ANATOMY AND

PHYSIOLOGY OF EPIDURAL
ANALGESIA

MODERATOR: DR. KAJAL

VERTEBRAL
COLUMN

-7 CERVICAL
VERTEBRE
-12 THORACIC
-5 LUMBAR
-5 SACRAL
-3-5 COCCYGEAL
BONES

CURVATURES

- CERVICAL
LORDOSIS
- THORACIC
KYPHOSIS
- LUMBAR
LORDOSIS
- SACRAL KYPHOSIS
 Anatomy of the Epidural Space

Epidural space : everything outside dural sac but within vertebral canal

 Boundaries-

Anterior :posterior longitudinal ligament , vertebral bodies, disc

Posterior: ligamenta flavam, laminae , facet joint capsule

Lateral: pedicles and intervertebral foramina

Superior: closed at foramen magnum

Caudally: ends at sacral hiatus, closed by sacrococcygeal ligament.

..
  Measurement of the epidural space

 Depth of epidural space

- Varies considerably

- commonly 4cm -6cm in 80% adult population

- obese patients > 8 cm, thin built < 3 cm

 Posterior epidural space

0.4 mm (C7-T1),
7.5 mm (upper thoracic region),
3-5mm (mid thoracic level)
4 mm ( T11-12 region )
4-7 mm (lumbar region)

 epidural space >subarachnoid space at same level.

1.5 – 2.0 ml per spinal segment in epidural space

0.3 ml in the subarachnoid space for a similar block.

Nickallis & Kokri, 1986.

 Shape and size of the epidural space

determined - shape of vertebral canal

position and size of dural sac .

cervical epidural space

- fusion of spinal and periosteal layers of dura
-foramen magnum to 7th cervical vertebra.

thoracic epidural space

- C7 to L1
-continuous in lower thoracic level
-cervicothoracic regions shallow space

lumbar epidural space

- L1 - S1 vertebra.
-segmented and dis-continous

sacral epidural space

- S1 to sacrococcygeal membrane
THORACIC AXIAL T2 MRI
LUMBAR AXIAL T2 MRI
 EPIDURAL SPACE and CLINICAL RELAVANCE

 lumbar epidural space segmented and discontinuous

impede catherter passage /coiling

 posterior epidural space continuous in lower thoracic

region

easy catheter passage

 semifluid fat pad occupies posterior epidural space

variability in response observed with epidural anesthetics

 venous plexus fills anterior epidural space

absorption of LA into vessel

 dural sac decreases L4-L5, the posterior longitudinal ligament falls away from dura,
fat fills space

increasing amount fat anteriorly  long latency of epidural anesthesia in

L5 and S1 .

 midsagittal gap b/w two halves ligamentum flavum in thoracic/cervical

regions

a variable LOR with midline approach

 lateral space comminicates with paravertebral space

Degenerative disease, aging narrow intervertebral foramina ,prevent

spread of LA out foramina  greater longitudinal spread )
 LUMBAR EPIDURAL SPACE
Plica mediana dorsalis

Clinical relevance : possibility of developing unilateral epidural blockade.

 The contents of the epidural space

 semi-liquid fat

 lymphatics

 arteries,

 loose areolar connective tissue

 spinal nerve roots

 extensive plexus of veins.

 EPIDURAL FAT

 FUNCTIONS
-buffers pulsatile movements of dural

- protects nerve structure

- reservoir of lipophilic substances

- facilitates movement of dura over periosteum .

 Drugs in dural sleeves fat greater impact on nerve roots

 different pathologies alter absorption / distribution of drugs

 distributed along dorsal margin

-minute quantity of agent react with the nerve roots,

-slight resistance experienced during insertion

 Vertebral venous plexus
.

-Batson’s plexus
- antero-lateral part of epidural space
- drain into azygous system

Clinical importance

- valveless  increased intrathoracic or intra-abdominal pressure lead

major congestion and vessel enlargement

- traumatic /bloody tap

 Epidural arteries

-lumbar region of vertebral column

-branches of ilio-lumbar arteries.

-lateral region of the space .

