CENTRAL

NEURAXIAL
BLOCKADE

DR.ARUN KRISHNAN A U
DEPT.OF ANESTHESIOLOGY
INTRODUCTION

• Central neuraxial anesthesia is a type of regional anesthesia that

involves injecting local anesthetics in to the nerves of central nervous
system
• It include
1) Spinal anesthesia
2) Epidural anesthesia
3) Caudal anesthesia
4) Combined spinal and epidural anesthesia
HISTORY

• 1885- Corning accidentally administered cocaine intrathecally in order to

insert a catheter onto the urethra.

• 1891- Quinke demonstrated usefulness of spinal puncture in diagnosis.

• 1898- Beir, produced spinal anesthesia in animals and man. Actually

introduced the technique as an anesthetic mode.

• 1901- first reported use of intrathecal morphine described by R.Pitesti

VERTEBRAE
The major bones of back are 33 vertebrae
7 cervical,12 thoracic,5 lumbar,5 sacral,4 coccygeal

The angles of spinous processes vary along the spinal

cord.

• The relatively perpendicular orientation of cervical

and lumbar spinous processes to the vertebral
bodies favors a midline approach.

• The acute angle of the Upper and middle thoracic

processes favors paramedian approach.

• The intermediate angulation of lower thoracic

allows either approaches
 SPINAL CORD:
• Spinal cord is continuous with the medulla oblongata
near foramen magnum at base of the skull.
• Cylindrical in shape, it occupies the vertebral canal
of the vertebral column.
• Extension –from foramen magnum to the lower border
of L1 vertebra in adults, L3 in neonates.
• Length – 45cm; weight – 30g.
• The distal end of cord – conus medullaries ( cone shaped).
• A fine filament of connective tissue (pial part of filum
Terminale) continues inferiorly from the apex to conus
Medullaris.
• The spinal cord gives rise to 31 pairs of spinal nerves, each composed
of an anterior motor root and a posterior sensory root.
• The nerve roots are in turn composed of multiple rootlets.
• The portion of the spinal cord that gives rise to all of the rootlets of a
single spinal nerve is called a cord segment.
• The skin area innervated by a given spinal nerve and its corresponding
cord segment is called a dermatome
 Blood supply of spinal cord:
• 3 longitudinal arterial channels arising superior to cervical portion of cord, which descend on
surface of the cord.
• posterior spinal artery - originate in cranial cavity as branches of of either the vertebral
artery or posterior inferior cerebellar artery( PICA).

• Anterior spinal artery - originates within cranial cavity from the union of two contributing
branches of vertebral arteries.

• Segmental spinal arteries give rise to anterior and posterior radicular arteries.

• Segmental medullary arteries: 8-10 reinforcing arteries.

• Artery of Adamkiewicz / arteria radicularis magna– entering between T7 to L4 and

supplies lower thoracic or upper lumbar region. Present typically on left side and
contributes significantly to perfusion of lower two-thirds portion of the spinal cord.
SURFACE MARKING
INDICATIONS OF NEURAXIAL ANAESTHESIA

• Procedures of known duration that involve the

lower extremities
perineum
pelvic girdle or abdomen.
• When patient wish to remain conscious .
• When comorbidities such as severe respiratory disease or a
difficult airway increase the risks of using general
anesthesia.
 CONTRAINDICATIONS
ABSOLUTE
• Infection at the site of injection
• Allergy to any of the drugs planned for
administration.
• A patient’s inability to maintain stillness during
needle puncture, which can expose the neural
structures to traumatic injury.
• Patient refusal
 RELATIVE CONTAINDICATIONS

