British Journal of Anaesthesia 98 (3): 396400 (2007)

doi:10.1093/bja/ael370 Advance Access publication February 5, 2007

Trendelenburg position with hip flexion as a rescue strategy to

increase spinal anaesthetic level after spinal block
J.-T. Kim1, J.-K. Shim2, S.-H. Kim2, C.-W. Jung1 and J.-H. Bahk1*
1
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
2
Department of Anesthesiology and Pain Medicine, Yonsei University Hospital, Seoul, Korea
*Corresponding author: Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul
National University College of Medicine, #28 Yongon-Dong, Jongno-Gu, Seoul 110-744, Korea.
E-mail: [email protected]
Background. When the level achieved by a spinal anaesthetic is too low to perform surgery,
patients are usually placed in the Trendelenburg position. However, cephalad spread of the
hyperbaric spinal anaesthetics may be limited by the lumbar lordosis. The Trendelenburg pos-
ition with the lumbar lordosis flattened by hip flexion was evaluated as a method to extend
the analgesic level after the administration of hyperbaric local anaesthetic.
Methods. When the pinprick block level was lower than T10 5 min after intrathecal injection
of hyperbaric bupivacaine (13 mg), patients were recruited to the study and randomly allocated
to one of the two positions: the Trendelenburg position with hip flexion (hip flexion group,
n20) and the Trendelenburg position without hip flexion (control group, n20). Each
assigned position was maintained for 5 min and then patients were returned to the horizontal
supine position. Spinal block level was assessed by pinprick, cold sensation, and modified
Bromage scale at intervals for the following 150 min.
Results. The maximum level of pinprick and cold sensory block [median (range)] was higher
in the hip flexion group [T4 (T8 C6) and T3 (T6 C2)] compared with the control group [T7
(T12 T4) and T5 (T11 T3)] (P,0.001). The maximum motor blockade median (range) was
not different between the two groups being 3 (3 3) in the hip flexion group vs 3 (0 3) in the
control group.
Conclusions. When the level of spinal anaesthesia is lower than required, flexion of the hips
in the Trendelenburg position may be useful as a strategy attempt to increase the level of the
block.
Br J Anaesth 2007; 98: 396400
Keywords: anaesthetic techniques, subarachnoid; anaesthetics local, bupivacaine; position,
Trendelenburg
Accepted for publication: November 5, 2006

During spinal anaesthesia, the lumbar lordosis may affect analgesic level was reported to be higher in the
the spread of intrathecally-administered hyperbaric local Trendelenburg position compared with the horizontal
anaesthetics. Hyperbaric local anaesthetics administered supine position.2 3 Contrary to a unimodal distribution of
at interspaces lower than L3 4 may result in a lower- the maximal spinal block level without lumbar lordosis,
than-anticipated spinal block level owing to pooling of lumbar lordosis seems to cause a bimodal distribution by
drug in the sacral region. When the spinal block level is dividing the injected drug between the sacral and thoracic
not high enough to perform surgery, the Trendelenburg regions.4 5
position is used to extend the level of the block. However, Because the lumbar lordosis can be flattened by hip
if cephalad spread of hyperbaric local anaesthetics is flexion,4 6 we hypothesized that with hip flexion the
limited by the lumbar lordosis, Trendelenburg positioning Trendelenburg position would be more effective for
may be less effective.
Although Trendelenberg positioning does not ensure
Presented in part at the International Anesthesia Research Society
spread of a local aneasthetic into the thoracic region,1 the Annual Meeting, San Francisco, USA, March, 2006.

# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
 Hip flexion and spinal block

