Anatomy & Physiological Alteration of Central Neuraxial Blocks

Central Neuraxial Blocks
(Spinal and Epidural Anesthesia)
APPLIED ANATOMY
-V ertebral column consist of 3⃣3⃣vertebrae:
7⃣cervical, 1⃣2⃣thoracic, 5⃣lumbar, 5⃣fused sacral and
4⃣fused coccygeal.
- Vertebral column has 4⃣curves:Thoracic and sacral spine are convex posteriorly(kyphotic) while
cervical and lumbar spine are convex anteriorly (lordotic).
- Vertebral canal is bounded
Anteriorly by: vertebral bodies and intervertebral disc. Laterally by: pedicles.
Posteriorly by: lamina, ligamentum flavum and roots or vertebral spines.
- In the vertebral canal lies the spinal cord with meninges.
- Structures encountered during spinal anesthesia:
From posterior to anterior ☺
1.skin
2.Subcutaneous tissue.
3.Supraspinous ligament: Connecting the tips of spinous processes.
4.Interspinous ligament: Joins the spinous processes together.
5.Ligament um flavum: Running from lamina to lamina, Composed of yellow ligaments.
6.Dura.
7.Arachnoid.
🍁 Surface landmarks which are important while giving spinal or epidural anesthesia are:
🎯 C7: Spinous process or 7th cervical vertebrae is
🎯T7: T7 lies opposite to the inferior angle of scapula.
very prominent and easily palpable.
🔥IMPORTANT 🔥
-The line joining the highest point on iliac crest (intercristal line, also called as Tuffier's line)
corresponds to L4 and L5 interspace or L4 spine;It is very important to identity this intervertebral
space while choosing the space for giving spinal or epidural anesthesia.
🍇 Epidural Space (Extradural or Peridural Space)

-It lies outside the dura mater,( between dura and ligamentum flavum). It extends from foramen
magnum to sacral hiatus. Epidural anesthesia is given in this space.
-Epidural space is triangular in shape with apex dorsomedial.
-Contents of Epidural Space
1.Anterior and posterior nerve roots
2.Epidural veins
3.Spinal arteries
4.Lymphatics
5.Fat.
- The epidural veins form a plexus in epidural space called a plexus of Batson, they directly
drain into inferior vena cava.
🛑 Anatomy of Spinal Cord:

#-Spinal cord extends from medulla oblongata to lower border of L1in adults and L3 in infants.
©©(Adult level is achieved by the age of2 years).
#-So.. Spinal anesthesia should be given in L4-5 in infants and L2-3 /L3-4/L4-5 in adults.
#-The spinal nerves are 31 pairs in number, i.e. 8 cervical, 12 thoracic,lumbar, 5 sacral and 1
coccygeal.
#-Each spinal nerve has an anterior root which is efferent (motor) and a posterior root which is
afferent (sensory).
#-Anterior+posterior roots join to form mixed spinal nerves which exist from intervertebral
foramina.
#-As spinal cord ends at Ll therefore lumbar, sacral and coccygeal nerves run downword ⬇ to
exist from intervertebral foramina forming➡ cauda equina (horse tail).
Blood Supply of Spinal Cord

#-It is supplied by 2 posterior spinal arteries and 1 anterior spinal artery.
#-Anterior spinal artery is reinforced by many arteries of which artery of Adamkiewicz (arteria
radicularis magna) is very important which can enter anywhere between T5 and
L2 and usually it enters from the left side. Damage or vasoconstriction to this artery can lead to
➡ cord ischemia and paraplegia.
🔺
Meninges
🔺
From inside to outside➡ piamater, arachnoid mater and duramater.
Duramater extends up to S2 in adults and S3 in children while piamater extend up to coccyx.
Cerebrospinal Fluid
#- CSF is present between pia and arachnoid mater (subarachnoid space).
#-The CSF is secreted by the choroid plexus of third,fourth and lateral ventricles and is
absorbed into venous sinuses via arachnoid villi.
#-500 mL is secreted in 24 hours.
#-Specific gravity= 1.003-1.009 (Average 1.004).
#- pH is 7.35.
#-CSF pressure: It is same in cranium and spinal canal in lying position which is 100-150
mmH20 (10-15 cmH20), while in sitting position the CSF pressure at lumbar level may increase
to 180-240 mmH20.
SYSTEMIC EFFECTS (PHYSIOLOGICAL

ALTERATIONS) OF CENTRAL NEURAXIAL
BLOCKS
Cardiovascular System
-The most prominent effect is hypotension which occurs due to of the following reasons:
1.Sympathetic block. 2.bradycardia.
3.Blockage of nerve supply to adrenal glands(decreased catecholamine release) .
4. Direct absorption of drugs into systemic circulation.
5. Compression of inferior vena cava and aorta(supine hypotension syndrome).
Nervous System
-In spinal nerve autonomic fibers are on most outer (posterior) side while motor on most inner
(anterior) side therefore the first function to be blocked is autonomic followed by sensory and
then motor(The recovery occurs in reverse).
-Due to different sensitivity of nerve fibers to local anesthetics➡ autonomic level is 2 segments
higher than sensory ➡which is 2 segments higher than motor. This is called a differential
blockade and the segments where one modality is blocked and another is not, forms the zones
of differential blockade.
-Autonomic level is tested by temperature {cold),sensory by pin prick (needle) and motor by toe
movement.
Respiratory System
-Tidal volume, minute volume, arterial oxygen tension are well maintained in normal individuals.
-in COPD/Asthma patients there can cause (Dyspnea)
if the block is high enough to block abdominal and intercostal muscles.
-Apnea after spinal anesthesia is usually due to severe hypotension causing medullary
ischemia.
Other causes of apnea are:
1. High spinal: high enough to block phrenic nerves (C3, 4, 5).
2. Total spinal: When the drug reaches up to cranium.
3. intravascular injection and systemic toxicity.
Gastrointestinal System
-Sympathetic block leads to parasympathetic overactivity producing contracted gut with relaxed
🤢 🤮
sphincters;Peristalsis is increased.
🙁
-Nausea and vomiting : The most common cause is hypotension.
Other causes may be :
🤢🤮
bile in stomach(due to relaxed pyloric sphincter) or ⬆peristalsis due to parasympathetic over
activity. & due to these causes treated by atropine.
Genitourinary System
-Renal functions are not impaired unless there is severe hypotension (MAP- 55 mm Hg).
-Urinary retention is the most common postoperative complication➡ due to blockade of sacral
parasympathetic fibers (S2, 3, 4).
-Flaccid and engorged penis is one of the signs of a successful block.
Endocrine System
-Central neuraxial blocks by blocking the sympathetic nerves and adrenals blocks the stress
response to surgery.
-The response to insulin is augmented and there can be hypoglycemia.
Thermoregulation 🌡
Vasodilatation causes heat loss which is compensated by vasoconstriction above the block and
shivering which is a very common occurrence after spinal anesthesia.

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Anatomy & Physiological Alteration of Central Neuraxial Blocks

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Central Neuraxial Blocks

(Spinal and Epidural Anesthesia)

🍇 Epidural Space (Extradural or Peridural Space)

🛑 Anatomy of Spinal Cord:

Blood Supply of Spinal Cord

SYSTEMIC EFFECTS (PHYSIOLOGICAL

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