications to spinal anaesthesia are shown in Table 1.
Equipment
Spinal needles are available with different needle-tip designs and
a variety of gauges. Needle-tip design has been shown to affect
the frequency of post-dural puncture headache (PDPH), which is
due to low CSF pressure.2 Pencil-point tipped needles (Whitacre,
Sprotte) reduce the chance of PDPH and should be used in
preference to Quinke needles which have a cutting bevel
(Figure 1). Smaller needle size (25G, 27G) is also associated with
reduced PDPH.2 Most narrow gauge spinal needles come with a
short introducer needle designed to assist with spinal placement
and reduce carriage of tissue into the subarachnoid space. Pencil-
point needles are often described as ‘atraumatic’ because it was
traditionally thought that they gently spread the dura, allowing it
to close over after the needle was withdrawn. In fact, this is a
misnomer. Electron microscopy has demonstrated that pencil-
point needles produce a bigger and more ragged hole which is
thought to promote an inflammatory reaction and healing. In
contrast, the cutting needles produce a smaller, neater hole, but
one with a flap which allows persistent leakage of CSF.3
Technique
Spinal anaesthesia can be performed either via a midline or
paramedian approach. A midline approach (the most common) is
described here.
1. Informed consent must be obtained from the patient.
2. The procedure should be performed with the help of a
trained assistant and in an area with full resuscitation
equipment.
3. The patient should have intravenous access and monitoring
(oxygen saturation, ECG and blood pressure.
4. Position the patient either sitting or lateral with maximal
lumbar spine flexion.
5. Full aseptic technique should be used (hat, mask, surgical
scrub, gown, gloves).
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 TECHNICAL SKILLS
Contra-indications to spinal anaesthesia
Absolute Relative
Patient refusal Fixed cardiac output state
Local infection Systemic sepsis
Genuine allergy to any drugs used Hypovolaemia
Raised intracranial pressure Neurological disease
Unknown duration of surgery
Coagulopathy
Table 1
6. Prepare the back with antiseptic solution (chlorhexidine
0.5% with 70% alcohol) and allow it to dry. It is vital that
the work surface, equipment and gloves are not contami-
nated with chlorhexidine.
7. Position a sterile drape.
8. Identify the midline of the selected interspace.
9. Inject local anaesthetic (usually lidocaine) subcutaneously at
the chosen insertion point.
10. Insert the introducer needle and slowly advance it (beware
advancing fully in a slim patient because of the risk of dural
puncture with the wide bore introducer).
11. Insert the spinal needle through the introducer. When the
ligamentum flavum is reached, the needle will feel like it is
being ‘gripped’. There will then be a subtle pop or click felt
as the dura is penetrated.
12. Withdraw the trochar and wait for free flow of CSF.
13. Attach the syringe containing local anaesthetic solution,
aspirate to ensure clear CSF and free flow, and then inject.
14. Withdraw the needle and introducer together.
15. Move the patient supine and monitor while waiting 5e10
minutes before checking the block.
Drugs
Agents used in spinal anaesthesia should be preservative-free to
reduce the risk of neurotoxicity or arachnoiditis. The most
commonly used local anaesthetic agents are probably bupiva-
caine and levobupivacaine. Prilocaine, another amide local
anaesthetic agent, has a comparably shorter onset time with
faster block regression, and is therefore an option for shorter
duration day case procedures. Lidocaine is best avoided because
Common tip designs for spinal needles
Quincke
Whitacre
Sprotte
Reproduced, with permission, from Anaesthesia and Intensive
Care Medicine 2006; 7: 418—21.
Figure 1
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of its association with transient neurological symptoms (TNS),
which may manifest as back pain or lower limb dysaesthesias.
Permanent nerve damage has also been recorded with concen-
trated lidocaine administration.
Various adjuvants can also be added for spinal anaesthesia.
The most commonly used are opioids which can optimize intra-
operative block and prolong postoperative analgesia by acting on
opioid receptors in the dorsal horn of the spinal cord. Options are
fentanyl (up to 50 mg), diamorphine (up to 300 mg) and morphine
(up to 300 mg). Lipid solubility is the primary determinant of
duration of action. The relatively insoluble agent morphine has a
longer duration of action than diamorphine, which in turn is
longer acting than fentanyl, which is the most soluble of the
three. Opioid side effects that may be seen are mostly doserelated
and can be delayed for up to 24 hours after administration. They
include pruritus, nausea and vomiting, urinary retention and
respiratory depression. Due to the potential for delayed respira-
tory depression, patients who have been given intrathecal opioid
should be observed appropriately, and guidelines will often
suggest supplemental oxygen for up to 24 hours following
administration of diamorphine and morphine.
