Neuroaxial regional anesthesia

In this type of anesthesia, the local anesthetic is put near the spinal cord, where it arrives by diffusion.
Intradural anesthesia
It is also known as subarachnoid, intrathecal and spinal. The local anesthetic is deposited in the subarachnoid space
and it produces blocking of the spinal nerves at central level.
Spinal anesthesia requires the injection of a small volume of local anesthetic agent directly into the cerebrospinal fluid
(CSF) in the lumbar region, below the level of L1/2, where the spinal cord ends
TECHNIQUE
The skin puncture point corresponds to the intersection of the line joining both upper borders of the iliac crests and the
line joining the spinous processes. This point usually corresponds to the L3-L4 space. In general, for spinal
anesthesia, L2-L3, L3-L4 or L4-LS spaces are usually used due to the lower risk of accidental puncture of the spinal
cord.
The puncture can be performed with the patient in lateral decubitus or, if the clinical situation allows it, in a sitting
position. Once a large skin surface has been disinfected, we proceed to do the puncture in the spinal cord. To do this,
the needle must pass through the supraspinous ligament, the interspinous ligament, the ligamentum flavum, the
epidural space, the duramater and the arachnoid. Spontaneous outflow of clear cerebrospinal fluid (CSF) confirms
proper needle position, allowing the introduction of the desired dose of local anesthetic.

FACTORS INFLUENCING THE LEVEL OF ANESTHESIA

The puncture point in intradural anesthesia is fixed (between L2-L3 and L4-L5). However, various characteristics of
local anesthetics or the performance of certain maneuvers allow reaching higher levels of anesthesia:

 Baricity (specific weight of the local anesthetic with respect to LCR). The Local anesthetics can be classified
into:
o Hyperbaric (heavier weight than the CSF). For this reason, once deposited in the subarachnoid space,
due to the effect of gravity, they go towards declining regions of the medullary canal. They are
achieved by adding dextrose to the local anesthetic.
o Isobaric (similar weight to CSF). Its distribution will be independent
of the position of the patient. Although in reality isobaric anesthetics
are mildly hypobaric.
o Hypobaric (lower weight than CSF). In this case, local anesthetics go
towards the highest regions of the medullary canal, depending on the
position of the patient. They are achieved by adding distilled water
to the local anesthetic.
Changes in the patient's position (Trendelenburg or anti-Trendelenburg), will
determine the final level of anesthesia.
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  Drug dose. The anesthetic level is proportional to the dose of local anesthetic used.
 Drug volume. The larger the volume of local anesthetic, the greater its diffusion in the LCR and, therefore,
higher levels of anesthesia can be achieved.
 LCR turbulence. Rapid injection of the local anesthetic will cause increased turbulence in the CSF,
increasing diffusion of the drug and the level of anesthesia achieved. Performing bubbling (repeated aspiration
and reinjection of small amounts of LCR through the local anesthetic injection syringe) also increases CSF
turbulence.
 Opioids. The combination of local anesthetic with small doses of opiates (generally 10-20 µg of fentanyl) has
a synergistic effect, increasing the impact of the local anesthetic.
 Increased intra-abdominal pressure. In those clinical situations in which there is an increase in intra-
abdominal pressure (pregnancy, obesity, ascites...), there is a decrease of the subarachnoid space and,
therefore, of the CSF volume, which allows greater diffusion of the local anesthetic, reaching an anesthetic
plus level.
 Drugs. The most widely used local anesthetics are bupivacaine, levobupivacaine, and ropivacaine.
 Duration of the anesthetic block. The duration of the anesthetic block depends of the type of local anesthetic
used. The combination with opiates or vasoconstrictors (adrenaline or phenylephrine) prolongs the duration of
intradural anesthesia.
COMPLICATIONS
POST-DURAL PUNCTURE HEADACHE
It is the most frequent complication of neuraxial anesthesia. It usually appears 24 hours after the anesthetic
technique. It consists of a very intense occipital or frontoparietal headache that radiates towards the posterior
cervical region. It typically worsens while standing or sitting and improves with supine position. Other symptoms
(nausea, vomiting, diplopia, blurred vision, or tinnitus) can be associated. Its etiology lies in the continuous loss of
CSF through the orifice of the duramater, which causes a decrease in LCR pressure and the traction of meningeal
nerves and vessels.
Factors that have shown a relationship with a higher incidence of post-puncture headache are:
- Young patients, preferably women
- Use of larger gauge needles
- Use of sharper bevel-type (bisel) point needles (Quincke) vs lower incidence
with pencil point needles (Sprotte or Whit acre)
- Number of puncture attempts: the higher the number, the greater the probability
of headache onset.
The initial treatment consists of the administration of fluids (oral or intravenous), corticosteroids, caffeine,
analgesics and bed rest in supine position. If the headache is very intense and/or lasts more than 48 h, subarachnoid
administration of physiological saline solution or a epidural hematic patch may be chosen (for this, 10-20 ml of
peripheral blood is extracted from the patient and injected into the epidural space).
SYMAPATHETIC BLOCK
Neurons of the sympathetic nervous system are located at the spinal cord level between C8 and L2. Local
anesthetics block sensory and motor nerve fibers, as well as sympathetic nerve fibers. Therefore, if a sufficiently
extensive blockage occur, sympathetic activity may decrease, and a characteristic clinic appears:

