SPINAL AND EPIDURAL

ANESTHESIA
DEPARTMENT OF ANESTHESIOLOGY

CHARISSE ANN G. GASATAYA

Clinical Clerk, WVSU-COM
What are Spinal and Epidural Anesthesia?

 Spinal and Epidural anesthesia fall under the category of

REGIONAL Anesthesia
 Using local anesthetics to block sensation from certain areas of the body
 Spinal Anesthesia
 Injecting agent into the SUBARACHNOID SPACE
 Epidural Anesthesia
 Injecting agent into the EPIDURAL SPACE
Basic Anatomy: Spinal Column
Basic Anatomy: Ligaments
Basic Anatomy: Spinal Cord
Meninges
 Dura Mater
> fibroelastic membrane
> prevents displacement of an epidural catheter into the
fluid-filled subarachnoid space
 Arachnoid membrane
> adherent to the inner surface of the dura
> major pharmacologic barrier preventing movement of
drug from the epidural to the subarachnoid space
 Pia
> innermost layer
> highly vascular
> inner border of the subarachnoid space
Landmarks

 C2 – first palpable spinous process

 C7 – most prominent vertebrae
 T7 – tip of the scapula
 L4 – level of iliac crest
 S2 - PSIS
Indications
 Spinal anesthesia
 is generally used for surgical procedures involving the lower
abdominal area, perineum, and lower extremities.

 Epidural anesthesia
 abdomen and lower extremities
Control of labor pain
 supplement anesthetic for thoracic and upper abdominal procedures
(i.e. provide continuous epidural anesthesia postoperatively)
Contraindications
Absolute:
 Patient refusal
 Localized sepsis
 Allergy to any drugs planned for administration
 Infection at the site of planned needle puncture
 Elevated ICP
 Bleeding diathesis
Relative:
 Bacteremia
 Preexisting neurologic disease (Myelopathy, Spinal stenosis, Spine Surgery, Multiple
sclerosis, Spina bifida)
 Cardiac disease (cardiac stenosis, hypovolemia)
 Abnormal coagulation
SPINAL ANESTHESIA
Spinal Anesthesia
 Agent injected into the subarachnoid space
 Spread by CSF which bathes the spinal cord and nerve roots

 Preparations prior to procedure:

 IV Infusion
 Equipment, drugs, monitors necessary for procedure
 Supplemental oxygen
 Opioid premedication or local anesthetic infiltration of site
 Aseptic technique with proper sterile protective equipment
 Patient Positioning:
 Lateral Decubitus
 Patient lies on his side with back and legs flexed
 More comfortable for the ill and frail
 Sitting
 Encourages flexion and recognition of midline
 Patient bends his back to a “C” shape
 Lumbar CSF is elevated in this position, the dural sac is distended, thus providing
a larger target for the spinal needle.
 Jack-knife or Prone
 Limited flexion, the contracted dural sac, and the low CSF pressure
 For perineal procedures
 Spinal Needles:
 Gauge 22-25
 Shape of the tips: open ended, closed
tapered tip (pencil point)

 Local anesthetic solution is infiltrated to

anesthetize the skin and subcutaneous tissue
at the anticipated site
Induction technique
 Free flow of CSF confirms correct placement
 Needle is secured by holding the hub between the thumb and the index
finger (pencil like manner)
 Syringe is then attached and the CSF is aspirated to reconfirm placement
 Contents delivered to the space over an 3-5 second period
 Aspiration and reinjection is done as the induction nears end
Approaches
MIDLINE
 Needle inserted at the top margin of the lower spinous process
of the selected interspace, easily identified by visual inspection
and palpation
 Needle is progressively advanced with a slight cephalad
orientation
 Once the needle tip is believed to be in the subarachnoid space, the stylet
is removed to see if CSF appears at the needle hub.
 When redirecting a needle it is important to withdraw the tip into the
subcutaneous tissue.
 If the tip remains embedded in one of the vertebral ligaments, then
attempts at redirecting the needle will simply bend the shaft.

 The patient should NOT BE HEAVILY SEDATED because

successful spinal and epidural anesthesia requires patient
participation to maintain good position, evaluate block height, and
indicate to the anesthesiologist about paresthesias if the needle
contacts neural elements.
 The presence of CSF confirms that the needle encountered a cauda
equina nerve root in the subarachnoid space and the needle tip is in
good position.

 CSF is gently aspirated to confirm that the needle is still in the

subarachnoid space and the local anesthetic slowly injected (≤0.5
ml/s-1).

 After completing the injection, a small volume of CSF is again

aspirated.
PARAMEDIAN
 Point of insertion is 1cm lateral to the midline
 Prone to bleeding since one can encounter a lot of vasculatures
 The paramedian approach to the epidural and subarachnoid spaces is
useful in situations where the patient's anatomy does not favor the midline
approach:
 inability to flex the spine or
 heavily calcified interspinous ligaments.
 Surpasses the suprasinous and interspinous ligament and the
ligamentum flavum will be the first resistance encountered
LUMBOSACRAL
 Taylor
 L5-S1 interspace
 widest but inaccessible from midline
 Needle passed 1 cm caudad and 1 cm
medial to the posterior superior iliac
spine and advanced at a 45=55-degree
angle with a medial orientation based
in the width of the sacrum
INDUCTION Layers traversed by the

Spinal Needle:

1. Skin

2. Subcutaneous tissue

3. Supraspinous ligament

4. Interspinous ligament

5. Ligamentum flavum

6. Epidural Space

7. Dura

8. Subarachnoid space
FACTORS FOR DISTRIBUTION OF
ANESTHETIC
 Distribution of local anesthetic solution in CSF is influenced by:
1. Baricity of the solution
2. Contour of the spinal canal
3. Position of the patient
4. Dose, volume and concentration
5. Patient characteristics
Baricity
 RATIO OF local anesthetic solution’s density relative to the density of CSF
 Predicts the direction the solution will move after injection