• Neurologic
-Myelopathy or Peripheral Neuropathy
-Spinal stenosis
-Spine surgeries
-Multiple sclerosis
-Spina bifida
• Cardiac
-Aortic stenosis
-hypovolemia
• Hematologic
-Patients on thromboprophylaxis
-Inherited coagulopathy
• Systemic Infection
SPINAL ANESTHESIA
• It is a temporary, reversible blockade of conduction of impulses in the
spinal nerves caused by deposition of the local anaesthetic drugs in
the subarachnoid space
• Spinal needle:
• Made of stainless steel and must meet standerds of stifness,flexibility
and resistance to breakage
• Luminal size varies from 16-29G
Dural separating needles CANNULA
Require more force to insert
Needles are not deflected from the path
Provide better tactile feel of various tissues
Less chances of PDPH
 Eg:Whitacre, Greene, Sprotte
HUB
Dural cutting needles
More chances of PDPH STYLET
Require less force to insert
Needles are more commonly deflected
from the path
Quincke babcock, Pitkin BEVEL
TECHNIQUE OF SPINAL
ANAESTHESIA
• Preparation
• Position
• puncture
 PREPARATION
• Informed consent must be obtained
• Resuscitation equipment's must always be available
• Adequate intravenous access
• Syringes loaded with general anaesthesia drugs should be ready
• Monitoring of pulse oximetry, non invasive arterial blood pressure and
ECG with recording of basal readings
• A large area over the lumbo sacral region and to the crests of the ilia
should be painted using povidine iodine or similar solutions
 POSITIONS
SITTING POSITION
• Identification of midline may be easier
• CSF flow is better in sitting position.
• The tuffier’s line coincides with the body of L4.
• Patient is made to sit at the edge of the table
with their feet planted on a stool so that knees
are flexed
• Hands are placed over the knees and patient is
instructed to lean forward and flex the head
• Recommended for saddle block anaesthesia, in
obese patients, difficult cases
 Lateral Decubitus Position
• In the lateral decubitus position, the patient
is placed on one side with the back at the
edge of the operating table that is closest to
the anesthesiologist.
• The spinous processes should be oriented parallel to the floor to
prevent rotation of the spine.
• The thighs should be flexed on the abdomen with the knees drawn to
the chest and the neck flexed so that the chin rests on the chest.
• Asking the patient to “assume the fetal position” or “touch your
knees with your chin” may help with positioning during lumbar
epidural placement
•JACK KNIFE MODIFICATION
OF PRONE POSITION

• Chosen usually when the patient is to

be maintained in that position during
the surgical procedure and while using
hypobaric drug. Rectal ,perineal or
lumbar procedures.
• Here the operating table is flexed under
the flanks that is just above the crest of
ilia.
• Disadvantage is that CSF will not freely
flow after puncture , so that correct
needle tip placement in subarachnoid
space is confirmed by aspirating the
csf
 TUFFIER’S LINE
It is the imaginary horizontal line joining the highest points of both of
the iliac crest .
It is also known as intercristal line or
Jacoby’s line
The intercristal line most often intersects
the body of L4 or its inferior endplate in
men and body of L5 or its superior
endplate in women.
Significance
-It is a more accurate method for
numbering the lumbar vertebra clinically.
PUNCTURE
Palpating the iliac crest the lumbar interspaces
are identified
The widest interspace is identified . Usually the
first lumbar interspace is not selected in adults as
the spinal cord ends at the lower border of L1
The skin over the selected inter space is
anaesthetised by using 2% lidocaine contained in
a 2 ml syringe and 25 gauge needle
A small skin wheal is raised and later deeper
tissues are infiltrated while simultaneously
withdrawing the needle.
Introduce spinal needle
INTRODUCTION OF SPINAL NEEDLE CAN BE
DONE BY FOLLOWING THREE APPROACHES

• Midline approach

• Para median approach

• Taylor approach or lumbosacral approach

 TECHNIQUE FOR MIDLINE APPROACH
• The spine is palpated to ensure that the patient’s back is perpendicular to the floor
• The depression between the spinal processes of the vertebra above and below the level
is palpated, this will be the needle entry site
• The needle is introduced holding the distal end of the shaft in the midline directed
slightly cephalad, since the spinous processes course downward from the spine towards
the skin
• The bevel of the spinal needle should be kept parallel to the dural fibers that run
longitudinally
• The needle is slowly advanced entering the skin, subcutaneous tissue , supraspinous
ligament, interspinous ligament(felt as an increase in the tissue density)
• As the needle enters the ligamentum flavum an increase in resistance is felt
• Sudden loss of resistance is felt as this ligament is pierced. Then the needle is forwarded
a little to pass through epidural space, duramater, subdural space and arachnoidmater
to enter into the subarachnoid space.
• The stylet is then removed to see for free and clear flow of CSF.
PARAMEDIAN APPROACH
Useful in situation where patients anatomy does not favor midline
approach such as-

• Inability to Flex spine as in arthritic or deformed spine.

