Spinal Anesthesia

Spinal Anesthesia
This presentation will be divided into
two sections:
ANATOMY & PHYSIOLOGY
PROCEDURE & TECHNIQUE
 Spinal Anesthesia
Spinal, Epidural and Caudal block
are also referred to by several other
terms:
1) NEURAXIAL Anesthesia (Nerve Axis
Blockade)

2) CONDUCTION Anesthesia (Nerve

Conduction Blockade)
 Spinal Anesthesia
Back to the basics:
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacrum/Coccyx
Spinal Anatomy
 Spinal Anesthesia
Boundary of Spinal CORD:
Foramen Magnum to L1

Boundary of Spinal CANAL:

Foramen Magnum to Sacral Hiatus

Beyond L1:
The Cauda Equina
 Spinal Anesthesia
Review of Ligaments, Membranes &
Spaces: (from skin in)
1) Supraspinous Ligament
2) Interspinous Ligament
3) Ligamentum Flavum
4) Epidural Space (potential)
5) Dura
6) Arachnoid
7) Sub-arachnoid space (our target)
8) Pia Mater
 Spinal Anesthesia
Anatomic Landmarks to perform a
Spinal Anesthetic:

Bilateral Iliac Crests

Body of L4 Vertebra (which should
correspond to the position of a line
drawn between the tops of both Iliac
crests)
 Spinal Anesthesia
An IMPORTANT point:

When you perform your spinal

anesthetic at L4-L5 or L5-S1 or L3-L4,
you are injecting into the Cauda
Equina and NOT any where near the
actual Spinal Cord so there is no
danger of damaging the spinal cord
itself.
 Spinal Anesthesia
(NEW STUFF):
CSF total volume between brain and
spinal cord: 150cc (between 30-50cc
in the Spinal Cord at any given time)
The pH of the CSF is approx. 7.32
It is secreted by EPENDYMAL cells of
the Choroid Plexus within the
ventricular system at a rate of 30cc/hr
Your entire volume of CSF is replaced
once every 3-4 hours
 Spinal Anesthesia
NEUROANATOMY: (start at the top!)

The area of the brain that is primarily

responsible for receiving painful stimuli
is the Postcentral Gyrus of the Parietal
lobe
The area responsible for motor function
and movement away from painful
stimuli is the Precentral Gyrus of the
Parietal lobe
 Spinal Anesthesia
The Spinal Cord:
1) Extends to L1 and continues as the
Filum Terminally ending at the first
segment of the coccyx.
2) 31 (Thirty one) pairs of spinal nerves
carry motor and sensory information:
Cervical (8), Thoracic (12), Lumbar
(5), Sacral (5) and Coccygeal (1)
 Spinal Anesthesia
The spinal cord is made up of Gray and
White matter
The Gray matter is composed of Neuronal
cells and unmyelinated fibers. A large
number of Interneurons are found in the
Gray matter
The white matter contains the various
tracts, both ascending and descending, with
the dorsal white matter containing the
ascending sensory tracts and the lateral
and ventral white matter containing the
descending motor tracts
 Spinal Anesthesia
The nerve roots that exit the Spinal
cord are divided into to two:
DORSAL ROOT: carries all afferent
signals heading INTO the spinal cord
and brain
VENTRAL ROOT: carries all efferent
signals heading out to the periphery
They fuse together to form the main

nerve root that exists the spinal cord

at that particular level
 Spinal Anesthesia
IMPORTANT:

The NERVE ROOT is the primary site

of action of the Local Anesthetics,
both with Spinals AND Epidurals. The
only difference is WHERE the root is
being anesthetized, either
Subarachnoid or in the Epidural space
 Spinal Anesthesia
To tie it all together:
A stimulus is generated and travels through a
peripheral nerve back through the DORSAL
root and synapses with several neurons in
the gray matter and from there it goes two
ways:
1) Up to the brain via tracts in the white matter
2) Back out peripherally through the VENTRAL
root to muscles to cause you to withdraw
from the pain
 Spinal Anesthesia
Then, via the tracts in the white matter of
the spinal cord, it travels via several other
nerves and ends up in the Postcentral gyrus
and pain is perceived
Then if further action is needed to withdraw
from the pain, an impulse is generated in the
Precentral gyrus, or motor center, travels
DOWN the tracts in the spinal cord, synapses
again in the gray matter and goes out
through the VENTRAL root to the peripheral
site of a muscle to cause movement
 Spinal Anesthesia
Shortly after leaving the spinal cord,
the meningeal coverings of the
peripheral nerves merge with the
connective tissue layers that cover the
peripheral nerves
This becomes the Epineurium
The bundles of nerves within a
peripheral nerve are covered
individually by the Perineurium
 Spinal Anesthesia
The nerves are further divided into
the Mantle which is the periphery of
the nerve and the core which is the
center portion of the nerve
Each nerve bundle is further divided
into the various TYPES of nerve fibers
with the smallest on the periphery
and the larger in the center.
 Spinal Anesthesia
That is why as a nerve is anesthetized, the
order of block is:
Sympathetic/Parasympathetic small fibers
(C fibers; B fibers, preganglionic; afferent
& efferent)
Sensory small & middle intermediate
diameter fibers (C, A-delta and A-Beta;
afferent & efferent)
Motor large, thick diameter fibers (A alpha,
efferent) (A beta, afferent & efferent) (A
gamma, efferent)
 Spinal Anesthesia
The Peripheral nervous system is divided
into the SOMATIC and AUTONOMIC
The Somatic system contains sensory
neurons for control of skin, muscles and
joint movement
Somatic motor fibers arise from the motor
neurons in the ventral horn, their axons
exiting the spinal cord via the Ventral root
A few centimeters out the somatic motor
fibers join with incoming sensory fibers to
form a mixed nerve root which eventually
becomes one or many peripheral nerves
 Spinal Anesthesia
So the SOMATIC system contains:

INCOMING (afferent) sensory neurons for

pain, proprioception, pressure, touch,
etc.

OUTGOING (efferent) motor fibers to

skeletal muscles for movement, both
reflexive and purposeful
 Spinal Anesthesia
The AUTONOMIC nervous system is
the other branch of the peripheral
nervous system and is divided into
two parts:
SYMPATHETIC (stimulating)

PARASYMPATHETIC (relaxing)
 Spinal Anesthesia
The SYMPATHETIC system differs from the
PARASYMPATHETIC in many ways but one
of the primary differences is where the
preganglionic nerve fibers end
With the Sympathetic system, they end in
the sympathetic chain, in one of the many
sympathetic ganglia
The Parasympathetic system preganglionic
fibers actually end IN the organ that they
innervate.
 Spinal Anesthesia
The Sympathetic nerves also differ in that
they originate in the intermediolateral
gray matter of T1-L2 spinal cord segments
These sympathetic neurons run with the
corresponding spinal nerve to a point just
beyond the intervertebral foramen where
they exit to join the sympathetic chain
ganglia
The parasympathetic nerves only
originate in the Cranial nerves or the
Sacral nerves
 Spinal Anesthesia
The Sympathetic nervous system has
Alpha, Beta and Dopamine receptors
The primary neurotransmitters are
Norepinephrine and Dopamine
The Parasympathetic nervous system
has Nicotinic and Muscarinic
receptors with Acetylcholine as its
primary neurotransmitter
 Differential Blockad
Spinal Anesthesia interrupts
SENSORY, MOTOR AND SYMPATHETIC
nervous system innervation
As the LA is injected, it blocks the
small C fibers of the sympathetic
system first and gradually diffuses
into the interior of the nerve where
the larger fibers are for sensory and
then motor
 Differential Blockade
Sympathetic nervous system blockade
typically exceeds somatic (sensory)
blockade by two (2) dermatomes
This actually may be a conservative
estimate with Sympathetic blockade
sometimes exceeding sensory blockade
by as many as six (6) dermatomes
This explains why hypotension can
accompany even low sensory block
levels
 Differential Levels
The Motor level is usually 2 dermatomes
BELOW your sensory level due to the
position of the motor fibers in the middle
of the nerves. It takes longer for
diffusion to get the LA into the nerves
and as the concentration of LA decreases
as the level rises, the amount of LA
available for diffusion decreases
consequently providing a weaker motor
block
 Differential Levels
This can have serious implications if you
end up with a T4 sensory level and the
sympathectomy is at T2 or higher
Cardiac Accelerator fibers of the
sympathetic nervous system originate at
T1-T4, so with a block at T4 you may loose
their effect and bradycardia will result
Usually treated with Atropine; in severe
cases Epinephrine is necessary to
stimulate the heart rate sufficiently to
maintain adequate cardiac output
 Level of Spread
Distribution of Local Anesthetic
solutions in CSF is dependent on:
1) Baricity
2) Contour of the spinal cord
3) Position of the patient during and in the
first few minutes after placement of the
drug into the subarachnoid space
4) Dosage of LA used
5) Other contributing factors (see chart)
 Baricity
Three different mixtures of Local
Anesthetics are possible:
Hyperbaric Solutions
Hypobaric Solutions
Isobaric Solutions
CSF has a baricity (specific gravity)

