SPINAL ANAESTHESIA

Dr. Apexa Chhatrola

Guided by:
 DEFINATION OF SPINAL ANAESTHESIA

 A form of neuraxial regional anesthesia

producing reversible sympathetic block
involving the injection of a local anesthetic into
the subarachnoid space.

 Commonly at L3-L4

 Largest Interspace
 INDICATIONS OF SA

 All procedures carried out on the lower half of the

body.

 Indications include surgery on the lower limb, pelvis,

genitals, perineum, lower abdominal surgeries and
most urological procedures.
 CONTRAINDICATIONS OF SPINAL
ANAESTHESIA

ABSOLUTE -

 Patient refusal
 Infection at the site of injection
 Coagulopathy and other bleeding disorders
 Severe hypovolemia
 Increased intracranial pressure
 Severe MS & AS
Contd…
Relative –

 Sepsis
 Uncooperative patient
 Preexisting neurological deficits
 Severe spinal deformity
 Prolonged operation
 Major blood loss
 THE ADVANTAGES OF SPINAL
ANAESTHESIA

Prolonged block: Pain free postoperative period

Alternative to GA in certain patients esp.
Difficult airway
Respiratory disease
Blunt the stress response to surgery
Cost
Patent airway

Contd…
VERTEBRAE ANATOMY
 CURVES OF SPINE:

The cervical curve: convexity anterior

 The dorsal curve: convexity posterior
 Lumbar curve: convexity anterior
 Sacrococcygeal: convexity posterior

When pt lies in supine position,

•The highest point : Third lumbar vertebra
•The lowest point : Fifth thoracic vertebra.
•Solution heavier than spinal fluid deposited at L3 will flow away
both cranial and caudal directions from the third lumbar vertebra
and tend to pool in region of the fifth thoracic vertebra.
 SPINAL CORD

Extends from foramen magnum to

Adult : lower border of L1 / upper border
of L2
Infants/children : Lower border of L2.

It is about 42-45 cm long.

Duramater, Subarachnoid space & subdural

space: S2 in adults( S3 in children)

S. C gives 31 pairs of spinal

nerves.(8+12+5+5+1)

An extension of piamater, the FILUM

TERMINALE penetrates the dura and attaches
with the terminal end of spinal cord [conus
SPINAL ANAESTHESIA/ANALGESIA
SURFACE LANDMARKS
SURFACE ANATOMY
Anatomic Landmarks to Identify
Vertebral Levels
Anatomic Features
Landmark

C7 Vertebral prominence, the

most prominent process in the
neck
T7 Inferior angle of the scapula
L4 Line connecting highest
points of iliac crests(Tuffier’s
line)
S2 Line connecting the posterior
superior iliac spines
Sacral Groove or depression just
hiatus above or between the gluteal
clefts above the coccyx
SITE
 Adult : L3-L4 or L4-L5 ( or even L2-
L3)
Infant : L4-L5
 A line drawn b/w the highest pt. of
iliac crests (Tuffier’s line) usually crosses
either body of L4 or the L4-L5
interspace

POSITION
• Sitting
• lateral
• Prone(anorectal procedure, hypobaric
solution, jackknife position)
 POSITIONING OF PATIENT

 Sitting
With Legs hanging over side of bed
Put Feet up on a Stool (no wheels)
Assistant MUST keep the patient from Swaying
Curve his/her back like a “C”,

 Lateral Decubitus (Left or Right)

Needs to be Parallel to the Edge of the Bed
Legs Flexed up to Abdomen
Forehead Flexed down towards Knees

 Jack-knife Position
Chosen for ano-rectal surgery
CSF will not drip from hub of needle
Use hypobaric solution
  Anesthetic dose is injected at a rate of approximately 0.2 ml/sec
.

 The patient and operating table should then be placed in the

position appropriate for the surgical procedure and drugs chosen.

Lateral decubitus positioning for a neuraxial block. The

assistant can help the patient assume the ideal position of
“forehead to knees.”
 SPINAL : APPROACHES

1) MIDLINE APPROACH Midline Approach Paramedian

2) PARAMEDIAN APPROACH approach
Skin Skin
Subcutaneous fat Subcutaneous fat
Supraspinous ligament
Structure Pierced Interspinous ligament
Ligamentum flavum Ligmentum flavum
Dura mater Dura mater
Subdural space Subdural space
Arachnoid mater Arachnoid mater
Subarachnoid space Subarachnoid
space
STRUCTURES PIERCED
 MIDLINE APPROACH

•With advancement of needle, two “resistance” are felt. The

first is penetration of the L. flavum & second is the
penetration of dura-arachnoid membrane.