 Bradycardia. Due to predominance of vagal tone. It is treated by the administration of intravenous bolus
atropine (0.5-1 mg). If severe and accompanied by hypotension, it may be necessary the use of ephedrine or
even adrenaline.
 Hypotension. Loss of sympathetic tone at the vascular level causes vasodilation of blood vessels below of the
block level (typically in the lower extremities). This discrepancy between the content (blood volume) and the
continent (fall of peripheral resistance) leads to a situation of relative hypovolemia that translates into
hypotension, especially in those patients with hypovolemia or dehydration prior to intradural block. The

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 administration of parenteral fluids and vasoconstrictor drugs (intravenous bolus ephedrine from 5 to 10
mg) is the treatment of choice.
URINARY RETENTION
Blockade of parasympathetic fibers of the sacral plexus can lead to the appearance of urinary retention that requires
decompressive bladder catheterization.
NAUSEA AND VOMITING
Secondary to hypotension or predominance of vagal tone.
HEMATIC PUNCTURE
Blood or a mixture of blood in the LCR, through the intradural puncture needle, may be due to a puncture of an
epidural vein. If the fluid does not become clear quickly, the needle should be immediately withdrawn and
another attempt should be made.
PRURITUS
It is characteristic of the administration of opiates at the neuraxial level. They can be useful for its control
ondansetron or pentazocine.
EPIDURAL HEMATOMA
Its overall incidence is low (0.05-0.1%), but it constitutes a neurosurgical emergency. It is more frequent in patients
receiving antiplatelet and/or anticoagulant medication. The clinic consists of the appearance of intense acute low
back pain together with a neurological deficit after recovery from neuraxial blockade or the absence of complete
recovery from intradural anesthesia. Diagnosis is made by RM. Treatment consists of immediate surgical
decompression.
PARESTHESIA
By direct trauma or nerve puncture at the spinal nerves.
DYSPNEA
It usually appears in high spinal anesthesia. It is due to the blockade of the nerve fibers of the intercostal and
abdominal muscles. It does not usually compromise the patient's ventilation, since it does not affect the function of the
phrenic nerve (C3-C5), so the diaphragm movements are preserved. The rise of root blockage to levels higher than
C5 causes a compromise to the open breathing and even apnea, requiring the use of mechanical ventilation.
TRANSIENT RADICULAR PAIN
It is a type of intense neuropathic pain of radicular distribution, that appears after performing a intradural technique
and whose duration is usually less than a week.
INFECTION
Meningitis, arachnoiditis and epidural abscesses may occur.
However, its incidence is very low.
CAUDA EQUINA NEUROTOXIC SYNDROME
It consists of urinary and fecal incontinence, loss of perineal
sensation and areflexic flaccid paresthesia.
INDICATIONS
Spinal anesthesia is used for a wide variety of both elective and
emergency surgical procedures below the level of the
umbilicus. For surgery above the umbilicus, high spinals are

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now rarely used because of associated difficulties of maintaining spontaneous ventilation and abolishing the painful
stimuli from traction on the peritoneum and pressure on the diaphragm.
CONTRAINDICATIONS
ABSOLUTE: puncture site infection, coagulopathy, intracranial hypertension, hypovolemic shock, severe stenosis
aortic or mitral valve and patient rejection.
RELATIVE: deformities spine, heart disease and neurological pathology.

