1. Contraindications spinal – MGMC Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology)

2. We know the indications Lower abdominal, pelvic surgeries Obstetric and urological Lower limb surgeries Rarely upper abdominal surgeries Laminectomies Labour analgesia Spinal opiates in pain relief Conscious, Respiratory illness, Risk of aspiration, Renal problems.

3. When not to administer ?? Absolute Coagulation problem, local sepsis, refusal Relative Aortic stenosis, Primary Pulm. Hypertension— HOCM – Spine surgery, LBA, gross kyphoscoliosis, under GA, sepsis, viral infections like HIV, herpes

4. Refusal Risks and benefits of neuraxial technique to be informed Physician recommendation as the best available option Not willing – sedate and give - may not be the answer

5. Preload dependent conditions eg, Aortic Stenosis A sympathectomy caused by a single shot spinal Decreased preload, afterload and tachycardia sometimes are detrimental to AS Decreased coronary perfusion and further damage … A titrated neuraxial – just OK

6. HOCM Dynamic obstruction Maintain euvolumia, afterload and rate are the king pins All of them – antagonistic after spinal

7. Primary pulmonary hypertension Decreased preload and afterload are detrimental Titrated blocks with invasive monitoring …. √ So –Preload dependent, Fixed output states – dangerous !!

8. Spinal instrumentation Harrington rods !! Technical difficulty Epidural more difficult than spinal Anxiety, backache, previous surgeon cautions are against spinal but Administration of spinal is acceptable if possible

9. Under GA !! Pain or paresthesia not recognized – dangerous after effects Preferably conscious Can we do it in children !! Major cord injuries are not reported

10. Septicemia or bacteremia Possible spread to CNS If antibiotics are started and infection is getting down in relation of clinical signs, Spinal is just acceptable especially single dose

11. Shock or severe hypovolemia Sympathetic block and vasodilation Dangerous decrease in cardiac output Inability to get the tap in three attempts is move towards GA

12. Tatoo in the back Pigment can be taken by the needle Can be implanted in spinal space Granuloma or inflammation may be there Go away from site Let CSF flow before injection of LA Options

13. Viral infections Active varizella Introduction of virus by spinal or post op pneumonia by GA Can give spinal if drugs are started and pencil point needles are used to lessen the introduction of virus into the CNS

14. HSV 2 infection There is an increased risk of cauda equina syndrome associated with HSV2 infection Someone puts the blame on spinal ?? Neuraxial local with opioids for herpes zoster – proved

15. Miscellaneous contraindications Increased intracranial tension Lack of skills in spinal Allergy to local anesthetics with psychiatric diseases, e.g. schizophrenia, manic depression, claustrophobia, Alzheimer’s, dementia, etc. are not suited for regional anesthesia

16. Spinal in neuromuscular disorders thorough neurological assessment documented, regional anaesthesia very good in whom respiratory depression with opiates is disadvantageous. In rapidly progressive disorders – can avoid the use of regional -- Can we distinguish disease progression In those with cardiovascular complications and autonomic dysfunction, severe hypotension may result from neuroaxial blockade.

17. Spinal in a known epileptic ?? Majority of seizures occurring in the perioperative period in patients with a preexisting seizure disorder are likely related to the patient's underlying condition and that regional anesthesia in these patients is not contraindicated.

18. Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) spinal anesthesia is acceptable for cesarean delivery in CIDP-patients when reasonable precautions have been taken. Multiple sclerosis – Spinal worsens the disease progress – NOT proved !!

19. Multiple sclerosis Document deficit Short duration More opioids with less LA No repeated doses But sometimes bladder spasticity gets better

20. Spina bifida

21. Spina bifida- problems Restrictive lung disease Neuro deficit Prior corrective surgery MRI Evaluate renal function Spinal below the level = just acceptable, but unpredictable effects

22. Spina bifida occulta Nothing is seen outside Usually at L5 level Better to give higher level

23. History of myelocele neonatal repair done Coming for some other pelvic surgery after 15 years Tethered cord Low lying conus Get the prick well below – as far as possible

24. HIV and anaesthesia IJA – 2007 S Parthasarathy M Ravishankar S ParthasarathyM Ravishankar Regional anaesthesia is safe but one must take into consideration the presence of local infections, bleeding problems & neuropathies

25. Relative contraindication ?? !! spinal anesthesia can be successful even in cases of severe thoraco lumbar kyphoscoliosis.

26. Diabetic peripheral neuropathy The patho physiology of diabetic neuropathy is unclear Local anesthetics are not proven to increase the damage Note down the deficits Think of other damages RA – OK

27. Coagulopathy – DIC NO spinal aPTT - > 2 times the control INR more than 2 Platelets < 75000 Active sepsis ??

28. Antiplatelets Aspirin is generally continued Not proved dangerous Don’t combine with heparin No to prostate and neurosurgeries – stop aspirin three days prior

29. Clopidogrel Clopidogrel is a thieno pyridine derivative – Inhibits ADP induced platelet aggregation Seven days stoppage is ideal Emergency – high dose steroids and aprotinin More towards surgical causes !! Ticlopidine 14 days

30. Intravenous heparin Antithrombin Usually can be administered one hour later But ideal to monitor coagulation profile Protamine is another option

31. LMWH Low dose – (enox 30 mg/ day )12 hours- later spinal Enoxaparin > 1.5 mg / kg /day = high dose High doses 24 hours later Think of obesity and renal compromise – hours extended

32. Ximelegatran and fondaparinux Antithrombin drugs Not well established- preferably 4 days – no spinal No action on platelets

33. ITP –hernioplasty Usually clinically fine Thrombocytopenia is acceptable till 50000 for spinal Single shot is better. HELLP syndrome – normalize all clotting problems before spinal !!

34. On warfarin 5 mg To stop the drugs usually 4- 5 days prior Get the INR around 1.4 Administer neuraxial block Sometimes restart warfarin day 0 !!

35. Tirofiban, abciximab Glycoprotein IIb/IIIa inhibitors No spinal till 8 hours after Tirofiban No spinal till 24 hours after abciximab

36. COX 2 inhibitors Coxibs No contraindications to spinal

37. Drugs Rifampin Quinine Quinidine, Septran Some drugs which can cause thrombocytopenia other than heparin Get the platelet level up before spinal

38. V W brand s disease Various types =Minor forms – OK Nasal spray of DDAVP IV DDAVP Factor activities - Remain elevated for 8-10 hours

39. Previous spinal given Patient developed PDPH Epidural blood patch given Can we spinal in this case if it comes for lower limb surgery after 1 year ?? Because of fibrosis, difficult technically but can be given after explanation

40. Already a low back ache patient History, MRI and diagnosis Better to avoid the same disc region RA is not contraindicated Less likely to exacerbate

41. Patients on VP shunt Shunt without complications – yes spinal can be given. – Reported cases of injury to lumboperitoneal shunt – Symptoms of shunt failure – headache vomiting – confused with PDPH !!

42. Summary Indications Contraindications,Absolute --Relative Cardiac Spinal surgeries, anomalies Infections Coagulopathy Demyelination Antiplatelets Miscellaneous

43. Thank you all