 HYPERBARIC SOLUTIONS (>1.007)

 Most commonly selected local anesthetic solutions, achieved by the addition of
glucose (dextrose)
 Principal advantage is the ability to achieve greater cephalad spread of
anesthesia
 Ex. 0.75% bupivacaine with 8.25% glucose, 5% lidocaine with 7.5% glucose
 GRAVITATES TOWARD THE DEPENDENT PORTION.
 HEAD DOWN POSITION FOR CEPHALAD SPREAD
 HYPOBARIC SOLUTIONS (<0.997)
 Reserved for patients undergoing perineal procedures in jackknife position
 PREPARED USING STERILE WATER
 HEAD UP POSITION
 ISOBARIC SOLUTIONS
 Limited spread in the subarachnoid space (VOLUME DEPENDENT)
 More profound motor block and more prolonged duration of action
 Distribution not affected by gravity, not influenced by patient position
 For perineal or lower extremity procedures, lower part of the trunk (hip
arthroplasty, inguinal hernia repair)
Patient Position
 spine is flexed by having patient bend at waist bringing the chin
towards the chest, optimizing the both the interspinous space and
interlaminar foramen

Dose Volume and Concentration

 directly proportional with the spread and time of onset.

Patient Characteristics
 acute abdomen, pregnant patients and elderly- all need lower doses
Adjuvants
 Vasoconstrictors

 Directly proportional with the spread and time of onset.

 Increase the duration of spinal anesthesia
 Due to reduction in spinal cord blood flow, which decreases loss of
local anesthetic from the perfused areas and thus increases the
duration of exposure to local anesthetic
 Epinephrine (0.1-0.2mg) or phenylephrine (2-5mg)
 Opioids and Other Analgesics

 Added to enhance surgical anesthesia and provide postoperative

anesthesia

 Effect is mediated at the dorsal horn of the spinal cord where

opioids mimic the effect of endogenous enkephalins

 Ex. Fentanyl (25 g), Morphine (0.1-0.5 mg), Clonidine

Side effects and complications
 Hypotension
 Bradycardia
 Post spinal headache
 Nausea
 Urinary Retention
 Backache
 Neurologic sequelae
 Hypoventilation
EPIDURAL ANESTHESIA
Epidural Anesthesia
 Injection of local anesthetic into the epidural space
 Anesthesia occurs more slowly (30 mins -1hour) than with spinal
anesthesia and develops in a segmental manner
 Major site of action: spinal nerve roots
 Epidural Kit

 LARGER GAUGES
 17- or 18-gauge needle which permits passage of a 19- or 20-
gauge catheter
 Both have calibrated markings
 1 or 2 needles for infiltration of the skin and for probing the
intervertebral space
Layers Traversed by
Epidural Needle

1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous process
5. Ligamentum flavum
 Areas and Approaches
 Lumbar and Low Thoracic
 Both midline and paramedian approaches are used
 Midline approach is more popular due to:
 Simpler anatomy and easier orientation
 Passage of needle through less sensitive structures

 Thoracic
 Generally uses a paramedian approach
Identification of Epidural Space

 LOSS OF RESISTANCE TECHNIQUE

 A syringe containing air/saline or both is attached to the needle
 Needle is slowly advanced while assessing resistance
 An abrupt loss of resistance to injection signals passage through the ligamentum
flavum and into the epidural space

 HANGING DROP TECHNIQUE

 A small drop of saline is placed at the hub of the epidural needle
 The drop is retracted into the needle by the negative pressure in the epidural
space
Administration
 SINGLE SHOT EPIDURAL
 Simplicity, more uniform than through indwelling catheter
 Administration of a test dose of local anesthetic solution assessed after
3mins
 injection of local anesthetic solution over a 1 to 3 min period

 CONTINUOUS EPIDURAL ANESTHESIA

 A catheter is advanced 3-5cm beyond the tip of the needle positioned in
the epidural space
 epidural needle is withdrawn over the catheter
 Things To Remember With Epidural Placement
 Thread the catheter 3-5 cm
 Remove the needle while keeping positive pressure in
the catheter
 Check position
 Secure catheter

 Test dose
 Aspirate for blood or CSF
 Paramedian insertion usually results in higher blood
vessel puncture
 1.5% lidocaine with epinephrine
Adjuvants
 EPINEPHRINE
 Decreases vascular absorption
 Maintains effective anesthetic concentrations
 OPIOIDS
 Enhance surgical anesthesia and to control post operative pain
 Lipid solubitilty:
 Morphine- hydrophilic, spreads rostrally within the CSF
 Fentanyl- lipophilic, rapidly absorbed and exhibits less rostral spread.
 SODIUM BICARBONATE
 Because local anesthetics are weak bases, they exist largely in the ionic form,
adding sodium bicarbonate favors the non-ionized form of local anesthetic and
favors faster onset of anesthesia
Side Effects

 Backache
 Postdural puncture headache
 Hearing loss
 Systemic toxicity
 Total spinal
 Neurologic injury
 Spinal Hematoma
Summary:
 SPINAL EPIDURAL
Injecting local anesthetic solution Injecting local anesthetic solution
into the CSF into the epidural space
Limited to the lumbar region May be given at various levels of
below the termination of the the neuraxis
spinal cord
Less time to perform Ability to produce segmental
sensory block
Less discomfort
Greater control over the intensity
Requires less anesthetic of sensory and motor block
More intense sensory and motor Allows titration of the block to the
block duration of surgery, control post –
op pain
- End -