34.

SPINAL ANAESTHESIA

Spinal anaesthesia is the temporary blockage of nerve transmission in the subarachnoid

space produced by the injection of a local anaesthetic into the cerebrospinal fluid. It
provides safe and reliable anaesthesia for surgery with minimal equipment and drugs.
Absolute contraindications to spinal anaesthesia include patient refusal, infection at the site
of injection, severe uncorrected hypovolemia, and increased intracranial pressure. Relative
contraindications include coagulopathy, sepsis, fixed cardiac output and indeterminate
neurological disease. In addition, the anaesthesia provider must be careful in providing
spinal anaesthesia for a patient with a difficult airway as emergency airway management
may still be required. Spinal anaesthesia should only be performed if all resuscitation drugs
and airway management equipment are available. 
The patient's preparation for spinal anaesthesia should be the same as for general
anaesthesia. The patient should have a preoperative assessment, be fasted, have
intravenous fluids running, monitoring and all appropriate equipment and drugs for securing
the airway should be checked. The patient’s blood pressure should be checked before
performing spinal anaesthesia. Intravenous fluid preloading before spinal anaesthesia is not
effective in preventing spinal induced hypotension; however pre-existing hypovolaemia
must be corrected. Successful spinal anaesthesia depends on  a good knowledge of the
anatomy of the vertebral column and careful positioning of the patient.

Vertebral Column

The vertebral column consists of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral and
4 coccygeal) and has four curves. The cervical and lumbar curves face forwards and the
thoracic and sacral curves face backwards. These curves will affect how far the local
anaesthetic spreads. When the patient is lying supine, the low points of the vertebral
column are at T5 and S2 and the high points at C5 and L5.
Each vertebral body is connected to adjacent vertebral bodies by several ligaments. The
supraspinous ligament runs between the tips of the spinal processes. The interspinous
ligament runs between the spinous processes and the ligamentum flavum connects the
anterior surfaces of the lamina. The ligamentum flavum is a very important ligament for
identifying the spinal and epidural space. It is a very tough ligament and when the epidural
or spinal needle enters it the anaesthesia provider should feel an increase in resistance to
advancing the needle. It is this increase in resistance that warns that they are about to enter
the epidural space and then the subarachnoid space. Deep to the ligamentum flavum is the
epidural space, which contains fat, blood vessels and the spinal nerves that cross it. The
epidural space is widest posteriorly. Its width varies, ranging from 1 to 1.5 mm at C5 to 5 to
6 mm at the level of L2.

Spinal Cord

The spinal cord is contained in the subarachnoid space, surrounded by cerebrospinal fluid.
There are 31 pairs of spinal nerves. The spinal cord usually ends at the lower border of L1 in
adults and L3 in children, though it may be lower. There is an increased risk of damaging the
spinal cord if spinal anaesthesia is attempted above these levels. An important landmark to
identify is the line joining the top of the iliac crests. This line passes through either the
spinous process of L4 or through the space between L4 and L5 (L4/L5 interspinous space). 

Positioning

Correct positioning of the patient is very important for successful spinal anaesthesia. If the
vertebral column is tilted or rotated it will make spinal anaesthesia more difficult. It is
important to have an assistant to help maintain the correct position. The patient is
positioned either lying on their side or sitting up. Lying on the side may be more
comfortable for the patient and is safer for patients who have been premedicated. 

A patient lying on this/her side should be placed on the edge of the table with the knees
pulled up to their chest and the chin down on the chest. The anaesthesia provider must
check that the vertebral column remains parallel to the table and that the patient’s body is
perpendicular to the table. If the patient is allowed to roll either forwards or backwards this
will make spinal anaesthesia more difficult. There is a difference in the shape of the male
and female body. The spinal column of patients lying on their side is rarely truly horizontal.
The male is usually wider at the shoulders than the hips so the vertebral column slopes up
towards the head. The female is wider at the hips than the shoulders so the vertebral
column slopes down towards the head. With obese patients, folds of fat may hang down
making it difficult to identify the midline. Depending on the operative site and operative
position, a hypo-, iso-, or hyperbaric solution of local anaesthetic can be injected.
It is easier to position the patient correctly in the sitting position and identify the midline.
The anaesthesia provider must check that the patient’s back is parallel to the bed, that the
shoulders are at the same height and that the patient is not rotated to the left or right.
Using a stool for a footrest and a pillow for the patient to hold can facilitate maintaining a
stable comfortable position. The sitting position is ideal for providing lower lumbar and
sacral anaesthesia. The patient should remain in the sitting position for 5 minutes after a
hyperbaric spinal anaesthetic is placed. If a higher level of block is necessary, the patient
should be placed supine immediately after spinal placement and the table adjusted
accordingly. 

