British Journal of Anaesthesia 87 (5): 738±42 (2001)

Spinal anaesthesia with 0.5% hyperbaric bupivacaine in elderly

patients: effects of duration spent in the sitting position
B. T. Veering1*, T. T. M. Immink-Speet1 2, A. G. L. Burm1, R. Stienstra1 and
J. W. van Kleef1
1
Department of Anaesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden,
The Netherlands
2
Present address: Department of Anaesthesiology, Stichting Streekziekenhuis Coevorden-Hardenberg,
M. van Thijnensingel 1, 7741 GB Coevorden, The Netherlands
*Corresponding author

Sixty patients, aged 65±84 yr, undergoing minor urological surgery under spinal anaesthesia
remained sitting for 2 (group 1, n=15), 5 (group 2, n=15), 10 (group 3, n=15), or 20 (group 4,
n=15) min after completion of the subarachnoid administration of 3 ml of a 0.5% hyperbaric
bupivacaine solution. They were then placed in the supine position. Analgesia levels were
assessed bilaterally using pinprick. Motor block was scored using a 12-point scale. Systolic and
diastolic arterial pressures and heart rate were also recorded. Twenty minutes after the injec-
tion the upper analgesia levels were lower (P<0.05) in group 4 (median T9.0) than in the groups
1±3 (medians T6.6±T8.5). The highest obtained levels (medians T5.7±T8.0) did not differ
between the groups, but occurred later (P<0.05) in group 4 (median 35 min) than in groups
1±3 (medians 19±24 min). There were no signi®cant differences in the maximum degree of
motor block or haemodynamic changes between the four study groups.
Br J Anaesth 2001; 87: 738±42
Keywords: anaesthetic techniques, subarachnoid; anaesthetics local, bupivacaine; age factors
Accepted for publication: June 12, 2001

Clinical studies have shown that the characteristics of neural
block after subarachnoid administration of hyperbaric
bupivacaine change with increasing age.1±3 In particular,
the level of analgesia extends approximately three to four
segments higher in elderly compared with young adult
patients. Old age and high levels of analgesia appear to be
the two main factors associated with the development of
hypotension during spinal anaesthesia.4 The degree of
hypotension correlates with the level of sympathetic block,
which is generally two to four segments higher than the
level of analgesia.5 From a clinical point of view, it is,
therefore, important to limit the level of sympathetic block.
A spinal technique that prevents unnecessary high levels of
analgesia and sympathetic block in elderly patients is,
therefore, recommended. One of the bene®ts claimed for
hyperbaric solutions is that their spread can be controlled by
posture.6 The position of the patient at the time of injection
may affect the direction of subarachnoid distribution, at
least initially. There is, however, still discussion about the
duration of the sitting period that is needed to limit the
spread of analgesia.7±9
The present study examined the in¯uence of different
periods of sitting, before the patient is placed in the supine
horizontal position, on the spread of analgesia following
subarachnoid administration of a hyperbaric bupivacaine
solution in elderly patients.
Methods
We studied 57 male and three female patients (ASA I±III,
age 65±84 yr), undergoing minor urological surgery under
spinal anaesthesia. The study was approved by the Medical
Ethics Committee of the Leiden University Medical Center
and informed consent was obtained from all patients.
Patients with diabetes, a history of neurological disease, or
coagulopathy were excluded. Patients were randomly
allocated to one of the four study groups, which differed
with respect to the time during which the patients remained
in the sitting position after the spinal injection. A
randomization table was made before the start of the study
and codes were stored in sealed envelopes, which were
opened shortly before the subarachnoid injection.