Block requirements and dermatomes
Surgical anaesthesia for a particular procedure requires spinal
anaesthesia to reach an adequate dermatomal level. As a guide,
the twelfth thoracic dermatome (T12) corresponds to symphysis
pubis, T10 to umbilicus, T6 to xiphisternum and T4 to nipple
level. Transurethral resection of the prostate, for example, re-
quires a block to T10 to remove discomfort caused by bladder
distension.4
Factors affecting block height
The main determinants of block height are shown in Table 2.
It seems intuitively obvious why dose and volume of local
anaesthetic solution should affect the characteristic of the
block. This will not be further discussed here except to point
out that using low-dose spinal anaesthesia to enable early
mobilization may result in a higher failure rate. Care should be
taken accordingly.
Baricity is one of the main determinants of distribution of the
local anaesthetic following injection. Local anaesthetics can be
hyperbaric, hypobaric or isobaric when compared to CSF.
Glucose can be added to the local anaesthetic to render it hy-
perbaric, which causes rapid initial spread of the local anaes-
thetic solution by bulk flow. This leads to a more rapid onset of
block for hyperbaric solutions in comparison to plain solutions.
Factors determining block height
Patient related Anaesthetic related
Position Baricity of solution
Height Dose of drug
CSF volume e reduced in pregnancy Volume of solution
and may be increased (dural ectasia)
in conditions such as Marfan’s syndrome
Table 2
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 TECHNICAL SKILLS
The glucose makes it ‘heavy’ compared to CSF and it therefore
follows gravity in the subarachnoid space to block dependent
neurological regions. Hyperbaric solutions also produce a more
reliable bock with a more predictable maximal block height than
plain solutions. Commercially available ‘heavy’ bupivacaine
5 mg/ml contains glucose 80 mg/ml. Gravity-dependent spread
of hyperbaric solutions can also be utilized to ‘manipulate’ the
block. For example, a ‘saddle’ block can be performed for peri-
neal surgery by leaving the patient sitting for 10 minutes after
spinal insertion. Likewise, a block that is of inadequate height for
surgery may also be improved by putting the patient in a slight
‘head down’ position.
In contrast, plain local anaesthetic injectates are isobaric or
marginally hypobaric compared to CSF. In this case, gravity
plays less of a role in spread which is predominantly by the
slower process of diffusion. In addition to producing a less
reliable block with slower onset compared to hyperbaric prep-
arations, it has been shown that the residual effects of the spinal
take longer to wear off with plain solutions, and are also asso-
ciated with prolonged sacral sensory block and longer time to
regain full motor power.5 For this reason, plain solutions are not
a logical choice for patients undergoing ambulatory surgery.
Plain solution is perhaps more commonly used for spinal
anaesthesia in fractured neck of femur where the slower onset
of block could potentially result in improved cardiovascular
stability, but recent national guidelines recommend that hy-
perbaric solution should be used for this procedure.6 It is also
important to remember that there can be considerable variation
in spread and duration between patients receiving the same
spinal local anaesthetic preparations.
Physiological effects
The systemic effects of a spinal injection reflect the maximum
height of the block. Hypotension is common and reflects
blockade of the sympathetic chain. Management should include
a monitored fluid bolus although there is little evidence for pre-
emptive fluid loading. Vasoconstrictors are the mainstay of
treatment with options including ephedrine, metaraminol and
phenylephrine titrated to effect. Hypotension after spinal
anaesthesia can be exaggerated by the physiological changes of
pregnancy. Phenylephrine is probably the preferred vasocon-
strictor in this situation due to its association with better fetal
acidebase status. Patients with higher spinal blocks at and
above T4 may experience bradycardia due to effects on sym-
pathetic cardiac supply. Rapid onset of a spinal block tends to
add to cardiovascular instability. Similarly, a spinal block above
T10 may start to impact on intercostal muscle function as well
as abdominal muscles and have a negative influence on respi-
ratory function. Loss of sympathetic innervation of the abdom-
inal tract coupled with increased vagal activity can lead to
nausea and vomiting.
Complications
The incidence of major complications after spinal anaesthesia is
fortunately rare. A National Audit Project of the Royal College of
Anaesthetists estimated the risk of paraplegia or death after
spinal anaesthesia at 2.1 per 100,000 cases (95% CI 1.0e5.4).7
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Total spinal
This describes the extension of a spinal block up to the cervical
region and then on into the hindbrain. It typically presents with
rapid onset of profound motor and sensory blockade, followed by
cardiovascular and respiratory embarrassment and uncon-
sciousness. Urgent supportive management is required until the
spinal effects regress.
