Lecture on regional anesthesia

Biruk Abera (MD, Assistant Professor

of Anesthesiology)

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 outlines
• Spinal anesthesia
• Epidural anesthesia
• Caudal anesthesia
• Combined spinal epidural anesthesia
• Peripheral nerve block

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 Anatomy
• The spinal cord is continuous with the
brainstem proximally and terminates distally
in the conus medullaris
• L3 in infants and lower border of L1 in adults
• Pia mater, arachnoid mater, and duramater
• The CSF resides in the subarachnoid space
• The pia mater is a highly vascular membrane
that closely invests the spinal cord and brain
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 ……cont.
• Approximately 500 mL of CSF is formed daily
• The arachnoid nonvascular membrane; 90% of
the resistance to drug migration
• Epidural space; foramen magnum to S.hiatus
• Contents; nerve roots and fat, vessels
• Spinal canal is larger @lumbar level

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 BLOOD SUPPLY
• Spinal cord is supplied from one anterior spinal
artery (originating from the vertebral artery), two
posterior spinal arteries (originating from
posteroinferior cerebellar artery), and segmental
spinal arteries originating from intercostal artery
• The spinal arteries enter the spinal canal at each
intervertebral foramen and give off branches to
both the nerve roots and the medullary branches
to the spinal cord;

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 ANATOMIC VARIATIONS
• NERVE ROOTS; there is considerable
interindividual variability in nerve root size
• Generally larger than the ventral (motor)
roots, the dorsal (sensory) roots are often
blocked more easily
• Organization of the dorsal roots into
component bundles which creates a much
larger surface area on which the local
anesthetics act
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 …..cont.

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 …..cont.
• CSF; constant pressure but volume varies
• CSF volume accounts for 80% of the variability
in peak block height
• less CSF in subjects with high [BMI]
• Epidural space is more segmented and less
uniform and hence Spread of solution is
nonuniform

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 MECHANISM OF ACTION
• Neural blockade happens due to Local
anesthetic binding to nerve tissue disrupting
nerve transmission
• The spinal nerve roots and dorsal root ganglia
are the most important sites of action
• Nerves in the subarachnoid space are highly
accessible and easily anesthetized
• Extradural nerves are often ensheathed by
Dura mater (the “dural sleeve”)
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 ….cont.
• The speed of neural blockade depends on the
size, surface area, and degree of myelination
• Smaller nerves are more sensitive
• B fibers blocked 1st ,then C fibers ,then A-delta
fibers ,then A-beta fibers and A-alpha
• Regression is in the reverse order
• Differential sensory block; anesthesia to cold is
2 segments higher than pinprick
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 DRUG UPTAKE
• For spinal anesthesia
• After a drug is injected to the intrathecal space
it diffuses inward through the pia mater to the
dorsal root ganglia
• Some will diffuse outward through the
arachnoid and dura mater to enter the epidural
space
• Whereas some is taken up by the blood vessels
of the pia and dura maters.
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 Drug penetration and uptake
• Directly proportionate to;
• Drug mass, CSF drug concentration, contact
surface area, lipid content (high in spinal cord
and myelinated nerves), local tissue vascular
supply,
• Inversely related to ;nerve root size
• The concentration of local anesthetic in the
CSF is highest at the site injection

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 …..cont.
• For epidural anesthesia
• The bioavailability is low (<20%)
• Some of the drug will move from the epidural
space through the meninges into the CSF
• some will be lost into the systemic circulation
via absorption by the capillary vessels
• uptake into epidural fat

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 DRUG DISTRIBUTION
• In the subarachnoid space;
• Diffusion is the primary mechanism
• Rostral spread related to CSF circulation time
• Longitudinal oscillations generated by the
pulsations of the arteries in the skull
• distribution from the lumbar space to the
basal cisterns within 1 hour of injection