 Lymphatics

- concentrated in dural roots

-remove foreign materials including microorganisms

 Pressure of the epidural space

 negative pressure.

 initial bulging of ligamentum flavum

followed by its rapid return to resting position
once the needle has perforated the ligament.

 magnified by increasing and reduced by

decreasing flexion of spine.

 more negative in sitting <lateral decubitus

position
• The distribution of solutions in the epidural space

 cephalad direction

 less resistant compartments

 power of injection, negative pressure

 continuous infusion -penetration through dura mater facilitated

 LA affect spinal nerve in sub arachnoid space ( dural cuff)

Nishimura N, Fujimaki T, Oshibuchi M, Yoshikawa I, Aida M

Spread of LA in epidural space
Structures encountered during epidural
block(midline technique)
Structure Comment
Skin
Supraspinous ligament needle sits firmly in midline
Interspinous ligament clear cut resistance to syringe
plunger above L4

Ligamentum flavum increase in resistance to

plunger with elastic
Epidural space controlled well defined LOR,
no ‘drip back’
 Dermatomes and epidural

congruent epidural
Incision level Surgical procedure
placement
Lung reduction,
thoracic T4-T8
mastectomy
Cholecystectomy,
Upper abdominal esophagectomy, T6-T8
whipples

Middle abdominal  cystoprastactectomy, T7-T10

nephrectomy
Aortic aneurysm repair,
Colectomy,
Lower abdominal prostatectomy, T8-T11
hysterectomy
Lower extermity THR/TKR L1-L4

Optimal post op analgesia, minimal side effects

 Anatomical Considerations in paediatric patients

 Posterior superior iliac spines and sacral hiatus form equalateral triangle ( sacral
hiatus)

 Sacral Cornua 0.5-1.0 cm apart

 Dural sac extends to S4 (S2 in the adult)

-check for CSF reflex

 Delayed myelinization of nerve fibers

-Onset time is shortened, and diluted local anesthetic is as effective

 Increased fluidity of epidural fat -Increased

diffusion of local anesthetic

 epidural fat is less densely packed

- impair spread of LA
.
 Formula for depth of epidural space from skin

1. Rough estimate 1 mm/kg body weight

2. Depth(cm) = 1 + 0.15 X age (years)

3. Depth (cm) = 0.8 + 0.05 X weight (kg)

4. Mean depth in neonates= 1 cm

 Formula for calculating volume of drug to be given in epidural/caudal

Modified Bromage formula, i.e. V(ml) = 1.2 ml x 10 segments + 0.1 ml per segment
for each 10 cm height above 120 cm
 PHYSIOLOGY OF EPIDURAL ANALGESIA

 Mechanism

 Vascular absorption
-receptor
-smooth muscle
-cardiac muscle
-neural tissue

 Direct neural blocking effects

-spinal nerves : sympathetic(peripheral T1-L2, adrenal T6-L1, cardiac)

sensory
motor

-spinal cord (axons, cell bodies)

-secondary changes in vasoactive hormones

 Effect on nervous system

Erlanger and Gasser classification

 Sympathetic Nervous System-

 Pre-ganglionic sympathetic fibres most sensitive

 sympathetic denervation > sensory denervation in SAB - “Differential

Blockade”.

 sympathetic block =sensory (epidural)

 Sympathetic block wears off later than motor and sensory blockade
Sympathetic block, sensory block, motor block
 Afferent Sensory Nerves-

 dorsal root ganglia , nerve roots blocked

 sensory block cephalad to motor block

 A-delta fibers more sensitive than C fibers.[ “Fast” pain >“slow” pain]

 Somatic Motor Nerves-

 most resistant

 A-gamma fibers blocked readily than A-alpha fibers.

 better surgical conditions

 Spinal Cord-

 Subtle effects

 Intra-cordal transmission affected

 pain and somatic motor impulses caudad not affected

Brain-
 Cerebral Blood Flow-

 sympathetectomy negligible effect on cerebrovascular

resistance.
 CBF unchanged (MAP >65 mmHg)
 Cerebrovascular reactivity to CO2 tension reduced.

 Cortex-

Somnolence caused by-

 Systemically absorbed local anesthetic.
 Depression of Reticular Activating System.
 Changes in cerebral hemodynamics.
 Epidural block and motor function

 appropriate drug and regimen

 Deep breathing and coughing

 Early ambulation

 Motor effects determined by

1. local anesthetic( bupivacaine least, etidocaine most potent)

2.dose of drug

3. repeated dose of drug(top up technique)

4. epinephrine ( increases)
CARDIOVASCULAR EFFECTS

 Arterial Circulation-

 Sympathetic denervation causes arteriolar dilation.

