SPINAL ANESTHESIA - ANATOMY AND PHYSIOLOGY

CHAIR PERSON : DR.G.HARINATH ( PROFESSOR )

MODERATOR : DR.ZEESHAN WARSI ( ASSISTANT PROFESSOR )

PRESENTER : DR.VINUSHA ( 2021-22 batch)

MALLAREDDY INSITUTE OF MEDICAL SCIENCES

 CONTENTS

❖ HISTORY OF SPINAL ANESTHESIA

❖ VERTEBRAE PARTS

❖ LIGAMENTS

❖ EPIDURAL SPACE

❖ SPINAL CORD

❖ PHYSIOLOGY
 HISTORY

Spinal anesthesia is the regional anaesthesia obtained by blocking the spinal nerves in the subarachnoid space.
❖ The term ''Spinal Anesthesia'' was coined by Leonard Corning in 1885.

❖ August Bier performed the 1st case of SA in humans using the LA Cocaine in 1898.

❖ Heinrich Quincke had described the technique of lumbar puncture and observed that it can be safely performed at L3 and L4 lumbar interspace.
❖ Braun successfully performed spinal anesthesia using Procaine in 1905.
❖ Sise used Tetracaine in 1935.
❖ Gordon lidocaine by in 1949
❖ Emblem bupivacaine by in 1966
 INTRODUCTION

❑ The vertebral column has four primary functions are :

protection of the spinal cord

support of the head
provision of an attachment point for the upper extremities
transmission of weight from the trunk to the lower extremities

❑ In regard to regional anesthesia, the vertebral column serves as the landmark for a wide variety of
regional anesthesia technique so it is important for the anesthesiologist to develop a 3D mental image
of the structures comprising the vertebral column.
 SPINAL ANATOMY

❑ The vertebral column consists of 33 vertebrae :

7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal segments.
❑ A pair of spinal nerves leaves each segment of the spinal cord
❑ Two primary curvatures with their convex aspect directed posteriorly. These curvatures persist through
adulthood as the thoracic and sacral curves.

❑ The cervical and lumbar lordoses are secondary curvatures that develop after birth.

❑ The secondary curvatures are convex anteriorly and augment the flexibility of the spine.
❑Curvatures of spine
❖ Highest point of spinal curve : L3
❖ Lowest point : T5
❖ This is important because hyperbaric solutions given at L3 will pull at T5 and lower lumbar region and hypobaric
solution will concentrate at L3.
❖ Cervical and lumbar are LARDOTIC
❖ Thoracic and sacral are KYPHOTIC
TUFFIER’S LINE :
• Is a horizontal line that connects the highest points of iliac crests
• Is an important marker to determine the puncture level
 STRUCTURE OF A TYPICAL VERTEBRA
❖ Anteriorly : body

❖ Posteriorly: two pedicles

❖ Two lamina join the pedicles

❖ Lamina gives rise to :

➢ laterally : the transverse process
➢ posteriorly : the spinous process
acets :

a flat or nearly flat surface on a bone

bral articular facets are where two vertebrae articulate .
be one pair of facets on the superior side of the vertebrae and one pair on the inferior side of th
 CERVICAL VERTEBRAE
• C1 : has no body
• It consists of an anterior and posterior arch joined by the thick lateral mass
• The superior articular facets are strongly concave for articulation with the occipital
condyles
• C2: The superior articulating facets are large oval and they face upwards and outwards
• They have small transverse process and laminae are thick and the spine is large strong
and bifid
c7: The first vertebrae to be clearly palpable is C7 ( vertebrae prominens )
• Transverse process is large and has one posterior tubercle
 THORACIC VERTEBRAE
Body : heart shaped
Vertebral foramen : circular, diameter relatively small
Spinous process : long ,
T1 - projects almost horizontally backwards
Mid thoracic vertebrae - angled caudally
( therefore it is necessary to give a markedly cephalad
angulation to pass between the spines )
 LUMBAR VERTEBRAE
ey shaped
n :traingular , larger than the thoracic and smaller than the cervical

ss : slender , increase in length from L1 to L3 , then becomes shorter So T3 transve