• Heavily calcified interspinous ligament.
TECHNIQUE OF PARAMEDIAN APPROACH
• Spinous process forming lower border of desired interspace is
identified.
• Needle is inserted 1 cm lateral to this point and is directed towards
the middle of interspace by angling approximately 15 degrees
cephalad with just enough medial angulation to compensate for
lateral insertion point.
• The first significant resistance encountered should be ligamentum
flavum
 Structures pierced :
Midline approach Paramedian approach
Skin skin
Subcutaneous tissue Subcutaneous tissue
Supraspinous ligament
Interspinous ligament
Ligamentum flavum Ligamentum flavum
Dura mater Dura mater
Subdural space Subdural space
Arachnoid mater Arachnoid mater
Subarachnoid space Subarachnoid space
TAYLOR APPROACH OR LUMBOSACRAL
APPROACH
• It's a paramedian approach directed at L5 to S1
interspace which is the largest interlaminar space
• Needle inserted at a point 1 cm medial and 1 cm
below the lowest prominance of posterior superior
iliac spine.

• Needle is angled cephalad 45 to 55 degrees and

medially
• Very useful in case of
1. spine fusion ,
2. arthritic spine,
3. opisthotonous and
FACTORS DETERMINANING SPREAD OF LOCAL ANAESTHETIC
SOLUTION WITHIN THE SUBARACHNOID SPACE CAN BE
DIVIDED INTO
DRUG RELATED FACTORS PATIENT RELATED FACTORS

Amount of drug age

Volume of solution height

Place of injection Curvature of spine

Rate of injection pregnancy

Specific gravity of solution,density,baricity Position of patient during and immediately after

drug injection
1. AMOUNT OF DRUG
• With greater amounts of agent there is an increase in the duration and
intensity of spinal anaesthesia .

• There is an upper limit to total amount of agent used regardless of the

volume,and this is determined by that amount of drug that may produce
neurologic damage .

• If volume is fixed the amount of agent used is limited by concentration known

to produce CNS damage .
2.VOLUME OF SOLUTION

• If the amount of a drug remains constant then the

extent of anaesthesia may be increased by increasing
the volume.
• If larger volumes of 5 to 10 ml are injected or if a
small volume of spinal fluid is removed prior to
deposition of anaesthetic drug the levels attained are
significantly extended
3.CONCENTRATION EFFECT
• Total dose of a local anaesthetic dominates the quality of spinal
anaesthesia
• Highly concentrated solution present more hazards
• Maximum concentration of tetracaine,bupivacaine, dibucaine is set at 0.5%
solution.
• Maximum concentration of lidocaine and chloroprocaine has been set at
5%.

4. PLACE OF INJECTION
• Use the widest interspace that can be palpated.
• Lumbar interspaces are commonly selected.
• Selection of one or two spaces higher than 3rd and 4th
lumbar interspace theoretically provides a higher level
of anaesthesia when all other conditions are constant
3. SPECIFIC GRAVITY, DENSITY AND BARICITY
• Density of a substance is defined as mass per unit volume .
• Normal density of CSF for humans is 1.0010 +/- 0.0003

• Specific gravity is a relative term and compares the density of one

substance with that of the other in presence of constant temperature.
• Specific gravity of CSF is 1.007

• The normal osmolality of CSF ranges from 257-305 mosm

• Baricity depends on the basis of density of the anaesthetic

mixture versus CSF density .
• Three type of solutions need to be considered
• Hyperbaric
• Hypobaric
• Isobaric
HYPERBARIC
• Hyperbaric solutions are readily controlled after drug deposition by
positioning of the patient on the operating table.
• In supine position and on a horizontal plane the anesthetic drug will travel
preferentially to the Low points of subarachnoid space that is to the points
below L3 into the lumbar sacral concavity or above L3 into the thoracic
concavity to the T5 level.
• Hyperbaric solutions travel to the most dependent part of subarachnoid
space when there is deviation of the patient position from the
horizontal.

• The lithotomy position flattens the lumbar lordosis.