of 1.003-1.008 at normal body

temperature
 Baricity
Hyperbaric Solutions:
Prepared by adding glucose (dextrose)
in amounts sufficient to increase the
density of the LA above that of CSF
Lidocaine 5% and Bupivicaine 0.75%
are usually premixed with dextrose
and come in a Hyperbaric Solution in
your tray
 Baricity
Hyperbaric Solutions:
Being heavier than the CSF, the solution
settles in the most dependent aspect
of the subarachnoid space
This is determined by the position of the
patient
When supine, the solution tends to
gravitate to the thoracic kyphosis, the
average position being T6
 Baricity
Hyperbaric Solutions:
If given in the sitting position and the
patient is allowed to stay sitting, this
allows production of low sensory levels
of anesthesia
This is called a Saddle Block because it
numbs the area that would be in
contact with a saddle when riding a
horse
 Baricity
Hypobaric Solutions:
Prepared by adding 6 to 8cc of sterile
water to the LA
After injection, the LA Floats up since
it is now lighter than the CSF
Rarely used other than in an Academic
setting to demonstrate the technique
 Baricity
Isobaric Solutions:
Created by diluting the LA with CSF
Useful if you do not need your block to
go much above L1 (hip/knee surgery)
Again, is rarely used except in
Academic settings to demonstrate
the technique
 Position of Patient
The position of the patient during
and shortly after injection of the LA is
a primary determinate of how high
your level goes
Supine, head slightly down will push
your level up to T4-5
Supine level usually will give you a
T6-7 level
Supine with head slightly up will
usually give you a T10-11 level
 Level of Anesthesia
Other factors that can effect the
level of blockade:
1) Scoliosis alter LOW point
2) Kyphosis/Kyphoscoliosis alter low
point
3) Previous back surgery post surgical
anatomic change can effect the level
either higher or lower than expected
 Level of Anesthesia
Other contributing factors:
4) Any condition that lowers the amount of CSF
in the cord by increasing intraabdominal
pressure and causing engorgement of the
epidural veins, applying outside pressure on
the spinal cord
a) Pregnancy
b) Ascites
c) Large abdominal or pelvic tumors
All of these conditions will push your level much
higher than you anticipate
5) Age related decreases in CSF volume may
push your level higher than expected in the
elderly
Spinal Anesthesia

BREAK TIME
 Procedures and
Techniques
This section will include:

Preop evaluation and Patient selection

Review of Local Anesthetics
Spinal Anesthesia Techniques and
Approaches
 Preop Evaluation and
Patient Selection
Preparation in the OR and with your
Pre-anesthesia Evaluation are EXACTLY
the same as with GA (remember that
your Regional can turn into a General
in a matter of seconds!!!)
In addition to the above, a careful
examination of the back needs to be
done to look for spinal deformities,
scars or the presence of inflammation
or infection
 Review of Local
Anesthetics
Review of Local Anesthetics used in
Spinal Anesthesia:

Lidocaine
Tetracaine
Bupivacaine
Ropivacaine
 Local Anesthetics
Basic review of Mechanism of Action:
Local anesthetics produce conduction
blockade of neural impulses by
preventing passage of sodium ions
through ion selective sodium channels
in nerve membranes
They bond to the sodium channel itself
and keep it in the active or open
position
 Local Anesthetics
Remember, the lower the pKa, the lower
the amount of ionization for any given pH
Consequently, the lower the pKa, the
more rapid the speed of onset of the
block because it is the NEUTRAL form that
can diffuse across the cell membrane
The more NEUTRAL form that is available,
the more that diffuses and the faster the
onset of the block
 Vasoconstrictors
Epinephrine or Phenylephrine are
frequently added to LAs to prolong
their duration of action
Epinephrine dose is 0.1-0.2mg
Phenylephrine dose is 2-5mg
Can prolong spinal anesthesia by up
to 50% by causing localized
vasoconstriction and decreasing the
amount of vascular absorption
 Spinal Anesthetic
Techniques
There are three main approaches
for a spinal anesthetic:
1) Midline Approach
2) Paramedian (Lateral) Approach
3) Lumbosacral (Taylor) Approach
 Midline Technique
The anatomic landmarks must be
identified prior to performing your
procedure
They are the Spinous processes