 
Spinal Needle

The anaesthesia provider should choose the smaller gauge or a rounded non-cutting pencil-
point (Sprotte and Whitacre) needle to reduce the incidence of post spinal headache. Pencil-
point needles may reduce the incidence of post dural spinal headache to less than 1%.

Spinal Anaesthesia

Spinal anaesthesia must be performed as an aseptic technique. The anaesthesia provider

must at least wear gloves and must clean the patient’s back with an antiseptic solution. They
should feel for a suitable interspinous space remembering that the line between the tops of
the iliac crests passes through the L4 spinous process or L4/L5 interspinous space. 
A small amount of local anaesthetic is injected at the selected interspinous space to
anaesthetise the skin and subcutaneous tissue. More local anaesthetic is then administered
along the intended path of the spinal needle insertion. This will provide both anaesthesia
and also aid in identifying the correct path for spinal needle placement. The spinal needle is
inserted with a slight cephalad angle of 10° to 15° (though an introducing needle if
appropriate) with the stylet in the needle. It is important to insert the spinal needle in the
middle or lower half of the interspinous space and keep the needle in the midline. 
When the needle enters the ligamentum flavum there will be an increase in resistance
followed by a loss of resistance as the epidural space is entered. Another loss of resistance
may be felt as the dura is pierced. The stylet is removed and cerebrospinal fluid should flow.
For spinal needles of higher gauge (26–29 gauge), this usually takes 5–10 seconds.
If the spinal needle strikes bone at a shallow depth it is likely that it has hit the spinous
process of the vertebra above. The spinal needle should be removed and inserted 1cm
lower. If the needle strikes bone at a greater depth then it is likely that it has hit the
vertebral body of the vertebra below and the needle should be removed and inserted with
the needle angled slightly more towards the patient’s head. When the spinal needle needs
to be reinserted, it is important to withdraw the needle back to the skin level before
redirection.
When correctly inserted, the spinal needle should be carefully held in place. The needle is
best immobilised by resting the back of the non-dominant hand firmly against the patient’s
back, holding the hub of the spinal needle between the thumb and index finger. If the
patient moves, the provider’s hand and the spinal needle will move with the patient. The
syringe containing the local anaesthetic should be firmly attached to the spinal needle. It is
wise to gently aspirate some cerebrospinal fluid into the syringe to check that the spinal
needle is in the correct position.

Spread of Local Anaesthetic

Local anaesthetics are either heavier (hyperbaric), lighter (hypobaric) or have the same
specific gravity (isobaric) as cerebrospinal fluid (CSF). Hyperbaric solutions tend to spread
down from the level of injection due to gravity and it may be easier to predict the spread of
the local anaesthetic. Isobaric solutions may be made hyperbaric by adding dextrose.
Baricity is the ratio of the density of the local anaesthetic to the density of CSF.
More than 20 factors affect where and how far a local anaesthetic will spread in the CSF, but
not all are important. The patient’s weight, age, sex, concentration of local anaesthetic,
addition of vasoconstrictors, direction of the bevel of the needle, rate of injection and
barbotage have no significant effect on the spread of local anaesthetic. Rapid injection and
barbotage may make the spread less predictable. (Barbotage means to inject some of the
local anaesthetic then aspirate some CSF back into the syringe several times during the
injection). Slow injection without barbotage produces the most reliable results.
Factors that do have a significant effect include the level of injection, dose of local
anaesthetic, position of patient during injection, position of patient after injection and the
baricity of the local anaesthetic (hyperbaric, isobaric or hypobaric). The volume of the local
anaesthetic has a minor effect and only extremes of patient height will have an effect (e.g.
paediatrics). An increase in intra-abdominal pressure (e.g. pregnancy) will increase the
spread of local anaesthetic.
The effect of concentration, dose and volume of a local anaesthetic has been studied. The
level of anaesthesia will be higher if the patient is given a larger dose (mg). Patients given
the same dose (mg) but in a larger volume will have the same level of anaesthesia. The total
dose is more important than the volume or concentration of local anaesthetic in
determining the spread of local anaesthetic in the CSF.
The most important factors affecting the spread of spinal anaesthetic solutions, and the
factors that the anaesthesia provider can change, are the baricity of the local anaesthetic
and the dose of local anaesthetic, the level of injection and the position of the patient
during the injection and immediately afterwards. For example, if a lumbar spinal anaesthetic
is performed with the patient sitting up using a hyperbaric solution and the patient remains
sitting up for several minutes then the local anaesthetic will only block the sacral nerves
(saddle block). This spinal anaesthetic will not affect the patient’s blood pressure and is
suitable for all operations on the perineum.