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2001
 Spinal anaesthesia with hyperbaric bupivacaine
Table 1 Patient characteristics. Data are mean (SD) (range) or frequencies, as appropriate
Group 1 (2 min)
No. of patients 15
Age (yr) 74 (4) (67±82)
Weight (kg) 82 (15)
Height (cm) 181 (9)
Gender (F/M) 1/14
ASA status (I/II/III) 3/10/2
Patients were pre-medicated with temazepam 10 mg
orally and atropine 0.25 mg i.m., 45 min before the
induction of spinal anaesthesia. Before the spinal injection,
500 ml of glucose in saline was administered by rapid i.v.
infusion. Dural puncture was performed with the patient in
the sitting position by a standard midline approach using a
25-gauge Quincke spinal needle via an 18-gauge introducer.
When a free ¯ow of clear cerebrospinal ¯uid was obtained
and after aspiration of 0.2 ml of spinal ¯uid, 3 ml of 0.5%
bupivacaine in 8% glucose (Marcaine Heavy, speci®c
gravity 1.026 at 20°C) was injected at room temperature
at a rate of 0.2 ml s±1. Patients remained sitting for 2 (group
1, n=15), 5 (group 2, n=15), 10 (group 3, n=15), or 20 (group
4, n=15) min after completion of the subarachnoid injection.
They were then placed in the supine horizontal position.
Analgesia was assessed bilaterally in the anterior axillary
line by pinprick using a short beveled 25-gauge needle.
Assessments were made every 5 min during the ®rst 30 min
after the injection and at 45 and 60 min. Analgesia was
de®ned as inability to detect a sharp pinprick. Motor block
of the lower limbs was evaluated by asking the patient to
raise the extended leg (¯exion of the hip), ¯ex the knee, and
¯ex the ankle. It was rated per joint (0=no, 1=partial,
2=complete motor block). The results obtained in both
extremities were added, giving a maximum score of 12
(complete motor block). Assessments of motor block were
made immediately after the assessment of the analgesia
levels. The time to maximum cephalad spread of analgesia,
the highest level of analgesia attained and the maximum
degree of motor block were recorded. During the ®rst 20
min, all assessments were made by the anaesthetist who
performed the lumbar puncture. Assessments at 30, 45, and
60 min (i.e. when all patients were lying supine) were made
by another anaesthetist who was unaware of the period of
sitting.
Systemic arterial pressure, measured with an automatic
cycling device (Accutor 1, Datascope) and heart rate (HR)
(from the electrocardiogram) were monitored before the
subarachnoid injection, after induction of spinal anaesthe-
sia, during surgery and in the recovery room at 5-min
intervals during the ®rst 30 min, then at 15 min intervals
until the patients were returned to the ward. If the systolic
arterial pressure (SAP) decreased more than 30% below the
pre-anaesthetic value or to less than 90 mm Hg, ephedrine 5
mg was given intravenously. Bradycardia (HR <55 beats
Group 2 (5 min) Group 3 (10 min) Group 4 (20 min)
15 15 15
75 (5) (68±82) 74 (7) (65±84) 77 (5) (66±83)
75 (13) 85 (12) 75 (9)
178 (6) 177 (3) 176 (3)
1/14 1/14 0/15
5/8/2 3/9/3 3/10/2
min±1) was treated with atropine sulphate 0.25 mg intra-
venously.
Group sizes were based on a power analysis, which
demonstrated that with a variance s2=3.39 in the upper level
of analgesia (as observed in a previous study in elderly
patients),2 15 patients would be required per group to have
an 80% probability of detecting a difference of two
segments between group means at the 0.05 level of
signi®cance. Data are presented as mean (SD), mean (95%
con®dence interval), median (95% con®dence interval), or
frequencies, as appropriate. Medians and the corresponding
95% con®dence intervals were corrected for the presence of
tied observations.10 Maximum changes in SAP and HR
were analysed using one-way analysis of variance. Changes
in analgesia levels, as well as analgesia levels after 20 min,
the highest analgesia levels and the times at which
maximum analgesia levels and maximum changes in SAP
and HR were reached were analysed with the Kruskal±
Wallis test, followed by the non-parametric Student
Newman±Keuls test,10 when indicated. Multiple Fisher
exact tests were used to compare the numbers of patients
with a complete motor block, and the numbers of patients
requiring ephedrine or atropine. To adjust for multiple
comparisons in these tests, the sequentially rejective
Bonferroni±Holm method was applied. A P<0.05 was
considered signi®cant.
Results
Patient characteristics are presented in Table 1. Neural
block characteristics are summarized in Table 2. In all
patients symmetrical analgesia levels were obtained.
Median upper analgesia levels vs time are presented in
Figure 1. The increase in the upper analgesia level after
placing the patient in the supine position was similar in
groups 1±3, but smaller in group 4 (P<0.05). Twenty
minutes after injection, the upper levels were lower in
patients from group 4 than in patients from the other groups
(P<0.05; Fig. 2, Table 2). However, the increase in the
upper analgesia levels beyond 20 min was larger in group 4
than in the groups 1±3 (P<0.05). Consequently, the highest
recorded analgesia levels did not differ between the groups,
but were reached later in group 4 (P<0.05; Fig. 3, Table 2).
The number of patients with complete motor block did not
differ between the groups.
739
 Veering et al.