Epidural anesthesia
It consists of placing a catheter in the epidural space. Through said catheter, the local anesthetic is administered in
boluses or through continuous perfusion. The objective is to achieve a selective neural blockade of dorsal, lumbar or
sacral segments, depending on the need for anesthesia.
An important difference with intradural anesthesia is the possibility of using it both for analgesia (without motor
blockade) and for anesthesia (with motor blockade); as well as the possibility of administering repeated doses through
the catheter.
Local anesthetics reach spinal nerve roots by diffusion through the dura mater from the epidural space where they are
infused. Therefore, the onset of action is slower (epidural 20-30 min, intradural 5-10). Doses of local anesthetics
administered are much higher than in intradural anesthesia since part of the drug escapes through the conjunction holes
or are absorbed by the epidural venous plexus (systemic effects).
INDICATIONS
- Analgesia for labor
- Surgery of the lumbar spine, abdomen, perineum, hip and lower limbs.
- Postoperative analgesia. One of the advantages of the epidural catheter is
that it can be used continuously during surgery and as postoperative
analgesia.
TECHNIQUE
The most used puncture point is the lumbar (similar to the of puncture in the
intradural technique), although epidural catheters can be placed at cervical, dorsal
and sacral levels. Using an epidural needle, you slowly advance and insert about 2-
3 cm into the interspinous ligament, the needle guarantor (fiador) is removed and a
syringe with physiological saline or air is placed. A constant pressure is then
applied to the syringe plunger while slowly inserting the needle. With the bevel, you penetrate the flavum ligamentum
and you arrive to the epidural space….
El punto de punción más utilizado es el lumbar (similar al punto de punción en la técnica intradural), si bien pueden
colocarse catéteres epidurales a nivel cervical, dorsal y sacro. Utilizando una aguja epidural, se avanza lentamente y se
introduce unos 2-3 cm dentro del ligamento interespinoso, se retira el fiador de la aguja y se coloca una jeringa con
suero fisiológico o aire. Se aplica entonces una presión constante al émbolo de la jeringa, al mismo tiempo que se
introduce la aguja lentamente. Al atravesar con el bisel el ligamento amarillo, se llega al espacio epidural y se produce
una marcada pérdida de resistencia que permite desplazar el émbolo de la jeringa. En ese momento, se retira la jeringa
y se introduce el catéter epidural a través de la aguja, cuyo bisel se dirige en dirección cefálica. El catéter avanza 3-5
cm más allá de la punta de la aguja. Una vez colocado el catéter, se aspira con una jeringa para comprobar que hay
presión negativa y que no refluye LCR ni sangre y se administra una dosis de prueba para descartar la colocación
intradural o intravascular del catéter. Se denomina dosis test y se realiza administrando un bolo de anestésico local
junto con 10-20 microgramos de adrenalina. Si el catéter está en el espacio subaracnoideo, se producirá un rápido
bloqueo intradural (5 min; sin embargo, si está en posición intravascular, se producirá un aumento de la frecuencia
cardíaca e hipertensión, secundaria a la infusión de adrenalina. La dosis test se considera positiva si la FC aumenta
más del 10%.
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DRUGS
The most commonly used local anesthetics are bupivacaine, levobupivacaine and ropivacaine. Small doses of
opiates or adrenaline can be added to decrease the concentration of local anesthetic to be infused and prolong its
action.
COMPLICATIONS
They are similar to those described for intradural anesthesia:
- Post-puncture headache after accidental perforation of the duramater (wet puncture)
- Arterial hypotension
- Erroneous local anesthetic administration: intravascular and intoxication by local anesthetics
- High epidural anesthesia.
- Systemic local anesthetic overdose
- Direct spinal cord trauma: especially in catheters placed above L2
- Epidural abscess.
- Epidural hematoma
- Subarachnoid block
- Back pain
CONTRAINDICATIONS
ABSOLUTE: infection of the skin in puncture site, coagulopathies, therapeutic anticoagulation, intracranial
hypertension, hypovolemia, bacteremia, allergy to local anesthetics, spinal cord tumors and negative by the patient.
REALTIVE: herniated discs, anatomical deformities, sepsis, tattoos and poor patient collaboration

Pain assessment
Pain, by definition, is a subjective sensation and is difficult for an observer to accurately assess. The provision of a
reliable and valid means of assessing pain is important because it allows the degree of improvement, after an analgesic
intervention, to be documented in a reproducible way. There are a number of specific pain assessment scales that are
used in the postoperative setting to ensure that a history of the patient’s pain is recorded in a useful form so as to
inform treatment decisions. These include:

 Verbal rating scale (VRS): is the most simple and easy to use. The patient is asked to rate the pain as ‘none’,
‘mild’, ‘moderate’, or ‘severe’ when at rest and on movement. The numerical rating scale consists of a
numerical scale representing the pain from 0 = ‘no pain’ to 10 (or 5) = ‘the worst imaginable pain’
 Numerical rating scale (NRS): consists of a 10 cm long line which represents a spectrum of pain intensity
from ‘no pain at all’ on the extreme left through to ‘the worst pain imaginable’ on the extreme right. The
patient is asked to mark the point on this line that corresponds to the severity of the pain.
 Visual analogue scale (VAS): is primarily a research tool and, performed correctly, is arguably too complex
for routine postoperative use. There is no obvious advantage of the more detailed methods in terms of practical
patient management.
In very young children, physiological and behavioural indicators are used. Older children may choose from ranked
facial expressions on a chart.
Others: adult non-verbal pain scale (NVPS), behavioral pain scale (BPS), CRIES, NIPS….

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