Suggested dosage of local anaesthetics:

Ideally, the anaesthesia provider should aim to utilize the lowest spinal dose possible,
thereby minimizing adverse events and facilitating timely recovery. However, low doses may
compromise surgical anaesthesia when operating times are longer than normal.  
Several local anaesthetics are available. The major drawback of lignocaine is its association
with transient neurologic symptoms. Up to 14% of patients receiving lignocaine spinal
anaesthesia will present with lower back pain and abnormal unpleasant sensations radiating
to buttocks, thighs and lower limbs. 2-chloroprocaine must be preservative free. The
addition of sodium bisulfite as an antioxidant has been associated with chronic
neurotoxicity. Its usual dose is 40 mg with fast onset and duration of 120 minutes.
Tetracaine has an onset of anaesthesia within 5 minutes and a duration of 80 to 180
minutes. A 0.5% hyperbaric solution can be made by mixing equal volumes of 1% tetracaine
and 10 % dextrose. 
Bupivacaine is a long-acting anaesthetic and even small doses can inhibit the ability to
ambulate and void for a prolonged period. Combining fentanyl with bupivacaine prolongs
surgical anaesthesia, prolongs postoperative analgesia, and does not increase the incidence
of urinary retention.

        
    L4  T10 T4 -6      Duration
     Saddle      Hours
block

                    

      Hyperbaric Bupivacaine 5 – 10 mg      10 – 15      10 – 20 mg    1.5 – 2.5
0.5% (1 – 2 ml) mg      (2 – 4 ml)
     (2 – 3 ml)
                    
 Isobaric 5 – 10 mg     10 – 15 mg      10 – 20 mg    1.5 – 2.5
Bupivacaine 0.5%         (1 – 2 ml)     (2 – 3 ml)      (2 – 4 ml)

                          

Hyperbaric     25 – 50 mg     50 – 75 mg        75 – 100  1 – 1.5
Lignocaine 5%    (0.5 – 1 ml)     (1 – 1.5 ml) mg
       (1.5 – 2
         
    L4  T10 T4 -6      Duration
     Saddle      Hours
block

                    

      Hyperbaric Bupivacaine 5 – 10 mg      10 – 15      10 – 20 mg    1.5 – 2.5
0.5% (1 – 2 ml) mg      (2 – 4 ml)
     (2 – 3 ml)
                    
 Isobaric 5 – 10 mg     10 – 15 mg      10 – 20 mg    1.5 – 2.5
Bupivacaine 0.5%         (1 – 2 ml)     (2 – 3 ml)      (2 – 4 ml)

ml)
                 
  Lignocaine 2%    25 – 50 mg     50 – 75 mg       75 – 100  1 – 1.5
     (1.25 – 2.5     (2.5 – 3.75 mg
ml) ml)       (3.75 – 5
ml)

                        

     Hyperbaric  4 – 6 mg    8 – 12 mg     14 – 16 mg   1.5 – 2.5
Amethocaine     (0.8 – 1.2      (1.6 – 2.4       (2.8 – 3.2
    (Tetracaine) 0.5% ml) ml) ml)

              
      Hyperbaric Cinchocaine    4 – 6 mg   6 – 8 mg     10 –12 mg   2 – 3h
0.5%     (0.8 – 1.2      (1.2 – 1.6      (2 – 2.4 ml)
ml) ml)

Dr Matt Blair, https://drmattblair.com.au/spinal-dosing-guidelines/ provides an excellent

guide to case specific bupivacaine spinal dosing.

Vasoconstrictors / Additives

The effect on the duration of spinal anaesthesia by the addition of a vasoconstrictor

depends on the local anaesthetic used. Vasoconstrictors prolong the duration of tetracaine
and prolong the duration of lignocaine anaesthesia in the lumbar region but have little
effect on bupivacaine. The addition of a vasoconstrictor to the local anaesthetic is a
theoretical concern of spinal cord ischemia. (Adding 0.1 mL of 1:1000 epinephrine to 10 mL
of local anaesthetic yields a 1:100,000 concentration of epinephrine).

