Вы находитесь на странице: 1из 15

Figure 16–1. Sagittal section through lumbar vertebrae (A).

Common features of
vertebrae (B, C).

1
Figure 16–2. The vertebral column.

2
Figure 16–3. Posterior and sagittal views of the sacrum and coccyx.

Figure 16–4. Lumbar epidural anesthesia; midline approach

3
Figure 16–5. Exit of the spinal nerves.

Figure 16–6. The spinal cord

4
Figure 16–7. Sagittal view through the lumbar vertebrae and sacrum. Note the end of
the spinal cord rises with development from approximately L3 to L1. The dural sac
normally ends at S2.

5
Figure 16–8.

Arterial supply to the spinal cord. Anterior view showing principal sources of blood supply
(A). Cross-sectional view through the spinal cord showing paired posterior spinal arteries
and a single anterior spinal artery (B).

Figure 16–9. Surface landmarks for identifying spinal levels

6
Figure 16–10. Sitting position for helps in obtaining maximal spinal
neuraxial blockade. Note an assistant flexion.

7
Figure 16–11. The effect of flexion on
adjacent vertebrae. Posterior view (A).
Lateral view (B). Note the target area
(interlaminar foramen) for neuraxial
blocks increases in size with flexion.

Figure 16–12. Lateral decubitus position for neuraxial blockade. Note again the
assistant helping to provide maximal spine flexion.

Figure 16–13. Lumbar spinal anesthesia; paramedian approach.

8
Figure 16–14. Paramedian approach.
A needle that encounters bone at a
shallow depth (a) is usually hitting the
medial lamina, whereas one that
encounters bone deeply (b) is further
lateral from the midline. Posterior view
(A). Parasagittal view (B).

ASSESSING LEVEL OF BLOCKADE

9
With knowledge of the sensory dermatomes (see Image 1), the sensory
level achieved by a block can be assessed by a blunted needle (pinprick),
whereas the level of sympathectomy is assessed by measuring skin temperature
sensation.

Image 1. Sensory dermatomes.

10
11
Figure 16–15. Spinal needles.

Figure 16–16. The position of the spinal canal in the supine position (A) and lateral
decubitus position (B). Note the lowest point is usually between T5 and T7 where a
hyperbaric solution tends to settle once the patient is placed supine.

12
Figure 16–17. Angulation of the epidural needle at the cervical (A), thoracic (B), and
lumbar (C) levels. Note that an acute angulation (30–50°) is required for a thoracic
epidural block, whereas only a slight cephalad orientation is usually required for
cervical and lumbar epidural blocks.

Figure 16–18.
Epidural needles.

13
Figure 16–19. Positioning an anesthetized child for caudal block and palpation for the
sacral hiatus. An assistant gently helps flex the spine.

Figure 16–20. Caudal block. Note the sacrococcygeal ligament is penetrated with the
needle almost at 90° and then must be angled down and advanced to enter the sacral
hiatus.

14
Figure 16–21. The prone jackknife position often used for anorectal surgery can also be
used for caudal anesthesia in adults.

15