• The stylet is then removed, and CSF should appear at the

needle hub.

•For spinal needles of small gauge, this usually takes 5-10 sec
 PARAMEDIAN APPROACH

 Used in case of Calcified interspinous ligament or difficulty in

flexing the spine
 The needle : 1 cm lateral of the superior spinous process of
desired level.
 Angle : 10-25 toward midline.
 TECHNIQUE OF LUMBAR PUNCTURE

Monitors should be placed.

 Airway, oxygen and resuscitation equipment should be

readily available.

 All equipments for the spinal blockade should be ready

for use.

All necessary medications should be drawn up prior to

positioning the patient for spinal anesthesia.

Preload, Secure large bore IV Cannula in iv line; attach

pint with the help of IV set to vigo, start @10-20ml/kg drip
set.
Proper positioning of the patient is must.

The skin should be painted and drapped in sterile fashion.

The midline should be palpated. The iliac crests are palpated,

and a line is drawn between them in order to find the body of L4
or the L4-5 interspace.

 Local anesthetic is then administered.

Bupivacaine 0.5%, Ropivacaine 0.75%, are most common local

anesthetic drugs used in spinal anesthesia.
DERMATOMES
Dermatome level Surface Landmark
(sensory block)

C8 Little finger
T1,T2 Inner aspect of the arm
T4 Nipple line, root of
scapula

T6 Inferior border of
scapula ,Tip of xiphoid

T10 Umbilicus
L2 to L3 Anterior thigh
S1 Heel of foot
CHECK EFFECT OF ANAESTHESIA
MODIFIED BROMAGE SCALE FOR ONSET OF MOTOR BLOCK

Scale Criteria Degree of motor

block
0 Free movement of legs and feet with None
ability to raise extended leg

1 Inability to raise extended leg, knee Partial (33%)

flexion is decreased, but full flexion of
feet and ankles

2 Inability to raise leg or flex knee, Partial(66%)

flexion of ankle and feet present

3 Inability to raise leg, flex knee or move Complete paralysis

toes
 STOUTS PRINCIPLE FOR SPREAD OF
SOLUTION
• Height of anesthesia directly proportional to
1.Speed of injection
2.Volume of the fluid
3.Specific gravity of fluid
4.Concentration of drug

• Height of anesthesia inversely proportional to

5. Rapidity of fixation
6.Spinal fluid Pressure

7. Height of anesthesia varies with position of patient

ADDITIONAL FACTORS TO CONSIDER WITH
SAB…

 Patient Age
 Elderly patients
 Patient Height
 Intra-abdominal Pressure(Pregnancy &
Obesity )
 Addition of opioids
 Barbotage Technique
 Site of injection
 DIFFERENTIAL BLOCK WITH SAB

 Sympathetic Block- 2 dermatomes higher

than the sensory block

 Motor Block- 2 dermatomes lower than

sensory block
 SPINAL NEEDLE

Spinal needles fall into two main

categories:
(i) those that cut the dura :
Quincke- Babcock needle,
the traditional disposable
spinal needle

(ii) those with a conical tip(Pencil

tip) : Whitacre and Sprotte
needles
If a continuous spinal technique
is chosen, use of a Tuohy or
Hustead needle can facilitate
passage of the catheter QUINCKE WHITACRE SPROTEE
Blunt tip (pencil-
point) needle decreased
the incidence of PDPH.

 Sprotte is a side-
injection needle with a
long opening.
It has the advantage of
more vigorous CSF flow
compared with similar
gauge needles.
 Hustead Tuohy

Examples of continuous spinal needles, including a disposable, 18-gauge

Hustead (A) and a 17-gauge Tuohy (B) needle. Both have distal tips designed to
direct the catheters inserted through the needles along the course of the bevel
opening; 20-gauge epidural catheters are used with these particular needle
sizes.
 BARICITY OF LOCAL ANESTHETICS

 Isobaric – Stays where you put it

 LA has the same density or specific gravity as CSF (1.003-
1.008) – Normal Saline

 Hypobaric – “Floats” up – Lighter than CSF

 LA has a density or specific gravity that is less than CSF
(<1.003) – Sterile Water

 Hyperbaric – Settles to Dependent aspect of the

subarachnoid space – Heavier than CSF
 LA has a density or specific gravity that is greater than
CSF (>1.008) - Dextrose
 HYPOBARIC & ISOBARIC SPINAL ANAESTHESIA

 To make a drug hypobaric to CSF, it must be less dense than

CSF, with a baricity appreciably less than 1.000 or a specific
gravity appreciably less than 1.0069 (the mean value of the
specific gravity of CSF).