The addition of opioids improves the quality and duration of analgesia but also increases
risk. It is safe to add 10 to 20 µg of fentanyl for caesarean section. Many patients remain
comfortable for 24 hours after a single spinal (intrathecal) dose of morphine (0.1 to 0.3 mg);
however, patients receiving intraspinal morphine are at risk of early (within 2 hours) and
late (within 6 to 12 hours) respiratory depression. Patients should not receive a long acting
intraspinal opioid unless there is a trained nurse present postoperatively who can keep a
constant check on the patient. Intraspinal morphine can also cause severe itching, severe
nausea and vomiting and urinary retention. Clonidine (25 mcg) prolongs the sensory and
motor block of a local anaesthetic after spinal injection. Side effects can occur with the use
of spinal clonidine and include hypotension, bradycardia, and sedation.

Physiological Changes with Spinal Anaesthesia

There are three types of nerve: motor, sensory and autonomic. Motor nerves control
movement and sensory nerves transmit touch and pain. Autonomic nerves regulate
involuntary body functions and are divided into parasympathetic and sympathetic nerves.
Parasympathetic nerves arise from the brain and from the sacral part of the spinal cord.
They increase gastrointestinal activity and reduce arousal and cardiovascular activity.
Sympathetic nerves arise from thoracic and lumbar parts of the spinal cord. They increase
arousal, cardiovascular activity and constrict blood vessels. The smaller sympathetic nerves
are more easily blocked than the larger sensory nerves that, in turn, are more easily blocked
than motor nerves. 

Cardiovascular Physiology

Spinal anaesthesia produces important physiological changes. The most important

physiological changes involve the cardiovascular system. Initially these changes are the
result of blocking sympathetic nerves. The magnitude of the cardiovascular changes
depends on the level of the spinal anaesthesia. Sympathetic blockade causes vasodilatation
below the level of the block. If the spinal block only involves sacral nerves (a saddle block
suitable for surgery on the perineum) there will be no drop in blood pressure because
sympathetic nerves arise from T1 to L3. If the spinal block is extended to T1 to involve all
sympathetic nerves there will be a marked drop in blood pressure. Dilatation of arteries will
cause a 15% reduction in total peripheral vascular resistance, but the main cause of the fall
in blood pressure is dilatation of veins causing a reduction in blood returning to the heart
(preload). Hypovolaemic patients are at great risk of hypotension unless they are
resuscitated before attempting spinal anaesthesia.
Raising the patient’s legs, intravenous fluids and vasoconstrictors can treat hypotension. In
the obstetric patient, the anaesthesia provider must avoid aortocaval compression by
always positioning the patient with at least 15 degrees of lateral tilt. If the cardiac
sympathetic nerves (T1 to T4) are blocked the patient will also become bradycardic.
Myocardial oxygen supply decreases by up to 48% but myocardial oxygen demand is
reduced by up to 53% so that oxygen supply is still greater than demand. Myocardial oxygen
demand decreases because the total peripheral resistance decreases so the heart does not
need to contract as hard, heart rate decreases and preload decreases so the amount of
blood pumped by the heart decreases. The ability of the heart to contract is not affected by
spinal anaesthesia.
Cerebral blood flow is kept constant unless the mean arterial pressure falls below 50 mmHg.
Renal blood flow, like cerebral blood flow, is kept constant over a wide range of blood
pressures. Renal blood flow will only decrease if the mean arterial pressure is less than 50
mmHg. Blood flow to the liver will decrease in proportion to the fall in blood pressure.
Respiratory Physiology

Spinal anaesthesia has little effect on respiratory function. Arterial blood gases are not
changed in patients with high spinals breathing room air. A high thoracic spinal anaesthetic
will affect active exhalation due to paralysis of abdominal and intercostal muscles. Resting
tidal volume and maximum inspiratory volume are not affected. Arterial blood gases will
remain normal. Maximum breathing capacity, maximum expiratory volume and the ability
to cough will be reduced.

Miscellaneous

Urinary retention may occur. The bowel will contract. Blood loss may be reduced and deep
venous thrombosis may be less common. It is suitable for diabetic patients as there is little
risk of unrecognised hypoglycaemia in an awake patient.
Suggested minimum skin levels for spinal anaesthesia

Operative site Level

Lower legs T12

Hip T10

Uterus T10
Bladder, prostate T10

Testis, ovaries T8

Lower abdominal T6

Other Intraabdominal T4