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Mechanisms and
Management of Failed
Spinal Anesthesia

INTRODUCTION

In busy clinical practice, it is not uncommon that

intrathecal injection of local anesthetic in an
attempt to accomplish spinal anesthesia, perfectly
performed, fails. Indeed, despite the reliability of
the technique, the possibility of failure can never
be completely eliminated. Managing a patient
with an ineffective or inadequate spinal anesthetic
can be challenging, and prevention is better than
cure. In this section, we discuss systematically the
potential mechanisms by which spinal anesthesia
may fail: detail strategies to decrease the failure
rate and protocols for managing an incomplete
spinal anesthetic.

NYSORA Tips

Inability to reach the subarachnoid space,

errors in drug preparation or injection, the
unsatisfactory spread of the injectate
within the cerebrospinal fluid (CSF),
ineffective drug action on neural tissue,
and difficulties relating to patient
expectations and psychology rather than
genuine block failure.

The dense neuraxial blockade obtained by the

administration of a spinal (intrathecal) injection of
local anesthetic is widely held to be among the
most reliable regional techniques. The anatomy is
usually straightforward to palpate and identify, the
technique for needle insertion simple and easy to
teach, and the presence of CSF acts as both a
definite endpoint for needling and a medium for
carriage of local anesthetic within the
subarachnoid space. The simplicity of the
procedure was succinctly described by Labat, one
of the pioneers of regional anesthesia, almost 100
years ago.

‘Two conditions are, therefore, absolutely necessary

to produce spinal anesthesia: Puncture of the dura
mater and subarachnoid injection of an anesthetic
agent.’ – Gaston Labat, 1922

Yet, despite this simplicity, failure is not

uncommon. What constitutes failure? At the most
basic level, a spinal anesthetic has been attempted
but the satisfactory conditions for proceeding with
surgery are not obtained. Failure encompasses a
spectrum that includes the total absence of any
neuraxial block or the development of a partial
block that is of insufficient height, duration, or
quality.

In experienced hands, most anesthesiologists

would expect the failure rate of spinal anesthesia
to be low, probably less than 1%. A retrospective
analysis of almost 5000 spinal anesthetics by
Horlocker and colleagues reported inadequate
anesthesia in less than 2% of cases, and failure
rates of under 1% have been described. Yet, the
“failed spinal” demonstrates remarkable
interinstitutional variation, and in some published
reports, it may be much higher. One American
teaching hospital quoted a surprising failure rate of
17%, with the majority of failures deemed
“avoidable.” A second institution reported a 4%
failure rate—more in keeping with expectations,
but nonetheless significant. Analyzing their
failures, “errors of judgment” were felt to be the
main causative factor. The suggestion from these
reports is that with meticulous attention to detail
and appropriate management, most failures of
spinal anesthesia could be prevented.

Patients undergoing an operation under spinal

block expect reliable surgical anesthesia, and an
inadequate block will generate anxiety for both
patient and clinician. In addition, by conducting
this invasive procedure, such as spinal anesthesia,
we subject patients to small but well-established
risks. For these reasons and to improve our own
clinical practice, we must strive to minimize the
incidence of failure, and to do this we must
understand why failure occurs. Broadly, there are
three areas where shortfalls may occur: faulty
technique, lack of sufficient experience to
troubleshoot “on the go” and the lack of attention
to detail. It is helpful to distill the procedure into
five distinct phases and analyze the keys to
success at each stage. In sequence, these phases
are lumbar puncture, injection of local anesthetic
solution, spread of solution through the CSF, drug
action on neural tissue, and patient management.

MECHANISMS OF FAILURE

Unsuccessful Lumbar Puncture

The most evident cause of failure is an inability to

successfully access the subarachnoid space. This
may occur due to incorrect needling technique,
poor patient positioning, anatomical abnormality,
or equipment-related factors. The first two factors
are operator and experience-dependent and
therefore can be considered modifiable.
Anatomical difficulties such as scoliosis, kyphosis,
vertebral collapse, calcified ligaments, or obesity
may increase the difficulty of lumbar puncture,
particularly in the geriatric population, but can be
overcome at least to some degree by good
positioning and clinical experience. Issues with
equipment may result in a lack of CSF flow despite
the correct placement of the needle within the
subarachnoid space. Manufacturing problems
resulting in a needle with a blocked lumen are a
theoretical possibility, but obstruction of the
lumen by clot or tissue is more likely. For these
reasons, the needle and stylet should be visually
checked before starting the procedure, and to
prevent blockage, the stylet should always be in
place when the needle is advanced.