Table 2 Neural block characteristics. Analgesia data are median (95% con®dence interval); motor block data are frequencies (%). ³Data in group 1 are
increases after 5 min (analgesia levels were not assessed at 2 min). *P<0.05 compared with groups 1, 2, and 3, ²P<0.05 compared with group 1

Group 1 (2 min) Group 2 (5 min) Group 3 (10 min) Group 4 (20 min)
(n=15) (n=15) (n=15) (n=15)

Analgesia
Increase after supine positioning (dermatomes) 4.3³ (2.5±6.5) 4.5 (3.3±8.0) 4.0 (1.0±7.0) 2.0* (1.2±2.8)
Level after 20 min (dermatome) T6.6 (T7.5±T6.0) T7.5 (T9.4±T5.0) T8.5 (T10.5±T4.8) T9.0* (T11.7±T7.7)
Increase after 20 min (dermatomes) 1.3 (0.6±1.9) 0.8 (0.3±1.5) 1.0 (0.4±2.2) 2.0* (1.2±2.8)
Highest level (dermatome) T5.7 (T7.0±T5.1) T7.0 (T8.7±T5.0) T7.0 (T9.0±T4.0) T8.0 (T9.3±T6.5)
Time to highest level (min) 24 (18±28) 19² (16±24) 21 (15±24) 35* (25±41)

Motor block
Patients with complete block (%) 13 (87) 12 (80) 11 (73) 9 (60)

Analgesia was adequate for surgery in all patients.

Changes in SAP and HR were similar in all groups (Table
3). One patient in group 2 and four patients in group 3
required ephedrine for treatment of hypotension and one
patient in each of the groups required atropine for
bradycardia.

Discussion
The present study showed that a 20-min period of sitting is
not suf®cient to restrict the maximum cephalad spread of
sensory analgesia when using 3 ml of 0.5% bupivacaine in
8% glucose. The period of sitting (2±20 min) after a
subarachnoid injection of a hyperbaric bupivacaine solution
appears to have little, if any, in¯uence on the ultimately
attained analgesia levels in elderly patients. This suggests
that upward spread of local anaesthetic via the cerebrospinal Fig 1 Median upper analgesia levels vs time in the four study groups.
¯uid occurs when the patient is repositioned from the sitting Medians are corrected for tied observations.
to the supine position, even after prolonged periods of
sitting.
With shorter periods of sitting (<10 min), the upper
analgesia level increased by approximately four segments
after placing the patient in the supine position. With a longer
period of sitting, for example 20 min, the average increase
was only two segments. This suggests that with time less
local anaesthetic is available for upward spread. This
presumably is the result of binding of local anaesthetic to
tissue structures within the subarachnoid space, in particular
spinal cord.
The effect of the period of sitting on the spread of sensory
block following subarachnoid administration of a hyper-
baric anaesthetic solution has been studied previously by
Povey and colleagues.7 Their study showed that, irrespec-
tive of the period of sitting (2±25 min), analgesia levels
increased several segments after the patient had been put
Fig 2 Individual analgesia levels 20 min after the injection. Horizontal
into the supine position. Subsequent positioning in a 15°
lines represent median levels. Medians are corrected for tied
head-down position resulted in a further increase of the observations.
analgesia levels by approximately two to three segments.
On the other hand, Sinclair and colleagues11 reported that a
15° head-down tilt had minimal effect on the cephalad injection and were maintained in that position for only 10
spread of analgesia. In that study, however, patients were min before being placed into the supine horizontal position.
positioned in the head-down position immediately after the Taken together, the observations of both Povey and

