1. Donald H. Lambert Boston, Massachusetts
Spinal Anesthesia
Donald H. Lambert
Boston, Massachusetts

6. RULE N0. 1:
YOUR ATTENDING IS ALWAYS RIGHT.
RULE NO. 2:
IF YOUR ATTENDING IS WRONG, SEE RULE NO. 1.

7. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

8. Advantages of Spinal Anesthesia
Technically easy
Objective end-point
Rapid onset
Profound sensory and motor block
Low potential for systemic toxicity

9. Disadvantages of Spinal Anesthesia
Limited duration
Limited sensory and motor separation
“Hypotension”
Potential neuro-toxicity
Headache

10. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

11. Indications
Any operation in the lower abdomen and below

12. Absolute Contraindications
Patient refusal
Uncorrected hypovolemia
Uncorrected coagulopathy
Infection at site of injection
Increased intracranial pressure

13. Relative Contraindications
Some neurologic diseases
Bacteremia
Deformities that preclude doing an LP easily

14. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

15. Positioning for the Lumbar Puncture
Two choices
Sitting
Lateral decubitus (recumbent)

16. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

23. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

24. Getting the needle in the right spot
What is the object of the game of basketball?
Get the ball in the hoop (Red Aurbach).
What are we trying to do with spinal anesthesia?
Get the needle into the CSF.

31. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

32. Baricity
The density of the local anesthetic solution in relation to the density of the CSF
More dense than CSF
hyperbaric
sinks
Same density as CSF
isobaric
stay where it is injected (relatively)
Less dense than CSF
hypobaric
floats

35. Hyperbaric
Isobaric
Hypobaric

36. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

37. Spinal Anesthesia Dosing will affect Spread Duration
Quality of Anesthesia
That is, the need for supplemental IV medication

41. The dosing in this study was 10 mg, 15 mg, and 20 mg of bupivacaine
The lowest dose limited spread
The lowest dose also resulted in more failures than the higher doses.

43. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

44. Spinal Anesthesia Agents

45. Dosing Guidelines
Based on the spinal canal model (and many years of doing this)
Hyperbaric solutions extend into the thoracic region
Isobaric solution remain in the lumbar region
Hyperbaric
Isobaric
I give hyperbaric solutions for operations above the L1 dermatome and isobaric solutions for those below

46. Dosing Guidelines
Hernia operations and those operations whose innervation is by nerves above L1
HYPERBARIC
Those operations whose innervation is by nerves below L1 (pretty much all lower extremity operation including hip operations)
ISOBARIC

47. CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIA BASE DECISION ON THE DURATION OF THE OPERATION

48. CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIA GIVE ENOUGH TO PROVIDE ADEQUATE ANESTHESIA
? CHLOROPRACAINE, ? ROPIVACAINE

49. Isobaric Spinal Anesthesia
Epidural Bupivacaine for spinal anesthesia is an “off label use” of this agent
It says right on the bottle: “Not for spinal anesthesia”
What is the value or wisdom behind using that agent?
It works great and I have used it since the 1980’s.
I know of no reports of complications associated with using it.
Litigation for the off-labeled use of a drug has not appeared in the ASA closed claims database.
Who would know?
Unless you wrote on your anesthesia record, “I used the bupivacaine that is not for spinal anesthesia.”

50. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

55. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

56. Narcotic work here in the substantia gelatinosa
Local anesthetics work here in the nerve roots

57. Spinal Anesthesia Addition of narcotics
Fentanyl (15-25 ug lasts a few hours)
Sufentanil ( ug lasts a few hours)
Morphine ( ug lasts hours)
Side effects (increase with increasing dose)
Nausea and vomiting
Itching
Respiratory depression

58. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

59. Spinal Anesthesia Complications Cardiac arrest Hypotension Headache
Nerve injury

61. Cardiac Arrest Still Occurring
Editorial on Auroy’s study:
“Spinal anesthesia appears in this study to be more dangerous than other regional anesthesia techniques.”
“The risk of cardiac arrest is five- to six fold greater than with other regional anesthetic techniques ”
Eisenach, James C. Regional Anesthesia: Vintage Bordeaux (and Napa Valley) Anesthesiology 1997;87:

62. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Caplan, R A; et al. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11
Caplan, R A; et al. Injuries Associated with Regional Anesthesia in the 1980s and 1990s: A Closed Claims Analysis. Anesthesiology. 2004;101:

63. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Caplan, R A; et al. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11

64. Initial Clues of Impending Arrest
Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Initial Clues of Impending Arrest
Caplan, R A; et al. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11

65. Factors Predisposing to Asystole
Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Factors Predisposing to Asystole
High level
Loss of Cardiac Sympathetic Stimulation
Unopposed Vagal Tone
Decreased Venous Return
Empty Left Ventricle
Activation of Intracardiac Reflexes
? So-called Bezold-Jarisch Reflex
? So-called Vaso-vagal Syncope
Caplan, R A; et al. Anesthesiology 1988;68:5-11 and Mackey, D C, et al. Anesthesiology 1989;70:

66. Cardiac arrest during spinal anesthesia
How can this be prevented and/or treated?
Maintain venous return at all cost
Use epinephrine at the first sign of cardiac arrest
Keats, A. S. Anesthesia mortality--a new mechanism. Anesthesiology 1988;68:2-4.