and the iliac crest

You palpate the iliac crests and

draw an imaginary line between

the two
In 95% of patients, this level

corresponds to the body of L4

 Midline Technique
The patient is placed in position (if sitting,
I tell them to hunch over and push their
lower back out towards me, curved like a
shrimp; if Lateral, knees are pulled up as
far as possible and again, push the back
out towards me as far as possible)
This position opens the interspinous
spaces especially in the lumbar region
(like spreading out your fingers)
 Midline Technique
Next, ID your landmarks and locate your spot
Use the kit as per the directions in it (kits vary
tremendously; some are even made custom,
so familiarize yourself with the kit prior to use)
Wash your hands and STERILY place a pair of
gloves on (you need to be sterile from here on)
Sterilize the skin at and around the site
Place the sterile drape in position with your
intended spot in the center of the hole
 Midline Technique
Next, infiltrate local anesthesia at the
site of intended injection (each kit
usually comes with a 25g local needle
and a 3cc syringe along with Lidocaine
1% for skin infiltration)
Now you can insert your INTRODUCER
needle that is usually included in the
kit. It is a usually a short, 20g, yellow
hubbed needle and it is almost
impossible to insert a 25g needle
without your introducer needle in place
 Midline Technique
ID your space and approach it from
the lower portion of the interspinous
dent or space and place the needle
at a 50-60 degree angle to the skin
and gradually advance, keeping the
patient in position while advancing
the needle
You will feel a distinct pop in 90% of
the cases, but some you will NOT
 Midline Technique
As you advance the needle, especially if you
feel the POP, pull out the stylet and look for
spinal fluid flow
If it is there, connect your local syringe, initially
aspirate ONLY enough to create a swirl in your
local to show you are getting free flow of fluid
(the swirl is from mixing two fluids of different
densities)
Brace your hand holding the needle against the
patients back to stabilize the needles position
 Midline Technique
Inject your local slowly and smoothly and
aspirate slightly again at the end to still
show free flow of fluid (some people DO
NOT recc. Aspiration at the end, just to
withdraw needle)
I like to aspirate at the end just to show
you are still in the space
If your needle has moved, you will NOT get
the free flow and then your spinal may not
work as planned and thats good to know
 Midline Technique
At that point withdraw the needle and
if the patient is sitting, have them lay
down supine right away so as to
avoid a low level of anesthesia
Remember the local is heavier than
the CSF so it will sink if you leave the
patient sitting and then you will end
up with a Saddle block and that won t
help you if the case is a knee or hip!!
 Paramedian Approach
This approach is also called the LATERAL
approach
The difference between the Lateral and
the Midline is in its insertion site of the
needle and the angle of approach
The skin wheal is placed 1-2cm LATERAL to
the chosen interspace
The needle is directed medial and
cephalad at an angle of 15-20 degrees
pointing towards the midline
 Paramedian Approach
You advance the needle slowly and
steadily and you will feel the pop as
you penetrate the dura
From here the technique is the same as
the Midline technique
The Lateral Technique is better to use in
a patient with limited flexion of the
back
It also bypasses calcified ligaments
encountered in elderly patients
 Lumbosacral Approach
This approach is also called the
Taylor approach
Difference is that in this technique, it
utilizes the largest interspace in the
vertebral column, which is L5-S1
The needle is positioned as in the
Lateral approach and ends in a
midline dural puncture
 Clinical Usage
Studies have shown that there is NO
difference in Morbidity or Mortality
between GA and Regional in healthy
patients
In a few studies, what has been shown
is a lower incidence of
thrombophlebitis post operatively in
patients receiving Regional Anesthesia
for lower extremity orthopedic
procedures
 Clinical Usage
The reason for the lower incidence of
thrombophlebitis is postulated to be due
to the vasodilation of the lower
extremities with consequently higher
blood flow and a lower incidence of
venous stasis
The mechanism for the lower incidence
has never really been identified, but the
above is as good a reason as any others
 Clinical Usage
The use of Spinal Anesthesia Only as
suggested by many internists who are
asked for medical clearance of sick,
elderly patients is ill-informed and
NOT based on studies or data
It is thought on their part that a spinal
anesthetic is Easier on their
physiology, especially in the light of
co-existing CAD
 Clinical Usage
Even though it is NOT supported by the
data of multiple studies, many anesthetists
and anesthesiologists are convinced that a
Spinal Anesthetic is much less stressful to a
patients physiology than a GA
As a result, you will see it used in many
patients with significant co-existing
diseases, especially in the elderly patient
population
It is a comfort factor to think that the
patient may be too sick for GA but will
tolerate a Spinal without problems
 Clinical Usage
This cant be any farther from the actual
truth!!!
Sometimes the extreme drop in SVR with
resultant drops in blood pressure can do
more harm to the heart of an elderly patient
or a patient with CAD than a smoothly done
GA
Sometimes the sicker they are, the better
the candidate for a nice smooth GA instead
of a roller-coaster ride of alternating
hypotension and hypertension from a spinal
anesthetic
 Clinical Usage
If a spinal is used in a patient with
significant co-existing disease, the same
approach needs to be followed as if a GA
were to be used and that is to keep ALL
physiologic parameters as close to normal
as possible
Anticipate the side-effects and
complications that can occur and stay
ahead of them and you will be much
better off, whether you use a Spinal OR GA
 Clinical Usage
The ideal uses for Spinal Anesthesia are for:
1) Patients with co-existing Asthma or COPD;
long history of pulmonary disease or a
heavy smoker

2) Patient fearful of GA
3) OB patient for a C-section
4) Patient with a history of Thrombophlebitis or
at an increased risk of developing
Thrombophlebitis
5) Any patient with an obviously difficult
airway and who is undergoing a procedure
that can be done under spinal
 Clinical Usage
Last but NOT least, remember that ANY
Regional Anesthetic may have to be
converted to a GA at a moments notice
Always be prepared for that
contingency so you wont get caught off
guard
Always keep thinking What if? and
stay one step ahead by knowing what
can happen and anticipate it actually
happening
 Reading & References
S & M pg. 80-88 (Review LAs)
S & M pg. 168-183 (1st-5th weeks)
N & Z pg. 591-608 (1st-5th weeks)
N & Z pg. 977-1008 (1st-5th weeks)
M & M pg. 289-325 (1st-5th weeks)