NYSORA Tips

The needle and stylet should be visually

checked before starting the procedure.
Failure to obtain CSF flow despite an
apparently successful needle
placement(s) should raise the suspicion of
needle blockage and prompt needle
withdrawal and “flush test” to assure
patency.

Positioning

Optimal positioning is vital to facilitate needle

placement, particularly in more challenging cases.
The choice of sitting or lateral position is of
personal preference. Sitting may allow easier
identification of the midline, particularly in the
obese, and is often seen as the position of choice
for “difficult” spinals; however, the reverse may also
be true. In any event, the patient should be on a
firm, level gurney or bed that can be adjusted in
height for ergonomic ease. The patient should be
asked to curl up, flexing the entire spine to
maximize the space for needle insertion between
spinous processes. Flexing of the hips, knees, and
neck increases the effectiveness of this procedure.
The presence of a skilled assistant to “coach” the
patient and discourage any lateral or rotational
movement is invaluable.

NYSORA Tips

A useful position tip is to ask the patient

to “try to touch their knees with their
chin”.
This typically leads to a satisfactory flexing
of the spine and facilitates needle passage
into epidural or subarachnoidal space.

Needle Insertion

The classically described site for lumbar puncture

is in the midline between the spinous processes of
the third and fourth lumbar vertebrae. This level
can be estimated by drawing a line between the
anterior superior iliac spines: Tuffier’s line.
Evidence has shown that this landmark may be
very accurate at estimating their level of needle
insertion, and more detailed palpation and making
sure that the presumptive L3/4 level makes sense
(“reality check”). It must be emphasized that great
care must be taken to insert needle below the
conus medullaris, which in some individuals may
be as low as the second lumbar interspace. The
needle should be perpendicular to the skin in both
planes and advanced with caution. Fine
adjustments to the needle angle may be required
if an obstruction is encountered, with a slight
cephalad angulation most commonly required.
Lateral alterations in needle angle may be
required, especially in patients with significant
scoliosis and when needle bone contact occurs at
a greater depth (beyond spinal process),
suggesting needle-contact with the laminae and
the need to re-adjust the needle path lateral-
medial. A clear knowledge of vertebral 3D-spacial
anatomy and a mental image of where the needle
tip is thought to lie will assist the operator in
interpreting tactile feedback from the needle and
guide alterations in needle angle.

In addition to the midline technique, lateral or

paramedian approaches can be used. These have
the advantage of avoiding ossified midline
ligaments, particularly a problem in the elderly, but
are more technically challenging procedures. If
difficulty should be encountered, the same basic
principles apply: Ensuring the patient is optimally
positioned and a thorough understanding of the
path of the needle and the likely obstacle may
yield results.

Adjuncts

The ideal means of achieving the optimal spinal

position is with a patient who is comfortable and
calm, understands what is being asked of him or
her, and has full trust in the anesthesia provider.
Preprocedure counseling, the establishment of
rapport, and a reassuring, professional manner can
facilitate this during the spinal procedure. A small
dose of anxiolytic medication may assist
proceedings, but sedation should be titrated
carefully on the basis that it is easier to give more
drug than to mitigate the effects of an overdose.
Care must be taken to infiltrate local anesthetic to
provide effective analgesia without distorting the
spinal anatomy; an initial intradermal injection will
help to facilitate this. The purpose of these
adjuncts is to attain the ideal position, allay patient
concern, and minimize movement, thus providing
the best possible conditions for lumbar puncture.