 Sacral vertebrae
• 5 fused vertebrae
. In childhood the sacral vertebrae are Connected by cartilage ………..> fuse to
Single structure after puberty
• Sacral hiatus :Triangular and obliquely placed a lower end of sacrum
pating the sacral cornua as 2 bony prominences , the sacral hiatus could be identified as
e in between
dle is inserted at 45 degrees to the sacrum and redirected if the posterior surface of sacral bone is c
TYPES OF VERTEBRAE:

CERVICAL THORACIC LUMBAR

VERTEBRAL Small Heart Kidney

BODY Oval shape Shaped Shaped

Triangular
VERTEBRAL Large and Small and Larger than
FORAMEN Triangular Circular Thoracic ,smaller
Than cervical

Long and
Foramen
TRANSVERSE Long and strong slender
Transversarium
PROCESS
Present
posterolaterally l accessory
process +

ARTICULAR Obliquely Vertical Vertical

PROCESS placed facets articular facets articular facets

Long,slope
C3 -c5=short
SPINOUS c3-c6=bifid
posteroinferiorly, Short,sturdy,thick
tips extend to ,broad,hatchet
PROCESS c7=longer=vertrae level of vertebral
prominens
shaped
body below
 INTERVERTEBRAL FORAMEN:
• Formed by superior vertebral notch and
• for passage of spinal
inferivertebralnotches
nerve
VERTEBRAL CANAL:
Formed by
• 1.posterior surface of vertebral bodies
• 2.vertebral arch (pedicle +lamina)
• 3.intervertebral disc
• 4.connecting ligaments
Contains spinal cord
INTERLAMINAE FORAMEN:
LIGAMENTS:
* bind together the vertebral column
* assit in protecting the spinal cord
IMPORTANCE
for anaesthetist
Different sensations of resistance that these ligaments impart to the
advancing needle can with practice be appreciated by the operator
and are invaluable aid to successful technique
• Supraspinous ligament : strong, thick,fibrous band from C7 to sacrum
• Supraspinous continues as ligamentum nuchae from C7 and attach to the occipital protrubence
at the base of the skull
• Interspinous ligament :thin, fibrous structure extends from apex and upper surface of a lower spine
toward the root and inferior surface of the next higher vertebrae
connect adjoining spinous process from tips to their roots

Fuses :anteriorly with ligamentum flavour

Posteriorly with supraspinous ligament

In lumbar region : wide and dense

 LIGAMENTUM FLAVUM:
• The ligamentum flavour consists of yellow elastic
tissue
• They extend in perpendicular direction between
the anterior inferior surface of the upper lamina
downward to the anterior superior surface of the
lower lamina
• Thus the ligament exists as right and left half in
each intervertebral space with the halves fusing in
the midline
Blends
• Laterally : capsule of the facet joint
• Medially :interspinous ligament and its fellow fibers of opp.side
Thinest : cervical region
Thickest : lumbar region ( powerful stresses and strains have to be countered )
Function : these ligaments are muscle sparers
Therefore asset in straightening up after bending and in maintaining the erect posture
 INTERVERTEBRAL DISCS :

• responsible for quarter of the length of the spinal cord

Function : shock absorbers placed between the vertebral bodies

Thicker : cervical and lumbar regions ( allow greater mobility )

• If a lumbar puncture needle is accidentally pushed
too farthrough the SA space and into annulus ,the
Nucleus pulposus may prolapse(Sciatica )
EPIDURAL SPACE :
• extends from the Foramen magnum to sacral hiatus
• potential negative space within the bony cavity of spinal cord and outside the dural sac
• Negative pressure is encountered due to initial bluging of the ligamentum flavour in front of
the advancing needle .
Boundaries
Anteriorly :bodies of the vertebrae
Posterior longitudinal ligament
Laterally : pedicles and intervertebral foramina
Superiorly :closed by fusion of dura and periosteum atForamenmagnum
Posteriorly :vertebral arches
Ligaments flava
Inferiorly : sacrococcygeal ligament
Contents
• nerve roots and fat
• areolar tissue
• lymphatics
• blood vessels ( Batson venous plexus)
 SPINAL
direct continuation of medulla oblongataCORD :

42 - 45 cms in length

Weight : 24 to 36 gms

Beginning :upper border of atlas

Ends = adult : lower border go L1 vertebrae( 25%)

Newborn :L3 vertebrae

Fetal life : cord extends the entire length of Vertebral canal

( because of differential growth ratesbetween bony

vertebral canal and CNS )
Spinal cord ends at :