 Vascular smooth muscle retains significant tone.

 Total peripheral vascular resistance decreases by 15-18%.

 mean arterial BP decreases by 15-18%

 Venous circulation-

 Very few smooth muscles in the wall.

 Maximal vasodilation.

 Preload depends upon position of the patient

Cardiac Output-
 depends on position

 Heart Rate-
 Decrease by 10-15%
 Blockade of cardiac accelerator fibres T1-T4
 decreases in RAP and great veins ( bain bridge reflex)
 severe bradycardia, even asystole( Bezold-Jarisch reflex)

Blood Pressure-
 Depends on level -mid thoracic- 26%
-above T4 – 32%
 Myocardial Oxygenation –
 Decrease in CBF
 Myocardial oxygen demand decreases
 Decreased afterload,
 Decreased preload,
 Decreased heart rate.
 Cerebral Blood Flow –

Unaltered until MAP falls below 65mmHg in normotensive patients

Regional Blood Flow-

 Hepatic blood flow correlates to MAP.

 Renal blood flow unaltered if MAP >60

 Epidural anesthesia and respiration

 improves VC , FRC, PaO2

 improved respiratory exchange ,effective coughing

 Effect of thoracic epidural anesthesia on respiration

 ventilatory reponse to CO2 reduced

 hypoxic drive not impaired

 increase in diaphragmatic function ,

- interrupting inhibitory reflex of phrenic nerve motor drive

- increased abdominal compliance

Resting TV, Maximum inspiratory volume, negative intra-pleural pressure unaffected

dyspneic due to inability to feel chest wall movement

 THE BLADDER

 S2-S4 blockade -temporary atonia (short lived)

 segmental thoracic block (T5-L1) –bladder sensation intact

 GUT and epidural

 Minimal effects on gastric emptying

 stimulates bowel motility

 better surgical exposure

 beneficial effects on integrity of bowel anastomoses( laser doppler flowmetry)

 Epidural block and reduction of blood loss

 Operative blood loss reduced

-Reduction in arterial pressure

-increased venous capacitance

-prevention of high venous pressure

-Avoidance of reactive arterial hypertension

-avoidance of increased airway pressure ( venous

pressure)
 Venous return and epidural blockade

Decreased venous return

Sympathetic Positioning/
blockade OBSTRUCTION
Reduced
myocardial oxy Bain bridge
reflex CHANNELING

Decreased HR
INCREASED EPIDURAL
VENOUS PRESSURE

INCREASED
SEGMENTAL
ANALGESIA
 Venous return compromised

- Supine hypotension syndrome/ extreme lordotic posture

-uterine contraction

-intestinal obstruction, ascites and large intraabdominal tumors

 Common causes of vena caval obstruction

- poor positioning

- Heavy handed retractors

- Abdominal packs

- Extrema positiong ( jack knife, lateral kidney, hyperflexed lithotomy)

 Neuro endocrine effects of Epidural blockade

 Surgically induced endocrine and metabolic changes abolished

 degree of inhibition

- Extent of block
- Site of surgery

 Epidural opioids < LA

 thromboembolic episode, negative nitrogen balance, immunosuppresion

reduced
  HEPATIC SYSTEM

 HBF decreases

 hepatic oxygen extraction increases with decreasing hepatic blood flow.

 HBF is maintained as long as MAP is maintained.

 T4 block-minimal changes in hepatic blood flow, oxygenation and drug

metabolism.
  RENAL SYSTEM

 auto-regulation.

 renal blood flow unchanged (MAP>50mmHg).

 prolonged, severe hypotension, blood flow remains adequate

 Thermoregulation and shivering

 Sympathetectomy induced vasodilation

 redisturbution of heat (central hypotermia)

 Shivering like tremors -30% pts

 decrease core temperature triggers vasoconstriction and shivering above block

 pt donot feel cold (LA inhibits cutaneous cold receptor input to hypothalamus)

 spinal or epidural thermoreceptors in initiating shivering minimal

 non thermoregulatory etiology : systemic absorption of LA, central transfer of

epidural anesthetic