Hence a patient on horizontal position will have more even spread of
hyperbaric solution
• To assure a low spinal level for certain procedure (urologic gynaecology
and rectal) requiring lithotomy ,the table should be tilted head up.
ISOBARIC SOLUTION
• In general isobaric solutions are considered not to spread with
changes in position and the levels of anaesthesia are independent of
position.
• The tendency is for the solution to remain puddled near the site of
injection
HYPOBARIC SOLUTION
• Hypobaric solutions are predictably influenced by gravity and the
position of the patient after injection.
• These solutions are usually administered with the patient in the
prone position
• High spinal Block with hypobaric solutions may be achieved while the
patient is in the sitting position
 4.Baricity and Position of the patient affecting spinal anaesthesia

HYPOBARIC HYPERBARIC
• In head down position hypobaric • In head down position
solution moves caudal. hyperbaric solutions spreads
• In head up position hypobaric cephalad
solution ascends cephalad.
• In head up position
• In lateral position hypobaric
solution will achieve higher level hyperbaric solution settles
on the non dependent side caudal.
• In lateral position hyperbaric
solution will have a greater
effect on the dependent side
• In sitting position the hyperbaric solution gravitate into
the caudal areas and preferentially block the sacral
segments and the lower lumbar segments to some
extent .This is referred to as SADDLE BLOCK.

• In horizontal supine position hyperbaric solution tend to

concentrate in the lower lumbar and sacral portions.
This creates a greater gravitational influence on
hyperbaric solutions injected into the lumbar
subarachnoid area and enhances migration of anaesthetic
into the caudal area an action known as SUMP EFFECT.
• Drugs may be hypo, hyper or iso baric as compared to
CSF
• Hypobaric drugs
0.5% and 0.75% plain bupivacaine
2% plain lignocaine
2.5% procaine in water
0.5% tetracaine in water
• Hyperbaric drugs
0.5% bupivacaine in 8% dextrose
 5% lidocaine in 7.5% dextrose
• Isobaric solution
Tetracaine 0.5%
Lidocaine 0.5%
5. SPINAL FLUID VOLUME
Work of FOELSCHOW indicates that if a volume of spinal fluid
equivalent to the volume to be injected is first removed, then there is
a greater spread, and the extent of the anaesthetic level will be
increased by 3 segments.
 Lumbar CSF volume inversely correlates with the
dermatomal spread of spinal anaesthesia
 Age-related decrease in CSF volume are likely responsible for the
higher anaesthetic levels achieved in the elderly for a given dosage of
spinal anaesthetic.
6.THE RATE OF INJECTION
• Most important factor in determining the height of anaesthesia.
• Normal Speed of depositing the drug is 0.2ml/sec
• Slow injections do not cause marked diffusion and hence the
levels are low.
• On the other hand very rapid injections may cause anaesthesia to
reach well up into the thoracic area.
 7.BARBOTAGE
• This is the technique of stirring up ,to increase turbulence by
mixing of injected solutions with CSF and increasing
distribution of the drug in the subarachnoid space.
• The technique first described by BIER and consists of injection
of anaesthetic solution into the subarachnoid
space,immediate withdrawal of a portion of solution and
reinjection.
• Immediate withdrawal of portion of the
solution( which is now partially mixed with
CSF )and reinjection.
• This may be repeated
• To and fro movement agitates the inject in
the spinal fluid, and the currents mix the
agent more completely and carry the agent
more extensively and to higher level
 Patient factors affecting spinal
anaesthesia
AGE

Age related decrease in CSF volume are likely responsible for

the higher anesthetic levels achieved in the elderly for a given
dosage of spinal anesthetic.

A more rapid onset of block can be related to neural changes

such as axonal degeneration,reduction in conduction
velocity,reduction in number of fibers that occur with age

HEIGHT
Within the range of “normal-sized” adults, patient height does not seem to affect the spread of
spinal anesthesia.
• This is likely because the length of the lower limb bones rather than the vertebral column
contributes most to adult height.
• A correlation has been found between the vertebral column length and local anesthetic spread
and, only at extremes of height, consideration should be given to altering the dose accordingly
 PREGNANCY
• Pregnant patients will develop higher levels of
sensory block than nonpregnant patients when
given the same dose of intrathecal local anesthetic.
• In nonpregnant adults, increasing abdominal girth
correlates with increasing extent of sensory block
after intrathecal injection of isobaric bupivacaine.
• Increase in intra-abdominal and consequently
epidural space pressure associated with both
pregnancy and obesity may enhance sensory spread
by decreasing lumbar CSF volume.
• In pregnant patients the raise may be profound due
to:-
-Reduced levels of alpha acid
glycoproteins,resulting in reduced protein binding of
local anesthetic.
-Lumbar lordosis
-Engorged epidural veins

Thus,Pregnant women in the 2nd and 3rd trimester

require progressively smaller doses of spinal
anaesthesia .
 CURVATURE OF SPINE

• Placing the block becomes more difficult

• Abnormal spinal curvature affects the level by
changing the contour of subarachnoid space.