Ultrasound

The ubiquitous use of ultrasound in regional

anesthesia has not been adopted as a routine
neuraxial procedure but has several advantages to
offer over a landmark technique. A pre-procedure
scan can be useful in patients with abnormal or
impalpable anatomy to identify the midline and
level of injection and to assess the depth of dura
from the skin. Its use in epidural techniques has
been shown to increase success rates, reduce the
need for multiple punctures, and improve patient
comfort; it seems logical that this would translate
to increased success with spinal anesthesia. Real-
time scanning of needle placement for epidural
insertion has been described but is not a
technique in widespread use. The main obstacles
to uptake of ultrasound in a neuraxial block are
lack of awareness of the technique and limited
training in this area, with the technique requiring
knowledge of the sonoanatomy of the spine and a
high degree of dexterity.

Pseudosuccessful Lumbar Puncture

Rarely, the flow of a clear fluid of non-cerebrospinal

origin through the spinal needle may mimic
successful lumbar puncture without this having
occurred. There are two scenarios in which this
may occur. “Topping up” a lumbar epidural in
obstetric practice for a cesarean section may result
in a reservoir of local anesthetic in the epidural
space. An epidural spread of injectate has also
been reported following lumbar plexus block. This
may be mistaken for CSF at subsequent spinal
injection.

Traditionally, bedside testing for glucose has been

advocated to distinguish this fluid from CSF;
however, a positive glucose test does not definitely
confirm the presence of CSF as the fluid in the
epidural space will rapidly equilibrate with
extracellular fluid. Another, potential source of fluid
mimicking CSF is the presence of a congenital
arachnoid cyst. Tarlov cysts are meningeal
dilatations of the posterior spinal nerve root,
reportedly present in 4.5%–9% of the
population. Such a cyst could result in CSF flow
through the needle, but anesthetic injected may
fail to result in anesthesia. The actual clinical
relevance and occurrence of failed spinal
anesthesia due to the “false CSF” flow from
arachnoidal cysts is unknown.

Solution Injection Errors

Successful lumbar puncture is an absolute

requirement for spinal anesthesia but does not
preclude failure by a number of other
mechanisms. To ensure a block suitable for
surgery, a proper dose of local anesthetic must be
calculated, prepared, and delivered to the site of
action.

Dose Selection

Research into intrathecal drug spread has

demonstrated that providing a dose within the
therapeutic range is selected, alterations in drug
dose have a relatively minor part to play in the
height of spinal block achieved but are significant
in governing the duration and quality of the
result. The dose selected is dictated by a number
of factors, including choice of local anesthetic,
baricity of the solution, patient positioning, the
nature of block desired, and the extent and length
of planned surgery. To choose a suitable dose, the
clinician must have knowledge of the clinical
characteristics and pharmacokinetics of the
intrathecally injected local anesthetics.

Trials of drug dosing during continuous intrathecal

anesthesia have demonstrated that a satisfactory
block can be achieved with relatively low
anesthetic doses. Given that failure of a “single-
shot” spinal is distressing for the patient and can
be associated with increased morbidity (eg, the
requirement for general anesthesia and airway
management during cesarean section), doses
used in practice are often deliberately in excess of
the bare minimum required. The clinician must
weigh the difficulties of managing hypotension or
prolonged anesthesia versus the risk of block
failure.

Studies have shown that in many circumstances,

lower than commonly-used doses (ie, 5–10 mg
rather than 15 mg of hyperbaric bupivacaine) can
be used sufficiently to achieve effective
blockade. This has the advantage of potentially
lessening hypotension and, by increasing the
speed of block regression, aiding postoperative
mobility or decreasing the need for bladder
catheterization. While these techniques can be
successfully used in experienced hands and
appropriately selected cases, the margin for error is
significantly decreased. It becomes imperative
that the entire volume of the syringe is successfully
delivered into the subarachnoid space. Loss of
even a small amount of injectate either via spillage
(see the next section) or simply in the dead space
of the needle and hub may result in an ineffective
anesthetic.

Loss of Injectate

Leakage may occur at the Luer connection

between needle and syringe or from a deficiency
at the joint between needle hub and
shaft. Considering the small volumes involved,
even the smallest leak of the solution may result in
a significant decrease in the dose of drug
delivered. This pitfall can be avoided by ensuring a
good connection between the syringe and needle
hub and visually verifying that no leak is occurring.