Lowe border of L1 50 %

Upper border of L2 40%

Upper border of L3 3%

Opposite T12 5-6%

ANATOMICAL DIFFERENCES BETWEEN ADULT AND PEDIATRIC:

• Lower termination of spinal cord increased risk for direct trauma to the spinal cord
• Lower projection of Dural sac
• Delayed myelination of nerve fibers
• Cartilaginous structure of bones and vertebrae
• Lack of fusion of sacral vertebrae
• Delayed development of curvatures of the spine
• Tuffer line passes over L5 -S1 interspace
 MENINGES :
1.DURA MATER
thickest , outermost meningeal layer
Extends from Foramen magnum and ends at s2
2. ARACHNOID MATTER
delicate ,nonvascular membrane
middle of the 3 investing membranes
spinal arachnoid is a continuation of cerebral arachnoid

SUBARACHNOID SPACE : between Pia mater and arachnoid matter

Contains CSF
When drug injected into subarachnoid space the CSF removes and dilutes the drug,
limiting the possibility of the drug to have neurological damage

SUBDURAL SPACE : between the dura and arachnoid matter

is a capillary interface containing a little Serous fluid
functions as the principal barrier to drugs
It extends into the cranial cavity in the distribution of the
meninges , covering all neural structures , and ends distally at
the lower border of the second sacral vertebrae .
3. PIA MATER
highly vascular membrane
innermost layer
closely applied to the spinal cord and extends into the anterior median fissure
 nal is occupied by a leash of lumbar ,sacral and coccygeal
ne ( horse tail )

na :from the lower end of spinal cord extends a thread like structure ,which ends with the dura an

rna :from S2 ,eventually blending with periosteum on the back of coccyx

 31 pairs of spinal nerves : 8 pairs cervical
12 pairs thoracic
5 pairs lumbar
5 pairs sacra
1 pair coccygeal

Anterior root Spinal nerve trunks

Spinal nerves — Unite in
Posterior root Intervertebral foramina

Cauda equina syndrome : it is a lower motor neuron lesion which occurs due to
Damage to cauda equina
Causes : trauma , tumours and lesions , spinal stenosis and inflammatory conditions
Symptoms :weakness of lower extremities , urinary retention,fecal incontinence,
Sexual dysfunction
Treatment : surgical decompression
 • The nerve root that exits the spine at a
Particular level :exiting nerve root
• Another nerve root goes across the
Disc and exits the spine at the next
Level below :traversing nerve root
( due to unequal development of vertebra )

Spinal nerve traverses

Sclerotomic bodies between
2 segments
Caudal half of one sclerotom
Joins the cephalic half
Of the next sclerotom
Dermatome level doesn’t
correspond to the level of
anesthesia
Blood supply of spinal cord:

2(along the posterolateral sulcus ,from the

Inferior cerebellar artery )

Arteria vasocorona = arterial plexus

Of Pia matter covering the spinal cord

1(In relation to anterior median sulcus )

Formed at foramen magnum
One of anterior radicular branch is
Very large =Arteria radicularis magna
(Supply to lower 2/3 rd of spinal cord)
Or artery of adamkiewicz From vertebral arteries
 ANTERIOR SPINAL ARTERY SYNDROME :

drome caused by ischemia of Anterior spinal artery , resulting in loss of function of anterior 2/3rd of the s
affected : Descending corticospinal tract
Ascending spinothalamic tract
Autonomic fibers
d symptoms : motor paralysis
Loss of pain and temperature
Hypotension , sexual dysfunction, bowel and bladder dysfunction
 Spinal cord perfusion pressure :

• Determined by
Mean arterial pressure - intraspinal pressure
Hypotension
Vessel injury
Obstruction to blood flow decreases SCPP
Veins :6 longitudinal channels
-anteromedian channel Lie in midline
- posteromedian channel
-anterolateral channel (1 pair )
- posterolateral channel (1 pair)

Interconnected by a plexus of veins

Venous vasocorona

Radicular veins

Epidural /internal vertebral plexus

Segmental veins

Azygous and hemiazygous veins SVC

LYMPHATIC DRAINAGE OF SPINAL CORD :

• Deep lymphatic vessels commonly follow the arteries

• At each level , lymph drains to their associated nodes :