increasing spinal block level. This study was performed to extended legs, 2inability to flex the knee, 3inability to
assess if the Trendelenburg position with hip flexion is flex the ankle) every 5 min for the first 30 min after
effective as a strategy attempt to extend the level of spinal intrathecal injection, then every 10 min until the pinprick
anaesthesia when necessary. block level regressed to T10, and then every 30 min until
150 min had elapsed. Spinal blockade were assessed by
the first anaesthetist (J.-T.K) from 5 min after intrathecal
injection to the time that patients were returned from the
Methods Trendelenburg position to the horizontal supine position,
The study was approved by the Hospital Ethics Committee and thereafter were checked by the second anaesthetist
(Seoul National University Hospital, Seoul), and written (S.-H.K) blinded to the patient grouping. Before this
informed consent was obtained from patients before study, it had been confirmed that the interobserver vari-
surgery. Forty-nine male patients with the American ation in assessing spinal block levels was less than 5%
Society of Anesthesiologists physical status I were between the two anaesthetists. The time to the maximum
enrolled. They were scheduled for lower extremity fracture pinprick and motor block and the regression time to T10
fixation, lower extremity mass excision, varicocelectomy, were also recorded.
and inguinal herniorrhaphy under spinal anaesthesia Mean arterial pressure and heart rate were recorded
without premedication. The ECG and non-invasive blood every 5 min for 30 min after intrathecal injection and mon-
pressure readings were monitored during anaesthesia and itored throughout the surgery. Atropine 0.5 mg was admi-
surgery. An 18-gauge i.v. catheter was placed and approxi- nistered i.v. when heart rate was lower than
mately 500 ml of lactated Ringers solution was rapidly 45 beats min21 and, if the systolic arterial pressure
infused before spinal anaesthesia. All spinal punctures decreased to less than 90 mm Hg, 10 mg of ephedrine was
were performed by one anaesthetist (J.-T.K) using a administered i.v. Enquiry was made for back pain and
Quincke-type 25-gauge spinal needle (Hakko Co. Ltd, postdural puncture headache twice a day for the first two
Chikuma, Japan) at the L4 5 interspace with the patient postoperative days.
sitting. After confirming free flow of cerebrospinal fluid, For the purpose of statistical analyses, each dermatomal
2.6 ml (13 mg) of 0.5% heavy bupivacaine (Marcainew; level was scored in sequence starting at S51, such that
AstraZeneca, Sodertalje, Sweden) was injected over S15, L110, T815, T320, and C625. Statistical
approximately 20 s without barbotage. Immediately after analyses were performed using SPSS version 12.0 (SPSS
withdrawing the needle, the patient was gently returned to Inc., Chicago, USA). On the basis of the results of a pilot
the horizontal supine position. study, approximately 19 patients per group were required
Patients with a pinprick block level of T10 or higher to detect a difference of three levels in anaesthesia to
5 min after the intrathecal injection were excluded from pinprick using the Mann Whitney U-test with an a error
this study. If the pinprick block level was lower than of 0.05 and a b error of 0.2. Therefore, we allocated
T10, the patients were randomly allocated to one of the 20 patients per group in this study. The haemodynamic
two groups according to a computer-generated sequence variables were compared by repeated measures analysis of
until 20 patients were assigned to each group: the variance (ANOVA) and Tukey test, and any differences
Trendelenburg position with flexion of the hips and knees between groups were compared by two-way repeated
(the hip flexion group) and the Trendelenburg position measures ANOVA. Sensory and motor block was analysed
without flexion of both joints (the control group). Control using Mann Whitney U-test. The incidences of grade 3
group patients lay supine with their legs straight and the motor blockade, full motor function recovery, and ephe-
operating table was tilted 158 head down. Hip flexion drine or atropine requirements were analysed by Fishers
group patients were placed in the same degree of head exact test. Data are expressed as mean (SD) or median
down tilt, but with the hips and knees flexed and the hips (range). A P-value,0.05 was considered statistically
slightly external rotated. The patients were asked to flex significant.
the hips as much as possible without straining while two
assistants helped the patients to maintain flexion of the
hips and knees. The Trendelenburg position was main- Results
tained for 5 min in each group. Five minutes after Of 49 recruited patients, nine patients were excluded: six
Trendelenburg positioning, all patients were returned to because analgesic level was T10 or higher 5 min after
the horizontal supine position with the legs straight. The spinal block; one because of failed spinal block; and two
surgery was started when the pinprick block level was (inguinal hernia and ankle fracture) in the control group
confirmed to be at least two dermatomes higher than the because general anaesthesia was required during surgery
surgical field. owing to surgical or tourniquet pain. One of the patients
Sensory and motor blockade were assessed with in the hip flexion group was returned to the horizontal
21-gauge needle, alcohol sponge, and using the modified supine position during Trendelenburg positioning because
Bromage scale (0being no block, 1inability to raise the he complained of dyspnoea and his spinal block level