• Finding the midline and interlaminar space

may be difficult, paramedian approach may be
preferred in such patients.
• Abnormal curvature of the spine such as
scoliosis and kyphoscoliosis are associated
with decreased CSF volume and results in
higher than expected level.
• Previous spinal surgery can result in technical
difficulties in placing a block.
• Paramedian approach is preferred in such cases.

• Correctly identifying the interspinous and

interlaminar spaces may be difficult at the levels of
previous laminectomy or spinal fusion.
• Thus,block may be incomplete or the level may be
different than anticipated due to post surgical
anatomy changes.
 Assessing the Block

Sympathetic block
-assessed by measuring skin temperature.
Sensory block
-Sensation to pin prick with a needle .
-It is better to test for a loss of temperature sensation
using a swab soaked in either ether or alcohol.
Motor block

Modified Bromage scale

• 0-no motor blockade
• 1-unable to lift extended leg, able to flex knee, feet and toes
• 2- unable to lift extended leg ,unable to flex the knee, able to flex feet
and toes
• 3 –complete motor blockade
CONTINUOUS SPINAL ANAESTHESIA
DEFINITION:Continuous spinal anaesthesia is a technique of producing
and maintaining spinal anaesthesia with small doses of local anaesthetic
injected intermittently into subarachnoid space through catheter.
TECHNIQUE
• Use of flexible tip of 19 gauge epidural catheter single orifice / open
tipped catheter are best.
• Paramedian approach is preferred.
• Insert 2 to 3 cm into intrathecal space .
To help prevent PDPH leave catheter in situ
RISK WITH CSA
• Higher risk of infection.
• Transient paraesthesia- can be decreased by paramedian approach.
• Risk of cauda equina syndrome.
Unequal spread of local anaesthetic along with the use of high
concentration is the cause of cauda equina syndrome for 24hrs.
 EPIDURAL ANESTHESIA
• Anesthesia obtained by blocking spinal nerves in epidural space as the nerves
emerge from the dura and then pass into the intervertebral foramina.
• The anaesthetic solution is deposited out side the dura.
Contents of epidural space
Fat Varies in direct proportion to the rest of the body. Not uniform
in distribution; exists in bands at level of intervertebral foramina
Dural Sac Ends at approximately S2.contains the spinal cord ( to the lower
border of L1) and cauda equina.
Spinal nerves Spinal nerves exit at each level and are numbered according to
the thoracic, lumbar or sacral vertebra above. As there are eight
cervical spinal nerves and seven vertebrae, the nerves in this
region only are numbered according to the vertebra below. The
only exception is spinal nerve C8 that leaves between vertebra
C7 and T1.
Vessels • The epidural space contains the external and internal
vertebral venous plexus. These veins communicate
with the segmental veins of the neck, the intercostal,
azygos and lumbar veins. With the veins of bones of
the vertebral column, the internal and external
vertebral plexuses and form Baxton plexus.
• The epidural arteries located in the lumbar region of
the vertebral column are branches of the ilio-lumbar
arteries. These arteries are found in the lateral region
of the space and therefore not threatened by an
advancing epidural needle.
Connective Variable dorso-median folds , median fold. After leakage
Tissue of nucleus pulposus , surgery or previous epidural
catheterization maybe heavy scar tissue
Equipments

Antiseptic Solution
Syringe/needle for skin
localization
Epidural needle
Glass syringe
 Epidural catheter
 Glass filter
 Dosing syringe
Local anesthetic
EPIDURAL NEEDLES

1)CRAWFORD POINT NEEDLE:

• It is short beveled at 40degree with smooth edges.
• The distal end is open ,but a well fitted stylet closes the
orifice for insertion. This is suitable for single shot
anesthesia, often used for paramedian approach .