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 DRUG ELIMINATION
• decline in the CSF drug concentration, due to non
neural tissue uptake and vascular absorption
• Time for block regression is also inversely
correlated with CSF volume
• No drug metabolism takes place in the CSF
• Greater distribution greater vascular absorption
and short duration of action
• Lipid-soluble local anesthetics bind to epidural fat
to form a depot that can slow vascular absorption
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 PHYSIOLOGIC EFFECTS
• CARDIOVASCULAR; decreased SV and HR due
to blockade of sympathetic fibers
• Hypotension is believed to be more gradual
and less magnitude with epidural than spinal
• Biphasic response, characterized by an early
transient increase followed by an eventual
decrease in cardiac output
• Vasodilatation depends on baseline
sympathetic tone (e.g. age ,height of block..)
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 ….cont.
• Heart Rate; decrease
• high neuraxial block (T1-T4)
• Extensive peripheral sympathectomy (T5-L2)
• marked reduction in venous return
• marked increase in parasympathetic activity
(vagal tone)
• The Bezold-Jarisch reflex may be a cause for
profound bradycardia and cardiac arrest
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 …..cont.
• Coronary Blood Flow; A high thoracic block in
patients with IHD can be beneficial
• improvement in myocardial function and
reversal of ischemic changes
• Treatment; ephedrine is preferred
• Administration of crystalloids IV is probably
not a valid concept

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 …..cont.
• CNS; decreased regional CBF in elderly patients
and those with preexisting hypertension
• RESPIRATORY; little clinical consequence in
health individuals even the elderly
• should be used cautiously in the setting of
severe respiratory disease
• respiratory arrest due to hypo perfusion of
brainstem

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 ….cont.
• Pregnancy; little change in young healthy
pregnant women but overweight pregnancy
• Obesity; vital capacity–19% for BMI 30 to 40
kg/m2 versus –33% for BMI>40 kg/m2
• GASTROINTESTINAL; Nausea and vomiting in
as much as 20%
• RENAL; urinary retention
• Avoid excessive volumes of IV crystalloids

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 NEURAXIAL ANESTHESIA
• Spinal anesthesia; indicated in surgeries of
• the lower extremities,
• perineum, pelvic girdle, or lower abdomen
• Epidural technique can also be used for the
above indications

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 NEURAXIAL ANALGESIA
• Local anesthetics (as well as other additives)
applied to the neuraxis in subanesthetic doses
• intraoperative analgesia, acute postsurgical
pain, and severe chronic pain
• intrathecal and/or epidural opioids either alone
or in combination with local anesthetics can
provide excellent quality pain relief
• labor and delivery, after hip or knee
replacement, laparotomy, and thoracotomy
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 CONTRAINDICATIONS
• ABSOLUTE;
• Patient refusal,
• Localized sepsis,
• Allergy to any of the drugs
• A patient’s inability to maintain stillness during
needle puncture
• Raised intracranial pressure

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 Relative contraindications
A. Neurologic;
• Myelopathy or Peripheral Neuropathy
• Spinal Stenosis; may be increased risk of injury
• Previous spine surgery; postsurgical anatomy
• Multiple Sclerosis; may be increased
sensitivity to local anesthetics
• Spina Bifida; increasing the potential for
traumatic needle injury to the spinal cord
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 …..cont.
B. Cardiac;
• Aortic stenosis or Fixed Cardiac Output;
catheter-based neuraxial anesthetic with
repeated small doses of local anesthetic
• Hypovolemia; exaggerated hypotensive
response to the vasodilatory effects of
neuraxial blockade

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 hematology
• Warfarin ; INR<1.5
• 4 to 5 days free before placement/removal
• 24 hrs neurologic monitor after removal
• UFH-SC,1 Hr after and IV,1 hr after placement and 2
to 4 hrs before placement, normal aPTT
• LMWH- SC 10 to 12 hrs before and 6 to 8 hrs after
placement, IV >24 hrs before and 6 to 8 hrs after
• ASA and NSAIDs continue dosage
• Clopidogrel 7 days and ticlodipine 14 days before
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 …..cont.
• Infection; iatrogenic seeding of the neuraxis in
the setting of a systemic infection
• Lumbar puncture is a critical component of the
investigation of fever of unknown origin
• Profound vasodilation may be sufficient reason
to avoid neuraxial techniques in patients with
profound bacteremia
• May safely perform neuraxial techniques after
response to antibiotics
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 Spinal anesthesia(technique)
• Preparation; Informed consent
• Resuscitation equipment
• Adequate intravenous access
• Monitors and spinal set
• Duration of block matched with the procedure
• Sterility is an issue of utmost importance
• Wearing mask,alchol,iodine,chlorhexidine
• Choose appropriate needle
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 …..cont.
• Position;
• sitting position; fast operator performance
• Identification of the midline may be easier
• slower onset time and hypotension
• lateral decubitus position; more comfortable
• facilitates administration of sedatives
• prone position; rectal,perineal,lumbar surgery

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 …..cont.

