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SPINAL AND EPIDURAL
PRESENTED BY ---- Dr. KHAWER MUNEER
MODERATOR ---- Dr. JAVED IQBAL
HAVE A BASIC UNDERSTANDING OF
• Anatomic structure of spine and
•Anatomic structure of spinal cord
•Blood supply of spinal cord
•Features of neuraxial blockade
•Patient evaluation and preparation
•Local anesthetics and factors effecting
BRIEF HISTORY OF SPINAL ANAESTHESIA
CSF DISCOVERED ---- by Domenico Catugno 1764
CSF CIRCULATION---- by F . Magendie 1825
FIRST SPINAL ANALGESIA--- by J Leonard Corning
FIRST PLANNED SPINAL ANAESTHESIA--- by
August Bier in 1891
The epidural space was first described by Corning in 1901,
and Fidel Pages first used epidural anaesthesia in humans
DERMATOMESA dermatome is an area of skin innervated
by sensory fibers from a single spinal
DERMATOMAL LEVELS OF SPINAL
ANESTHESIA FOR COMMON SURGICAL
Procedure Dermatomal Level
Upper abdominal surgery T4
Intestinal, gynecologic, and
Transurethral resection of the
Vaginal delivery of a fetus, and hip
Thigh surgery and lower leg
Foot and ankle surgery L2
Perineal and anal surgery S2 to S5 (saddle block)
PHYSIOLOGICAL EFFECTS OF NEURAXIAL
• Vasomotor tone determined by sympathetic fibers
arising from T5 to L1 innervating arterial & venous
• A ↓ in blood pressure that may be accompanied by
↓ in heart rate.
• With high sympathetic block, sympathetic cardiac
accelerator fibers arising at T1-T4 are blocked,
leading to ↓ cardiac contractility.
• Bezold-Jarisch reflex has been implicated as a cause
of bradycardia, hypotension and cardiovascular
collapse after central neuraxial anaesthesia, in
particular spinal anaesthesia.
Even with high thoracic levels, tidal volume is
A small decrease in vital capacity due to paralysis
of abdominal muscles necessary for forced
exhalation & not due to decrease in phrenic nerve
or diaphragmatic function.
Effective coughing & clearing of secretions may get
affected with higher levels of block.
Rare respiratory arrest associated with spinal
anaesthesia due to hypoperfusion of respiratory
centers in brain stem.
Nausea and vomiting in upto 20% patients due to
gastrointestinal hyperperistalsis caused by
unopposed parasympathetic(vagal) activity.
Vagal tone dominance results in small contracted
gut with active peristalsis & can provide excellent
operative conditions for some laproscopic
procedures when used as an adjunct to GA.
Hepatic blood flow will ↓ with reductions in mean
Renal function has a wide physiological reserve. ↓
in renal blood flow is of little physiological
Neuraxial blocks are a frequent cause of urinary
retention which delays discharge of outpatients &
necessitates bladder catheterization in inpatients.
COMMON INDICATIONS OF
1. lower extremities
2. pelvic /lower abdomen
3. pain mgmt intra/post operative (narcotics)
1. similar surgeries as spinal
2. labour and delivery
3. post op pain mgmt
4. chronic pain mgmt
5. in combination with GA for abdominal &
1. patients refusal
3. infection at local site
4. severe hypovolemia
5. increased ICT
6. allergy to drugs
8. sever AS or MS
1. uncoperative pt
2. preexisting neurological
3. demyelinating lesions
4. severe spinal deformity
5. infection at site remote
SEQUENCE OF ONSET
Principal site of action is the nerve root.
Sequence of onset depends on conc. of LA
achieved, duration of contact, size & myelination of
CLINICALLY OBSERVED SEQUENCE
1. Sympathetic nervous system fibers (B fibers:
vasodilation, skin temp ↑)
2. Temperature & pain conduction (A & C fibers)
3. Proprioception & touch (Aγ & Aβ fibers)
4. Motor function (A fibers)
FACTORS AFFECTING THE LEVEL OF SPINAL
MOST IMPORTANT FACTORS
Baricity of the drug
Position of the patient
Site of injection
Curvature of Spine
Weight of pt
Remove your jewellery/watches
Wash your hands
I.V access/fluids bolus if needed
Emergency drugs /equipment
Sedation if needed
• Verbal contact with pt
TECHNIQUES FOR SPINAL
3. Taylor approach
The structures that will be passed in spinal :
Skin , subcutaneous tissue, supraspinous ligament ,
interspinous ligament , lagementum flavum , dura mater ,
subdural space , arachnoid matter,subarachnoid space in
SPECIFIC TECHNIQUES FOR EPIDURAL
LOSS OF RESISTANCE
AGENTS FOR EPIDURAL ANAESTHESIA
Mild to mod
Mild to mod
Mild to mod
Mod to dense
Mild to mod
Mod to dense
POSTDURAL PUNCTURE HEADACHE
ONSET= 12—72 hrs
it is postural and it is often fronto--occipital associated with stiff neck ,
nausea, vomiting , dizziness and photophobia.