It is not associated with a significant incidence of dural

puncture and widely used for thoracic surgery anesthesia
2)TOUHY NEEDLE

• •It was originally used for continuous spinal anesthesia.

• •Radical improvement suggested by Huber resulted in
bending the point and placing the bore orifice on the side
of the point.
• • This is TOUHY-HUBER point needle.
• Curved Huber tip prevents accidental dural puncture,
facilitates passage of the epidural catheter
TECHNIQUES FOR EPIDURAL CATHETER
INSERTION
• Patient should positioned in sitting or lateral decubitus position
• Epidural placement is done by Midline or paramedian approach
Insert epidural needle with stylet
• Dorsum of non injecting hand
rests on the patient’s back with
the thumb and index finger
holding the hub (Bromage grip).
• Needle advanced through
supraspinous ligament and into
interspinous ligament
(needle should sit firmly in midline
)
• A glass syringe or a low resistance plastic syringe is filled with 2-3 ml
saline /air and attached to hub of epidural needle ,after removing the
stylet.
• Maintain constant pressure on testing syringe with the dominant hand.
• Controlled needle advancement is made with the non dominant hand.
• As the needle enters the epidural space there is sudden loss of resistance
as the saline or air is rapidly injected .
• Once a LOR to air /saline has occurred , glass syringe  removed , depth 
noted.
• Noninjecting hand  continues to hold needle in place.
• Depth of the needle at skin Noted
(i.e. depth from skin to epidural space
• Thread the catheter gently through
the needle into the epidural space to
approximately the 15- 17-cm mark,
then remove the needle without
dislodging the catheter
• Add the skin-to-epidural depth plus
3–5 cm. Withdraw the catheter to
that point and secure.
• No more than 5 cm of catheter
should be left in the epidural space to
prevent displacement of the catheter
laterally or into extradural structures.
 SITE OF INJECTION
A spinal interspace is chosen as closely as possible to the
middle of the area to be anesthetized

Detection of epidural space

A) Negative pressure techniques. B) Loss of resistance technique

A)Negative pressure techniques

1)Hanging drop sign:
A small drop of sterile water is placed on the
hub of the needle with entry into epidural
space, this drop will be sucked into the
epidural space. this is called ‘sign of drop’
• Capillary tube method:
Odom devised a small capillary tube filled with sterile saline in which one or two
bubbles of air were placed.
As soon as needle enters epidural space, saline will be sucked in, and air bubbles
could be seen to advance into the space .

Manometer technique
• A small U shaped tube about 3-4 inches is used as a water manometer after
needle has been introduced into the interspinous ligaments .
• Manometer is attached to needle
• As it is advanced through lig flavum and enters the epidural space ,there is
an immediate movement of the liquid ,signifying a negative pressure
 Loss of resistance technique
• Syringe technique
A sudden loss of resistance to a pressure exerted on plunger of a
syringe filled with water as a needle advances through the
ligamentum flavum
Confirmatory Test for Epidural Puncture
1. Aspiration Test:­
• Suction done with 2ml syringe.
• CSF or blood can be easily detected if it is not in epidural space
• 1-2 ml of air is injected through needle and aspiration is again
performed.
• Air should go easily, but nothing should return on aspiration.

2. Sterile water injection:­

Fluids which differ from normal tonicity are painful in epidural
space — (Lund’s concept).
3. Rapid injection of NS ( or) LA:-
Rapid injections (epidurally) 
increase in CSF pressure
(feeling of discomfort and anxiety).
 In unconscious patient 
rate and depth of respiration is increased
(Durrans sign)
PARAMEDIAN APPROACH

The needle entry site Epidural needle angulation When (if) the bone (lamina)
is marked 45 degrees cephalad and is contacted during needle
approximately 1.5–2 very slightly medial. advancement, the cephalad
cm lateral and caudal
needle angle is lowered to
to the desired level of
walk off the lamina.
blockade
FACTORS AFFECTING THE SPREAD
OF EPIDURAL BLOCK
• Patient variables, drug dose, and site of injection are the main
determinants of the spread of epidural block.
• A given dose of local anesthetic will spread farther in older compared to
younger patients.
• As a result, the risk of hypotension associated with epidural local
anesthetics may be greater in older patients.
• Weight and BMI have no clinically significant effects on the extent of
epidural block.
• Pregnant patients will develop more extensive block after a fixed dose of
local anesthetic than nonpregnant patients
• The extent of epidural block is proportional to the dose of local
anesthetic injected
• Site of injection has a major impact on the spread of epidural block. Small doses
of local anesthetic (5 to 10 mL) will produce a band of block around the injection
site. Lumbar injection spreads more cephalad than caudal, whereas upper
thoracic drug blocks more dermatomes below than above the injection.