PDPH
Sufferers typically report a severe fronto-occipital headache
within 3 days of neuraxial anaesthesia. The headache is usually
worse when upright, improved by lying supine and may be
associated with nausea and vomiting, tinnitus and visual
disturbance. Risk factors include use of a ‘cutting’ bevel spinal
needle, larger gauge needles, multiple attempts, age (less com-
mon in the elderly) and female gender. Once other intracranial
pathology has been excluded, management is initially supportive
and includes analgesia and hydration. If the headache remains
resistant, an epidural blood patch may be considered.
Neurological sequelae
Permanent neurological damage is rare but potentially devas-
tating. It can be caused by direct damage to nerves or the cord
itself, or by the injection of neurotoxic substances. Radicular-
type pain or paraesthesia during spinal injection is a potential
indicator of nerve damage and injection attempt should be
terminated if this occurs. Use of drugs containing preservative is
not recommended, and concerns have been raised over the safety
of ketamine when used for neuraxial blockade. More recently,
neurological injury has also been linked to chlorhexidine
contamination during use as an antiseptic for neuraxial anaes-
thesia. Therefore, current guidance advises use of 0.5% chlor-
hexidine solution, rather than 2%, and meticulous care in taking
measures to prevent chlorhexidine from reaching the CSF, e.g.
ensuring it is kept separate from spinal equipment and allowing
it to first dry on the skin.8
Other neurological complications include infection and hae-
matoma. Infections such as meningitis and epidural abscess
remain rare and may reflect poor aseptic technique or endoge-
nous seeding from the patient. The classic triad of epidural
abscess (fever, back pain and neurological deficit) is not always
present and symptoms may be more insidious. Neurosurgical
review is important, and the treatment generally involves anti-
biotic therapy. Neuraxial haematoma is also rare but there may
be a higher index of suspicion in the context of coagulopathy
and procedural difficulty. Patients typically present with new
onset back pain associated with sensory loss, motor block and
bladder and bowel dysfunction. Symptoms may be masked by
the effects of the spinal block itself and it should always be
ensured that a block has worn off as expected. When haema-
toma is suspected, urgent neurological imaging and neurosur-
gical input should be obtained as improved neurological
recovery is possible in patients who have undergone surgical
decompression within a 6e12 hour window.
Abnormalities of coagulation
Neuraxial block in patients with abnormalities of coagulation is a
relative contra-indication and needs to be considered carefully.
The rarity of complications means it is difficult to make accurate
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 TECHNICAL SKILLS
estimates of risk but the potential for haemorrhagic sequelae
including haematoma is likely to be raised. The risk of spinal
haematoma is generally accepted to be lower with spinal
anaesthesia than with epidural anaesthesia because of the
smaller size of needle used. In elective patients it is important
that anticoagulant therapy is identified at pre-assessment and
managed appropriately. In urgent or emergency patients, a de-
cision to proceed or postpone surgery may need to be made to
allow for correction of coagulopathy. In all patients, a ‘stop
before you block’ safety pause is advisable, and coagulation
status should be considered as part of this. Anaesthetists should
be aware that new antithrombotic drugs, especially oral hep-
arinoids and antiplatelet drugs, are frequently appearing on the
market. National guidelines exist to aid decision-making and
should be referred to where appropriate.9 The benefit of regional
anaesthesia should always be considered in relation to the risk to
the patient of performing a block. It is advised that an experi-
enced anaesthetist perform the procedure if there is a known
abnormality of coagulation.
Failure
Although neuraxial block is a popular well-proven technique,
even experienced practitioners occasionally find that their spinal
block is inadequate or ineffective. Failure rates are generally
reported to be 1e2%, although in some series much higher in-
cidences have been reported.10 This will usually be the result of
failure to deliver the intended dose of local anaesthetic to the
subarachnoid space. Other factors that can result in inadequate
blockade are solution injection error, anatomical abnormality,
and also difficulties related to patient expectations. The strategy
for managing a failed spinal block depends on the suspected
cause, the nature of the failure and the timing. If there is no block
at all after at least 15 minutes time, then options include
repeating the spinal or offering general anaesthesia. Patchy,
unilateral or inadequate blocks may respond well to postural
manoeuvres (when a hyperbaric mixture has been used), and
patients can often be managed with judicious doses of sedation
and/or analgesia, although general anaesthesia may still be
necessary in some cases because inadequate sub-arachnoid drug
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administration will inevitably result in a significantly shorter
duration of surgical anaesthesia. A
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