740
 Spinal anaesthesia with hyperbaric bupivacaine
colleagues and Sinclair and colleagues suggest that the
ultimately achieved upper analgesia level is mainly depend-
ent upon the ®nal position of the patient. This is further
substantiated by another study of Povey and colleagues,8
which showed that sensory block following injection of a
hyperbaric bupivacaine solution may still extend rostrally if
the patient is placed supine after sitting for as long as 60 min
after subarachnoid injection. This indicates that the `®xation
time' of a hyperbaric solution takes at least 60 min with
bupivacaine. In both studies of Povey and colleagues, the
increase in the highest level of analgesia was considerably
larger than in our study. In part, this may be related to
differences in the dose of bupivacaine administered, which
amounted to 3 ml of 0.5% bupivacaine in this study and 4 ml
of 0.5% bupivacaine in the studies of Povey and colleagues.
Similarly, it has been demonstrated that changes in
position can alter the spread of sensory block for at least 1 h
following subarachnoid administration of a hypobaric
lidocaine solution for perirectal surgery.12 Dermatomal
levels remained low (T11±L5) while the patients were in the
prone (jackknife) position with the head down at 15° from
horizontal, but increased two to six dermatomes if the
patient was placed in a sitting position in the recovery room
after surgery.
Fig 3 Individual highest levels of analgesia. Horizontal lines represent
median levels. Medians are corrected for tied observations.
Table 3 Haemodynamic changes and ephedrine and atropine requirements. ²Data are mean (95% con®dence interval); ³data are median (95% con®dence
interval)
Group 1 (2 min)
(n=15)
Maximum decrease in SAP (%)² 20 (13±27)
Time to maximum decrease in SAP (min)³ 30 (20±47)
Maximum decrease in HR (%)² 15 (10±21)
Time to maximum decrease in SAP (min)³ 25 (13±40)
Patients requiring ephedrine (%) 0 (0)
Patients requiring atropine (%) 1 (7)
741
Positional changes may also extend the sensory block
after subarachnoid administration of glucose-free bupiva-
caine which is slightly hypobaric at body temperature.13 The
level of sensory block increased up to four segments when
the patient was placed 30° head up after lying supine for
80±115 min after the injection of glucose-free bupivacaine.
This is probably related to migration of unbound bupiva-
caine within cerebral spinal ¯uid (CSF). If a true isobaric
solution is injected, the epicentre of the local anaesthetic
concentration in CSF remains at the site of injection
regardless of the position of the patient during and after the
injection. This was demonstrated clinically by Wildsmith
and colleagues, who studied the effects of posture on the
spread of isobaric tetracaine and concluded that posture
should not be used to control the spread of isobaric
solutions.9
Several studies have shown that analgesia levels obtained
after subarachnoid injection of a hyperbaric local anaes-
thetic solution are approximately three to four spinal
segments higher in elderly compared with young adult
patients.1±3 The same presumably holds for levels of
sympathetic block that are associated with analgesia levels,
but are generally two to four segments higher. Conse-
quently, the highest levels of sympathetic block are often in
the upper thoracic region in elderly patients, which may
explain the higher frequency of cardiovascular side effects
in elderly compared with young adult patients.4 5 Factors
that contribute to the more extensive block in the elderly
include gradual degeneration of the central and peripheral
nervous system,14 15 changes in the anatomical con®gur-
ation of the lumbar and thoracic spine,16 and possibly a
reduction in the volume of the cerebrospinal ¯uid.6
Recently, we demonstrated that injecting hyperbaric
bupivacaine at a lower (L4±L5) than the usual (L3±L4)
lumbar interspace did not reduce cephalad spread of local
anaesthetic and did not limit the highest analgesia levels.17
In that study, as well in this study, there was a considerable
inter-individual variation in the highest level of analgesia.
These observations are in keeping with earlier reports on the
spread of analgesia following subarachnoid administration
of hyperbaric bupivacaine, in particular in elderly
patients.2 3 Because of this profound inter-individual vari-
ability, the predictability of the analgesia levels that will be
reached in an individual patient is low.2 3 17
Group 2 (5 min) Group 3 (10 min) Group 4 (20 min)
(n=15) (n=15) (n=15)
20 (15±25) 21 (14±28) 13 (8±18)
35 (23±47) 28 (20±40) 33 (18±43)
18 (14±23) 15 (10±21) 15 (12±18)
47 (25±54) 36 (23±53) 47 (20±54)
1 (7) 4 (27) 0 (0)
1 (7) 1 (7) 1 (7)
 Veering et al.
In conclusion, this study has demonstrated that during
spinal anaesthesia with a hyperbaric bupivacaine solution
the period of sitting has little, if any, in¯uence on ®nal
analgesia levels and on haemodynamic changes in elderly
patients. These results suggest that the use of posture does
not allow as much control over the spread of a hyperbaric
solution as is thought.
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