Onset and duration

Onset and duration of epidural anesthesia depend largely on the choice of
Anesthetic.
Some sign of sensory block should be detectable at the dermatomal level of
injection within 5 to 10 minutes.
The full extent of block usually develops within 20 to 30 minutes. Differences
in onset time between local anesthetics are small and rarely clinically
significant
Chloroprocaine has the shortest duration followed by lidocaine and
mepivacaine.
The more potent drugs, bupivacaine and ropivacaine have the slowest onset
but the longest durations.
• Lidocaine produces relatively more motor block than sensory block.
• Postoperatively patients may have pain before the motor block has
completely regressed.
• Sensory block usually outlasts motor block with mepivacaine, ropivacaine,
and bupivacaine.
• Surgery often outlasts the duration of the initial epidural injection.
• Injecting half the initial dose once the block has regressed by two
dermatomes should maintain an adequate level of block.
• Another way to maintain surgical anesthesia is to inject a fixed dose of
drug at regular intervals.
• For lumbar epidural catheters, inject 5 mL 0.5% ropivacaine or bupivacaine
every 60 minutes.
• Use the same approach with thoracic epidural catheters, but inject a smaller
dose (2.5 mL).
 ADDITIVES
• VASOCONSTRICTORS
Epinephrine reduces vascular absorption of local anesthetics in the epidural space.
 Effect is the most with lidocaine,mepivacaine, and chloroprocaine (up to 50%
prolongation), with a lesser effect with bupivacaine, levobupivacaine, and etidocaine, and
a limited effect with ropivacaine, which already has intrinsic vasoconstrictive properties .
 Phenylephrine has been used in epidural anesthesia less widely than in spinal
anesthesia, perhaps because it does not reduce peak blood levels of local anesthetic as
effectively as epinephrine .
• OPIODS
-Epidural morphine is administered as a bolus of 1 to 5 mg, with an onset time of
30 to 60 minutes and duration of up to 24 hours.
-Hydromorphone can be administered as a bolus of 0.4 to 1.5 mg, with onset at
15 to 30 minutes and a duration of 18 hours.
-The onset of epidural fentanyl and sufentanil is 5 to 15 minutes and lasts only 2
to 3 hours. Bolus doses of 10 to 100 μg may be used to provide analgesia ,
• CLONIDINE
-Epidural clonidine can prolong sensory block to a greater extent
than motor block .
-The mechanism appears to be mediated by the opening of
potassium channels and subsequent membrane hyperpolarization
rather than an α2-agonist effect .

• SODIUM BICARBONATE
-Addition of it increases the pH of LA solution and increases the
conc of non inonised free base,which theoritically increases the rate
of diffusion.
-Addition of 1mEq of it to each 10ml of commercially prepared
1.5% lidocaine produces a significantly faster onset of anesthesia
and more rapid spread of sensory block.
COMBINED SPINAL
EPIDURAL(CSE)
• CSE allows flexibility in a number of clinical settings because the more rapid onset
of spinal block compared with epidural anesthesia allows the operative procedure
to begin earlier.
• Whereas the epidural catheter still provides both effective postoperative
analgesia and allows anesthesia to be extended as the spinal resolves.
• Another significant advantage of CSE in general is the ability to use a low dose of
intrathecal local anesthetic, with the knowledge that the epidural catheter may be
used to extend the block if necessary.
• The addition of either local anesthetic or saline alone to the epidural space via the
catheter compresses the dural sac and increases the block height.
• This latter technique is called epidural volume extension (EVE)
 TECHNIQUE
• The CSE technique most commonly
involves placement of the epidural needle
first, followed by either a “needle through
needle” technique to reach the
subarachnoid space or
• An altogether separate spinal needle
insertion at either the same or different
interspace.
LABOUR ANALGESIA
• Lumbar epidural analgesia offers a safe and effective method of pain

relief during labour and is the mainstay of labour analgesia.