397
 Kim et al.

exceeded T4. This patient was not excluded. Therefore, 20 intrathecal injection and remained higher throughout the
patients were finally included in each group. The two study (P,0.05). The median (range) maximum cold
groups were comparable with respect to age, height, and sensory block level was higher in the hip flexion group
weight. The median (range) age in the hip flexion group than in the control group [T3 (T6 C2) vs T5 (T11 T3),
was 21 (18 28) yr and that in the control group 21.5 (19 P,0.01] (Fig. 1).
32) yr. The mean (SD) heights in these two groups were There was no difference between the two groups in the
175.4 (5.7) cm and 174.4 (4.7) cm, respectively, and median (range) maximum motor blockade [3 (33) vs 3
the mean (SD) weights 71.9 (7.1) kg and 70 (5.3) kg, (03)] and in the mean (SD) time to maximum motor block-
respectively. The types of surgery were evenly distributed ade [12 (4) vs 15 (10) min]. Nine patients in the hip flexion
between the two groups. group and 15 patients in the control group recovered full
Five minutes after intrathecal injection, median (range) motor function within the 150 min study period.
pinprick block level was comparable between the groups Unlike the control group, mean arterial pressure and
[L5 (S4 T12) in the hip flexion group and L5 (S5 L1) in heart rate were decreased in the hip flexion group
the control group, P0.53]. However, pinprick block level (P0.003 and P,0.001, ANOVA for repeated measures)
in the hip flexion group was higher than that of the control (Figs 2 and 3). In the hip flexion group, ephedrine was
group 10 min after intrathecal injection and remained at a administered in four patients and atropine injected in one
higher level throughout the study (P,0.05). The maximal patient. In the control group, one patient was managed
median (range) pinprick block level was higher in the hip with i.v. administration of atropine. There was no case of
flexion group than in the control group [T4 (T8 C6) lower back pain or postdural puncture headache in the
versus T7 (T12 T4), P,0.001] (Fig. 1). The mean (SD) postoperative period.
time for maximal spread of pinprick block was 28
(10) min in the hip flexion group and 21 (5) min in the
control group (P,0.01). The mean (SD) regression time of
Discussion
pinprick block to T10 was 102 (19) min in the hip flexion
group (n20) and 55 (25) min in the control group (n17; Miyabe and Namiki2 found that the cephalad spread of
three patients were excluded because the peak level of analgesia after intrathecal injection of 2 3 ml of 0.5%
analgesia had been lower than T10) (P,0.001). heavy tetracaine was higher in the Trendelenburg position
No difference in the median (range) cold sensory block than in the horizontal position. To the contrary, Sinclair
level was observed between the two groups 5 min after and colleagues1 observed that the spinal block level could
intrathecal injection [L3 (S2 T5) in the hip flexion group not be significantly increased by the Trendelenburg pos-
and L3 (S1 T8) in the control group, P0.80]. However, ition after intrathecal injection of 3 ml of 0.5% heavy
cold sensory block level of the hip flexion group became bupivacaine compared with the horizontal position. These
higher than that of the control group 10 min after inconsistent results may be explained by varying degrees
of cephalad spread of anaesthetics beyond the lumbar lor-
dosis during the Trendelenburg position. In our study, the
Maximal pinprick Maximal cold sensory
block level block level
C2 C2 120
Hip flexion
C3 C3 Hip flexion
Control
C4 C4 Control
110
Mean arterial pressure (mm Hg)

C5 C5
C6 C6
T1 T1 100
T2 T2
T3 T3
T4 T4 90
T5 T5
T6 T6 * *
80 * *
T7 T7 *
T8 T8
T9 T9 70
T10 T10
Trendelenburg with or without hip flexion
T11 T11
60
T12 T12
0 5 10 15 20 25 30
L1 L1
Time (min)
Fig 1 Distribution of maximal pinprick and cold sensory block levels in
the two groups. Both pinprick and cold sensory blockades extend more Fig 2 Changes in mean arterial pressure in the two study groups. The
cephalad in the hip flexion group than in the control group (P,0.001 for error bars represent standard deviations. The y-axis is truncated. *P,0.05
pinprick block and P,0.01 for cold sensory block). compared with baseline value of the hip flexion group.

398
 Hip flexion and spinal block

110
Hip flexion
control group, did attain full recovery of motor function
Control 150 min after intrathecal injection.
100 In our study, the hip flexion group had a tendency
Heart rate (beats min1)

towards a higher incidence of hypotension and bradycar-

90
dia, which can be explained by the higher spinal block
80 level. It suggests that the Trendelenburg position with hip
flexion can result in greater risk of haemodynamic pro-
*
70 blems due to higher spinal block.
* * It has been reported that spinal block level is increased
60 by position change even 60 min after injection of local
50
anaesthetics.16 17 However, the influence of body position
Trendelenburg with or without hip flexion on the spread of local anaesthetics decreases with time after
40 intrathecal injection. Therefore, earlier decision to place the
0 5 10 15 20 25 30 patients in the Trendelenburg position with the hips flexed
Time (min) would be more effective for elevating spinal block level.
There are some limitations to this study. First, because
Fig 3 Changes in heart rate. The error bars represent standard deviations.
The y-axis is truncated. *P,0.05 compared with baseline value of the hip data were obtained only from young healthy Asian male
flexion group. patients with normal body build, it may not be appropriate
to extrapolate our results into other patient groups.
Second, the simulated pooling of local anaesthetics in the
influence of the Trendelenburg position was augmented by sacral region may not resemble the real clinical situation.
flattening the lumbar lordosis. Nevertheless, Trendelenburg positioning with hip flexion
The peak of lumbar lordosis is located at L4 vertebra or could be a potential rescue measure to overcome the
L3 4 intervertebral space.7 Clinically, selecting the L4 5 impending low spinal anaesthesia level.
or L5 S1 interspace for spinal puncture may result in In conclusion, when the spinal block level is expected
inadvertent low analgesic level, which may be explained to be lower than required a few minutes after intrathecal
by sacral pooling of anaesthetics. During continuous injection, the block level may be extended cephalad more
spinal anaesthesia, positioning of the catheter in the sacral efficiently and reliably by the Trendelenburg position with
region or injection of hyperbaric solution with the catheter hip flexion when compared with the conventional
tip oriented caudad may result in pooling of the hyperbaric Trendelenburg position.
anaesthetic solutions caudad to the peak of lumbar lordo-
sis.8 11 In our study, we simulated sacral pooling by
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