A common method of formulating a hypobaric solution is to

mix solution with sterile water & for hyperbaric mix with
dextrose
 SPINAL BLOCK ADDITIVES

Fentanyl(<25µg)
Clonidine(25-50µg)
Dexmedetomidine (3-5 µg)
Neostigmine
Tramadol
Epinephrine (0.2 mg) or phenylephrine (5 mg)
 CARDIOVASCULAR EFFECTS OF SA
Hypotension and bradycardia are the most common side
effects.(30%of baseline fall.)

Arterial and venodilation both occur.

Total peripheral vascular resistance (TPVR) decreases only by
15% to 18%. So,MAP decreases by 15% to 18%,

Because preload determines cardiac output.

patient positioning is a major factor in determining preload.
Most patients do not experience a significant change in heart
rate after spinal anesthesia.
Sympathetic cardiac accelerator fibers emerge from the T1 to
T4 spinal segments, and blockade of these fibers is proposed as
the cause of bradycardia.
Decreased venous return may also cause bradycardia, due to a
fall in filling pressures.

Even though bradycardia is usually well tolerated after spinal

anesthesia, asystole and second- and third-degree heart block
can occur, so it is wise to be vigilant when monitoring.
 RESPIRATORY EFFECTS OF SA

Very little effect on pulmonary function.

Lung volumes, resting minute ventilation, dead space, arterial blood gas
tensions, and shunt fraction show minimal change after spinal anesthesia.

 Effect occurs during high spinal blockade when active exhalation is

affected due to paralysis of abdominal and intercostal muscles.
During high spinal blockade, expiratory reserve volume, peak expiratory
flow, and maximum minute ventilation are reduced.

Patients of COPD that rely on accessory muscle use for adequate

ventilation should be monitored carefully after spinal blockade.
AFFECTIVE DYSPNEA
• Can be seen in patients with normal pulmonary
function with high spinal block.
• Complain: pt can’t breath.
•Cause:loss of proprioception in thoracic cage
structures will provoke a sensation of not
breathing.
•It can be combated simply by asking patient to
take deep breaths or by having the patient smell
aromatic spirits.
ABGA:
Does not change during high spinal anesthesia in patients
who are spontaneously breathing room air; . The main effect
of high spinal anesthesia is on expiration, as the muscles of
exhalation are impaired.

Since a high spinal usually does not affect the cervical area,
sparing of the phrenic nerve and normal
diaphragmatic function occurs, and inspiration is minimally
affected
 GASTROINTESTINAL EFFECTS OF SA

Sympathetic blockade(from T6 to L2) and unopposed

parasympathetic activity.
Secretions increase, sphincters relax, and the bowel becomes
constricted.
Increased vagal activity after sympathetic block causes
increased peristalsis of the gastrointestinal tract, which leads
to nausea and vomiting.
 THE USE OF SA IN OBSTETRICS
Resuscitative equipment and emergency medication must be
readily available.

Require less local anesthetic to achieve the same level of

anesthesia as nonpregnant women.

A T4 level block is usually required for a cesarean section due to

traction on the peritoneum and uterine exteriorization.

Because of the sympathetic blockade, hypotension may result,

It is must to monitor the blood pressure very carefully and
frequently.
It should be treated immediately with medications or fluid
administration, or both.
WHY LESS VOLUME OF DRUG IS NEEDED
IN LSCS?
Explained by two mechanisms.
1) Mechanical factor:
Obstruction of inferior vena cava by gravid uterus.
Distension of epidural venous plexuses.
Effective volume of epidural space and CSF are reduced.
Enhances cephalad spread of LA agents during both spinal and epidural
anesthesia.