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 …..cont.
• Projection and Puncture.
A. Midline Approach
• Depression b/n spinous process palpated
• sterile field is established with chlorhexidine
• skin wheal is raised with local anesthetic
• Insert needle in the midline slightly cephalad
• ligamentum flavum penetration-resistance
• Now procedure for spinal and epidural differ
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 …..cont.
• Epidural anesthesia, a sudden loss of resistance
(to injection of air or saline)
• Spinal anesthesia, the needle is advanced to the
intathecal space, free flow CSF
• B. Paramedian Approach
• Skin wheal for is raised 2 cm lateral to the
inferior aspect of the superior spinous
• Needle is inserted 10–25° angle toward midline

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 …..cont.

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 …..cont.

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 Epidural Anesthesia
• Offers a range of applications wider than the
typical all-or-nothing, single dose spinal
• Can be done at lumbar, thoracic,cervical level
• Surgical anesthesia, obstetric analgesia, postop
analgesia,chronic pain treatment
• Differential block ;an epidural provides
analgesia without motor block
• Segmental block ; well-defined band of
anesthesia at certain nerve roots
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 Epidural insertion sites
• Hip surgery, Lower extremity, Obstetric
analgesia- lumbar L2-L5
• Colectomy, Anterior resection, Upper
abdominal surgery – lower thoracic ,T6-T8
• Thoracic surgery- T2-T6

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 COMBINED SPINAL-EPIDURAL
• Rapid onset of spinal block combined with the
benefit of epidural catheter to provide both
postop analgesia and allows anesthesia to be
extended as the spinal resolves
• Particularly useful during labor
• Ability to use a low dose intrathecally
• Epidural volume extension to increase block Ht
• Greater hemodynamic stability for high-risk pat

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 TECHNIQUE
• Placement of the epidural needle first, then
• Either a “needle through needle” technique or
• Altogether separate spinal needle insertion
• The later is advantageous to confirm that the
epidural catheter is functional
• Epidural catheter is to be relied upon for further
anesthesia
• Risks shearing the epidural catheter already
insitu
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 CAUDAL ANESTHESIA
• Popular in pediatrics combined with GA
• Performed after the induction of GA
• Indications in adults are essentially the same
as those for lumbar epidural anesthesia
• useful when sacral anesthetic spread is
desired (e.g., perineal, anal, rectal surgeries)
• in chronic pain and cancer pain management
• Ultrasonography has greater benefit in Childs
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 TECHNIQUE
• Caudal anesthesia requires identification of
the sacral hiatus
• The prone position most chosen in adults,
• The lateral decubitus most chosen in children
• The knee-chest most infrequently used
• 18–23 G needle or catheter is advanced at a
45° cephalad until a pop is felt
• Needle is then flattened and advanced
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 ……cont.
• Bupivacaine or ropivacaine 0.5–1.0 mL/kg of
0.125–0.25% can be used
• Can add Opioids, epinephrine and clonidine
• Higher dermatomal levels can be achieved
• Epidural catheters threaded cephalad into the
lumbar or even thoracic epidural space
• 1.5–2.0% lidocaine, with or without
epinephrine for anorectal surgery in adults
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 Complications
• Adverse or exaggerated physiological
responses
• Urinary retention
• High block
• Total spinal anesthesia
• Cardiac arrest
• Anterior spinal artery syndrome
• Horner’s syndrome
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 ….cont.
• Complications related to placement; Backache
• Dural puncture/leak ;headache, Diplopia ,Tinnitus
• Neural injury; Nerve root damage ,Spinal cord
damage
• Bleeding ;Intraspinal/epidural hematoma
• Misplacement ;No effect, Subdural
block ,Inadvertent subarachnoid block ,IV injection
• Catheter shearing/retention
• Arachnoiditis ,Meningitis and epidural abscess
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 High Neural Blockade
• Dyspnea and have numbness or weakness in
the upper extremities
• Nausea precedes hypotension
• Severe hypotension, bradycardia, and
respiratory insufficiency
• High spinal ;resulting from high levels of spinal
anesthesia
• Total spinal ;if block extends to cranial nerves,

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 references
• Millers anesthesia 8th edition
• Morgan and Mikhail’s clinical anesthesiology
5th edition

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