Cervical vertebral column - Deep cervical nodes

Thoracic - Posterior intercostal nodes
Lumbar column - Lateral aortic and retro aortic nodes
Pelvis - Lateral sacral and internal iliac nodes
 PHYSIOLOGY OF CEREBROSPINAL FLUID :
:
• clear colourless liquid, light opalescence ( due to presence of globulin )
• PH = 7.4
average volume = 135ml - 150 ml

35ml 25ml 75ml

Ventricles Cerebral Spinal

Subarachnoid Subarachnoid
Space Space

• secretion = choroid plexus of lateral ventricles

• secretion rate = 0.3-0.4ml/min
• protein content = 20mg/dl( equal albumin and globulin fractions)
• glucose = 2.5-4.4 mmol/l ( 50 - 80 mg / 100 ml )
• CSF pressure = 70 - 180 mmH2O - lateral position
= 375 - 550 mmH2O - vertical position

• specific gravity = 1.0003

 Factors affecting the density of CSF :

nsities in women ( 1.00049 ) than in men (1.00058 )

between age , weight or height and CSF density
gest that sex significantly influenced CSF density and may therefore modify subarachnoid distri

sity in pregnant and premenopausal women compared with postmenopausal women and men.
in CSF density depends on mass ( constituent concentrations of CSF, such as glucose and prote
 Circulation of CSF : CSF renewed about 4 times every 24 hours

Choroid plexus

Cerebral ventricles from lateral ventricles

Foramen of Monroe

Third ventricle

Aqueduct of Sylvius

Fourth ventricle Foramina of Luschke and Subarachnoid

Magendie
 Absorption of CSF :

CSF in cranial region occurs in supratentorial region through arachnoid villi

n bodies or granulations ( bulges of arachnoid villi ) and through the meningeal dura into the Grea
 VERTEBRAL ANAMOLIES

. Kyphosis
. Scoliosis
. Spina bifida
. Spina bifida occulta
. Meningocele
. Myelomeningocoele
. Myelocoele
 Kyphosis

Kyphosis is an exaggerated anterior flexion of the spine resulting in a rounded or Hunch back appearance
Scoliosis and kyphosis are often seen together
More common in women
 Scoliosis

omplex deformity of the spine resulting in lateral curvature and rotation of the vertebrae as well as deformity
lly secondary with involvement of respiratory , cardiovascular and neurological symptoms
 Spina bifida

ult from the failure of fusion of 2 arch enters

ciated with any neurological abnormality (spina bifida occult) although in such cases there may be overlying d
e in the vertebral column but majority of defects involve L5 or upper sacral regions
Spina bifida occulta: failure of vertebral arch fusion only
Meninges and nervous tissue are normal
Meningocele : protrusion of meninges through a posterior vertebral defect
Myelomeningocele : neural tissue produces into and may be adherent to the meningeal sac
PHYSIOLOGICAL EFFECTS OF SPINAL BLOCK:

Carries sensory sensation

Motor + autonomic sensation

Reflex arc :
• The reflex arc is a special type of neural circuit that begins with a sensory neuron at a
receptor ( pain receptor in the finger tip ) and ends with a motor neuron at an effector
( skeletal muscle )
 Autonomic system : sympathetic and parasympathetic
• The parasympathetic nervous system is composed of cranial and spinal nerves
• The sympathetic nervous system compromises cell bodies that lie within the gray column of
the spinal cord
• Nerve fibers have different sensitivity to local anaesthesia because of different
Diameter and myelination = B > C > A (A delta > A beta > A alpha )
B = preganglonic autonomic fibers
C = postganglonic sympathetic autonomic ( temperature and pain )
A = largest diameter myelinated fibers
Preganglionic B fibers > pain fibers > touch > propioception > motor fibers

• Intrathecally , local anaesthesia can block nerve conduction at about 1/10th of

Dose required Epidurally
Reason = there is ready access to dorsal and ventral roots which lie bare in the
CSF at their point of entry into ,or emergence from the cord, unprotected by
Dural sleeves or any surrounding glial tissue
SYSTEMIC MANIFESTATIONS OF SPINAL BLOCK:
1.cardiovascular system