CAUSE---loss of CSF at a faster rate than it can be produced causing
traction on the structures supporting brain, particularly dura and
FACTORS---that increase the risk are young age,female,pregnancy,large
gauge needle, multiple punctures
It is aggravated by sitting or standing and decreased or relieved by lying
TREATMENT----- conservative t/t involves recumbent position,
analgesics, i.v or oral fluids and caffeine.
EPIDURAL BLOOD PATCH
The epidural blood patch
consists of injecting 5-20 mLs
of autologous blood into the
epidural space, in the region
of the suspected dural 'hole.'
Autologous blood is typically
drawn in a sterile fashion, and
then injected as a bolus into
the epidural space.
In 90% of cases, the response
is positive and immediate.
Subsequently, long-term relief
of PDPH occurs in the
majority of cases
HIGH NEURAL BLOCKADE ,HIGH SPINAL AND
TOTAL SPINAL ANAESTHESIA
Can occur both with spinal and epidural
Admins . Of an excessive dose,failure to reduce doses in
selected pts (elderly,pregnant,obese , very short) or unusual
sensitivity or spread of LA maybe responsible
SA ascending into cervical level causes severe
hypotension,bradycardia and respiratory insufficiency and
Total spinal can occur following attempted epidural/caudal
anesthesia if there is inadvertent intrathecal injection
TREATMENT---vasopressors,atropine ,fluids,oxygen ,assisted
ventillation and even intubation and mechanical ventillation
may be needed
TRANSIENT NEUROLOGICAL SYMPTOMS AND
CAUDA EQUINA SYNDROME
TNS or transient radicular irritation refers to pain
,dysesthesia or both in the legs or buttocks after
spinal anesthesia, resolving spontaneously within
Most common with hyperbaric lidocaine and after
surgery in lithotomy position
CES characterized by bowel and bladder
dysfunction together with evidence of multiple
nerve root injury, assoc with use of continous
spinal catheters and 5% lidocaine
NEURAXIAL BLOCKADE IN SETTING OF ANTICOAGULANTS AND
ANTIPLATELET AGENTS---AMERICAN SOCIETY FOR REGIONAL
Pts taking NSAIDS or receiving subcutaneous unfractioned
heparin for DVT prophylaxsis are not viewed as being at
increased risk of spinal hematoma
DISCONTINUE---ticlopidine 2 weeks, clopidogrel for 1 week
,abciximab 24 to 48 hrs, eptifibate and tirofiban 4 to 8 hrs
before performing central neuraxial block.
Pt who are fully anticoagulated or who are receiving
thrombolytic or fibrinolytic theraphy should not receive
central neuraxial block except in very unusual circumstances
where other options are not viable.
Delay atleast 10 -12 hrs after last dose of LMWH
Post op t/t with LMWH delay 12hrs after compl of surgery
Removal of epi ,spi catheters should take place 10—12hrs
after last dose with subs dosing delay for atleast 2hrs.
ADVANTAGES OF SPINAL ANESTHESIA (SPA)
1. Cost. The costs associated with SPA are minimal.
2. Patient satisfaction. the majority of patients are very
happy with this technique.
3. Respiratory disease. SPA produces few adverse effects
on the respiratory system as long as unduly high blocks
4. Patent airway. As control of the airway is not
compromised, there is a reduced risk of airway
obstruction or the aspiration of gastric contents.
5. Diabetic patients. There is little risk of unrecognised
hypoglycaemia in an awake patient.
ADVANTAGES OF SPA CONTD
6. Muscle relaxation. SPA provides excellent muscle relaxation
for lower abdominal and lower limb surgery.
7. Bleeding. Blood loss during operation is less than when the
same operation is done under general anaesthesia
8. Splanchnic blood flow. Because of its effect on increasing
blood flow to the gut, spinal anaesthesia reduces the
incidence of anastomotic dehiscence
9. Visceral tone. The bowel is contracted by SPA and sphincters
relaxed although peristalsis continues. Normal gut function
rapidly returns following surgery.
10. Coagulation. Post-operative deep vein thromboses and
pulmonary emboli are less common following spinal
DIFFERENCES BETWEEN SPINAL AND EPIDURAL
Spinal anaesthesia Epidural Anaesthesia
Level: below L1/L2, where the spinal cord
Level: at any level of the vertebral column.
Injection: subarachnoid space i.e punture
of the dura mater
Injection: epidural space (between
Ligamentum flavum and dura mater) i.e
without punture of the dura mater
Identification of the subarachnoid space:
When CSF appears
Identification of the Peridural space: Using
the Loss of Resistance technique.
Dosis: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5%
Onset of action: rapid (2-5 min) Onset of action: slow (15-20 min)
Density of block: more dense Density of block: less dense
Hypotension: rapid Hypotension: slow
Headache: is a probably complication Headache: is not a probable. 37