67. Cardiac Arrest Associated with Anesthesia (per 10,000)
* ”Regional Anesthesia”

68. Cardiac Arrest Associated with Anesthesia
There appears to be two mechanisms for cardiac arrest during spinal anesthesia
Spinal factors
Vaso-depressor syncope
Factors other than the spinal
Blood loss
Cardiac events
Orthopedic manipulations

69. Spinal Anesthesia Complications Cardiac arrest Hypotension Headache
Nerve injury

70. Spinal Anesthesia Complications
Hypotension (happens!)

76. Spinal Anesthesia Complications Cardiac arrest Hypotension Headache
Nerve injury

77. The Two Components of Spinal Headache
There must have been a lumbar puncture
The headache is related to posture
Worst when standing or sitting
Gone or improved with recumbence

81. Effect of Age on the Incidence of Spinal Headache
Vandam and Dripps JAMA 1956;161:

82. Effect of Needle Gauge on the Incidence of Spinal Headache
Vandam and Dripps JAMA 1956;161:

86. Spinal Anesthesia Complications Cardiac arrest Hypotension Headache
Nerve injury

87. Nerve Injury with Spinal Anesthesia
Two types
Permanent
Cauda equina syndrome
Adhesive arachnoiditis
Non-permanent
Transient radicular irritation

88. Permanent Nerve Injury with Spinal Anesthesia
Lidocaine spinal anesthesia was associated with 14.4 per 10,000 neurologic complications compared to 2.2 per 10,000 for bupivacaine spinal anesthesia.
Auroy Y. et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002; 97:

89. Permanent Nerve Injury with Spinal Anesthesia
In the cases [of cauda equina syndrome and paraparesis] after subarachnoid block, hyperbaric 5% lidocaine was used in eight cases, bupivacaine 0.5% in 11 cases, and in one case a mixture of both drugs was used.
Moen V. et al: Anesthesiology 2004; 101: 950-9

90. Major Complication of Spinal Anesthesia
Spinal is somewhat more dangerous in causing cardiac arrest and major nerve injury than epidural or general
Epidural has a neurological injury rate similar to spinal but the injuries are different
Epidural are associated with hematoma and compressive nerve injury (? owing to volume)
Spinals are associated with local anesthetic toxicity

91. Permanent Nerve Injury with Spinal Anesthesia
Neurologic injury associated with paresthesia or pain on injection is believed to be traumatic.
Neurologic injury not associate with paresthesia or pain on injection is believed to be due to local anesthetic toxicity.

92. Nerve Injury Still Occurring
Editorial on Auroy’s study:
“Spinal anesthesia appears in this study to be more dangerous than other regional anesthesia techniques.”
“Neurologic injury is two- to threefold greater with spinal than with other regional anesthetic techniques.”
Eisenach, James C. Regional Anesthesia: Vintage Bordeaux (and Napa Valley) Anesthesiology 1997;87:

93. Non-permanent Nerve Injury with Spinal Anesthesia
Minor complications
Transient neurologic symptoms (TNS) a.k.a. transient radicular irritation (TRI)

94. Non-permanent Nerve Injury with Spinal Anesthesia
TNS/TRI
Most frequent with lidocaine (10-34% incidence)
More frequent with lithotomy position and knee arthroscopy
VAS pain score averages 6 out of 10
Many rate the pain worse than their incision
Can last up to three days
Least frequent with bupivacaine

95. Non-permanent Nerve Injury with Spinal Anesthesia
TNS/TRI
The best alternative to lidocaine appears to be bupivacaine.
Lasts too long
Other shorter acting substitutes have not caught on.
Procaine, mepivacaine, prilocaine, ropivacaine

96. Non-permanent Nerve Injury with Spinal Anesthesia
TNS/TRI
Chloroprocaine (off label) is being rediscovered as a short acting spinal anesthetic.
Series of ten articles by Dan Kopacz et al. in the last year (see Anesth Analg 2004 and 2005)
Comparable to lidocaine.
No TNS

97. Non-permanent Nerve Injury with Spinal Anesthesia
TNS/TRI
The spinal anesthetic profile of 40 mg chloroprocaine compares favorably with the same dose of spinal lidocaine
Lidocaine was associated with mild to moderate TNS in 7 of 8 subjects
No subject complained of TNS with chloroprocaine
Yoos JR, Kopacz DJ:. Anesth Analg 2005; 100:

98. Does General Anesthesia Cause Nerve Injury?

99. Spinal Anesthesia Advantages v. Disadvantages
Indications and Contraindications
Positioning
Getting ready
Getting the needle in the right spot
Baricity
Dosing
What to inject
Addition of a vasoconstrictor
Addition of narcotics
Complications (and how to avoid them)

100. Unanswered questions are better than unquestioned answers!

101. www.debunk-it.org - Anesthesiology Forum
Questions?
- Anesthesiology Forum