Sympathetic blockade

Dilation of both resistance and capacitance vessels

Decreased peripheral vascular resistance

Decreased cardiac output

• The fall in the blood pressure accompanying spinal anaesthesia depends upon
the blockade ( sympathetic block extends somewhat higher than sensory block because B fibers are
more sensitive than A delta and C fibers to local anaesthesia)
• If blockade extends above the level of T5 ,it becomes progressively more difficultto compensate
for the haemodynamic changes and BP will be markedly reduced
Spinal anaesthesia

Block autonomic

Block sympathetic Block parasympathetic

Doesn’t block vagus
• Decreased sympathetic tone
• Vasomotor tone decreases
• Peripheral pooling of blood
due to venous pooling of blood )
common complication of spinal anaesthesia
culating blood volume
ous return
diac output
be compensated by compensatory vasoconstriction above the level of block and sympathetic stimulation
• Cardiac accelerator fibers : postganglionic sympathetic nerve fibers originating in the superior ,
ervical ganglia of the sympathetic trunk , conveying nervous impulses to the heart that increases the rapi
 In normal hypotension :
Arterial BP decreases

Monitored by baroreceptors ( carotid sinus and aortic arch )

Central control ,medullary / hypothalamus

Parasympathetic outflow decreases Sympathetic outflow increases

Heart rate increases( compensatory tachycardia Vasoconstriction

= Marey’s law )

Force of cardiac contraction increases

 Bain bridge reflex ( cardiac reflex ) :
# stretch receptors present in right atrium
So infusion of NS

Increased preload

Stretch in right atrium

Increased heart rate

• In low volume condition = baroreceptor dominates over bain bridge reflex
• In high volume condition = Bain bridge reflex dominates
 Reverse bain bridge reflex :
In spinal anaesthesia block of the cardiac sympathetic nerves by
High spinal block

Venous pooling in periphery ( regional vasodilation )

Decreased stimulation of cardiac stretch receptors ( volume receptors )

Regional vasodilation may

Decreased activity of cardiac sympathetic nerve have beneficial effects = the
blood flow to the legs and the
splanchnic bed are increased .
Vagal predominance Thus the incidence of Deep
vein thrombosis after hip
surgery is signifycantly
Decreased heart rate reduced by spinal anaesthesia
 BEZOLD - JARISH REFLEX :
( Circulatory response )

Decreased left ventricle volume

Stimulate receptors

Paradoxical bradycardia

Increase ventricular filling

he bradycardia and hypotension that occur during SA/EA have been attributed due to this reflex
m
alterations in pulmonary physiology are minimal
pacity
ory reserve volume ( paralysis of abdominal muscles necessary for forced expiration)
ostal muscles and abdominal muscles are often compensated by unaltered function of diaphragm (is

: dependent on accessory muscle ( intercostal and abdominal )

So if the block is high, there can be sever respiratory impairment.
aesthesia should be avoided in COPD
iratory distress : Hypoxia,whether from paralysis of respiratory muscle, from medullary depression , o
ways be treated immediately by the administration of oxygen and by intubation and controlled ventila
3. GIT
• Neuraxial block induced sympathectomy : contracted bowl with relaxed sphincters.
• vagal tone dominance
• increased peristalsis
• nausea and vomiting may occur
4. Urinary system
• Neuraxial block at sacral level blocks both sympathetic and parasympathetic fibers
• urinary retention may occur

5. Metabolic and endocrine

• neuraxial block and suppress the stress response therefore preferred for cardiac patient
sion may decrease regional cerebral blood flow in elderly and hypertensive patients

renal blood flow accompanying neuraxial blockade this decrease is of little importance as renal bl

perfused when the MAP remains above 50mmHg .Transisent decrease in renal blood flow may oc
even after long decreases in MAP,renal function returns to normal when blood pressure returns t
 Identification of high regional block :
Spinal level Area affected Symptoms/signs

T3-T4 Cardiac sympathetic fibers Hypotension

blocked Bradycardia

C6-C8 Hand and arms Paresthesia or numbness ,weakness

of hands/arms
Sob ( accessory resp muscles
affected)
C3-C5 Diaphragm and shoulders Shoulder weakness: respiratory
compromise immenent
hypoventilation and
desaturation ,resp arrest
Intracranial spread Brainstem Slurred speech
Sedation
Loss of consciousness
CONTRAINDICATIONS :
REFERENCES :
. wylie and Churchill 5th edition
. Miller’s 9th edition
. Regional collins 3rd edition
. Barasah 8th edition
THANK YOU !