2) Hormonal factor:
Mediated by progesterone which makes the nervous tissue more
sensitive to LA agents.
 SA IN GERIATRIC PATIENTS
 Slightly higher spinal levels of sensory and motor blockade.
At somewhat greater risk of hypotension.
Thus, bolus doses of local anaesthetic should be reduced.
 The duration of blockade last longer in the elderly after peripheral nerve
blocks also.
 The clearance of LA decreases with age.
Consequently, infusion rates or top-up bolus doses may need to be adjusted.

 Regional anaesthesia has several beneficial effects for elderly patients,

ex.,reduced blood loss,
better peripheral vascular circulation,
suppression of the surgical stress response and
better postoperative pain control.
 COMPLICATIONS

BRADYCARDIA -
 Defined as HR < 50 beats/ min.
 T1-4 involvement, unopposed vagal tone, decreased
venous return which leads to bradycardia and asystole

NAUSEA AND VOMITING -

 Causes(Hypotension, Increased peristalsis, Opioid
analgesia)
 Associated with neuraxial block in up to 20% of patients,
 Ondensetron is almost universally effective in treating the
nausea associated with neuraxial anesthesia.
 HYPOTENSION
 Fall of >30% from baseline systolic BP of the patient.
 Prevented by - Volume loading with 10-20 mL/kg of
intravenous fluid.
 Treatment of hypotension:
100% O2

FLUIDS -
Crystalloid
Colloid [500-1000ml] preferred due to
increased intravascular time, maintaining
Cardiac output, uteroplacental circulation.
 SYMPATHOMIMETICS:

 Mephentermine:
causes vasocnstriction, increases CO,SBP,DBP.
Variable effect on HR(depends on vagal tone)

Epinephrine:
increases HR, CO, SBP, decrease DBP.

 Phenylephrine:
Increase in SVR, SBP, DBP. Causes reflex
bradycardia, coronary blood flow increased.

 Ephedrine:
increase myocardial contractility and rate.
 SHIVERING

Cover the patient with sterile cloth.

Slow down the speed of pint.
Give Tramadol preceded by emset to control
shivering.
 HIGH REGIONAL BLOCK

Due to inappropriately high spread of LA affecting spinal

nerves.
• High spinal block: spread of LA above T4.
Effects are of variable severity depending upon the
maximum level that is involved.
Includes cardiovascular and/or respiratory
compromise.

•Total spinal block: Intracranial spread of LA resulting in

loss of consciousness.
Spinal level Areas affected Symptoms/signs
T1-T4 Cardiac sympathetic Hypotension
fibers Bradycardia

C6-C8 Hands and arms Parasthesia or numbness

Accessory respiratory in hands and arms
muscles Weakness of hands/arms
Shortness of breath

C3-C5 Diaphragm and Shoulder weakness

shoulders Hypoventilation and
desaturation
Respiratory arrest

Intracranial Cranial nerves/ Sedation

spread(Total spinal) brainstem Slurred speech
Loss of consciousness
Management of total spinal –

 Airway - Secure airway and administer 100%

oxygen

 Breathing - ventilate by facemask or intubate.

 Circulation - treat with i/v fluids and vasopressor

e.g. ephedrine 3-6mg or 0.5-1ml adrenaline 1:10
000 as required

 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.
 POST DURAL PUNCTURE HEADACHE

 Leak of CSF leads to traction in supporting structure especially in dura and

tentorium.
 vasodialatation of cerebral blood vessels.
 Usually bifrontal or occipital.
 Usually worse in upright , coughing , straining
 Causes nausea, photophobia, tinnitus, diplopia[6th nerve], cranial nerve
palsy
 Treatment plan
• Keep patient supine.
• Adequate hydration.
• NSAIDS.
• Epidural blood patch (if not relieved within 12-24 hrs)
Factors that May Increase the Incidence of Post–spinal Puncture
Headache
Age Younger more frequent
Gender Females > males
Needle size Larger > smaller
Less when the needle bevel is
Needle bevel placed in the long axis of the
neuraxis
Pregnancy More when pregnant
Dural punctures (no.) More with multiple punctures

Onset of headache :Usually 12-72 h following the procedure

 Time to shift patient :

Patients should be allowed to leave the recovery room

once it can be demonstrated that…

• Their block is receding appropriately (at least two

dermatomes regression or a spinal level of less than
T10).
•Hemodynamically stable.
THANK YOU…