Misplaced Injection

It is crucial that during the process of ensuring a

leak-tight connection between needle and syringe,
meticulous attention is paid to avoid accidental
movement of the needle. Once the syringe is
securely connected, aspiration of CSF can be used
to confirm that the tip is still within the
subarachnoid space. This maneuver in itself carries
the potential for needle displacement, as does the
injection of anesthetic solution. For this reason, it is
imperative that the operator secure the needle
position prior to any further manipulation. This can
be achieved by stabilizing the dorsum of one hand
against the patient’s back and anchoring the hub
of the needle between thumb and forefinger while
the other hand has control of the syringe. Many
anesthesiologists would advocate aspirating CSF
postinjection to ensure the needle position has not
moved during the process. Although there is no
evidence to suggest this reduces the failure rate, it
may at least alert the anesthetist to the possibility
that not all of the drug has reached its intended
destination.

NYSORA Tips
Gentle aspiration of 0.5-1 ml before
injection to assure CSF retrieval from the
subarachnoidal space.
Gentle aspiration of 0.5-1ml at the end of
the spinal injection can be done to assure
that the needle tip stayed in the
subarachnoidal space throughout the
injection process.
The aspirated 0.5ml-1ml is then re-injected
and the needle is withdrawn.

Stabilization of the needle during injection is

important with all types of spinal needles but
particularly so with pencil-point” needles
commonly in use. In these needles, the opening
through which injectate emerges is some distance
proximal to the tip; therefore, minimal posterior
displacement of the needle can result in this
opening being outside the subarachnoid space
and subsequent block failure. As the length of the
opening of pencil-point needles is significantly
longer than the bevel of a Quincke needle, it is also
possible for the dura to bridge this opening (Figure
1).

Figure 1. Correct needle placement with (A) all drug delivered to

CSF and (B) malposition where some of the drug is lost into the
epidural space.

This problem may be compounded by the dura

mater working as a flap valve. The opening CSF
pressure results in an initial successful flow of CSF
through the needle (Figure 2a), but on injection,
the dura moves forward and a portion of the
solution flows into the epidural space (Figure 2b).
As with leakage between the needle and syringe,
given the small volumes involved, loss of even a
small amount of injectate may substantially
influence the quality of the block.

If the needle tip is misplaced such that the

arachnoid mater acts as the flap valve, local
anesthetic will spread into the subdural space
(Figure 2c). Subdural block is well recognized as a
potential side effect of epidural anesthesia (where
it may result in a more extensive, prolonged, or
unpredictable effect because of the larger volume
of local anesthetic used for epidural anesthesia),
but it has also been recorded as a consequence of
attempted spinal anesthesia. Subdural injection is
seen relatively frequently during myelography and
its occurrence in daily clinical practice of
anesthesiology is likely underestimated. Due to the
initial flow of CSF and minute distances between
the layers of the dura, these subtle misplacements
are difficult to identify or eliminate. One suggested
solution, once CSF has been successfully located, is
to rotate the needle a full 360° before aspirating.
Theoretically, this may lessen the chance of the
dura layers catching on the opening of the needle.

Due to the initial flow of CSF and minute distances

between the layers of the dura, these subtle
misplacements are difficult to identify or eliminate.
One suggested solution, once CSF has been
successfully located, is to rotate the needle a full
360° before aspirating. Theoretically, this may
lessen the chance of the dura layers catching on
the opening of the needle.

Figure 2. The flap valve effect: (A) CSF is aspirated but on

injection the meningeal layers move, resulting in (B) epidural or (C)
subdural injection of drug.

Inadequate Intrathecal Spread

Even when the entire volume of injectate is

successfully delivered to the intrathecal space, the
spread of solution within the CSF can be
somewhat unpredictable. The practitioner must
have an understanding of the common factors
affecting intrathecal spread and the degree to
which they may be manipulated.

Anatomical Abnormality

Dispersion of injectate within the CSF is dictated

by the complex interaction between the anatomy
of the spinal canal, the physical properties of the
solution, and gravity.

The normal kyphotic and lordotic curvatures of the

vertebral column are important anatomical factors
affecting the spread of solution, and the presence
of anatomical abnormality, including scoliosis, will