Pregnancy

Extent of epidural pressure

Increase in intra abdominal pressure
increases in synchrony with
causing IVC compression
uterine contractions.

Engorgement of ureteral Direct transmission With increased awareness of these contractions by

venous plexus and lumbar through inter-vertebral the parturient, further increase in abdominal muscle
epidural veins foramina. contraction occur

This inturn leads to further increase

in epidural pressure.
• For Stage I analgesia, segmental
sensory block required is T10-L1 and
for Stage II, its T10-S4.

• Achieving surgical block conditions

takes longer with an epidural than
spinal technique but can be rapid
enough for use in many urgent
situations if already in place and used
for maternal analgesia.
 CAUDAL ANAESTHESIA
• Caudal block is the most commonly used technique of central
neuraxial blockade in children for surgeries in lower part of body.

• Rate of complete or partial failures is 3 to 11 % in upto 7 years of

age.

• Anatomic differences between pediatric and adult patients:

Age. End of spinal End of dural Intercristal CSF Volume. Intercranial

cord. sac. line. Vs Spinal
CSF (%)
Neonate L3 S4 L5 – S1 NA NA
1 Year L1 S2 L4 – L5 4 mL/Kg 50
Adult L1 S2 L3 – L4 2 mL/Kg 25
 TECHNIQUE
• Position : lateral decubitus / prone position either by rolled towel slipped under the pelvis
or with the legs flexed in the frog position.

• Location : the two sacral cornua limiting the “v” shaped sacral hiatus is located by palpation
of spinal process line at the level of sacrococcygeal joint.

• Techniques: single shot is most commonly used.

• Occasionally continuous infusion or repeat shots can be done by catheter placement.

• In children it is recommended to anaesthetize with inhalational agents while the procedure

is being performed
 Armittage formula :

Region. Dose (Bupivacaine)

Lumbo sacral 0.5 mL/Kg
Thoraco-lumbar 1 mL/Kg
Midthoracic 1.25 mL/Kg

(0.25% Bupivacaine up to a maximum of 20 mL can be used for analgesia and if motor

block is desired then 0.5% is used.)

Region. Dose. (Lignocaine)

Lumbo sacral 0.5 mL/Kg

Thoraco-lumbar 1.0 mL/Kg

Midthoracic 1.5 mL/Kg

Maximum of 20 mL, 1% for analgesia and 2% for motor block.

COMPLICATION
1) High neural blockade
• Exaggerated dermatomal spread of neural blockade can occur readily with either
spinal or epidural anesthesia.
• Administration of an excessive dose, failure to reduce standard doses in selected
patients (eg, older adults and patients who are pregnant, obese, or very short)
• Unusual sensitivity or spread of local anesthetic may be responsible
• Patients may report dyspnea and have numbness or weakness in the upper
extremities. Nausea often precedes hypotension
• Spinal anesthesia ascending into the cervical levels causes severe hypotension,
bradycardia, and respiratory insufficiency.
• Unconsciousness, apnea, and hypotension resulting from high levels of spinal
anesthesia are referred to as a “high spinal,” or when the block extends to cranial
nerves, as a “total spinal.
• Treatment of an excessively high neuraxial block involves maintaining adequate
arterial oxygenation and ventilation and supporting the circulation
2) Urinary retention
• Local anesthetic block of S2 to S4 root fibers decreases urinary
bladder tone and inhibits the voiding reflex.
• Epidural opioids can also interfere with normal voiding
COMPLICATION ASSOCIATED WITH
NEEDLE OR CATHETER INSERTION
1. Inadequate anesthesia or analgesia
• neuraxial blocks are associated with a low but measurable failure rate
• Failure may still occur even when CSF is obtained during spinal
anesthesia.
• Movement of the needle during injection, incomplete entry of the
needle opening into the subarachnoid space, subdural injection, or
injection of the local anesthetic solution into a nerve root sleeve may
be responsible
2.Intravascular injection
• Accidental intravascular injection of the local anesthetic for epidural
and caudal anesthesia can produce very high serum drug levels and
local anesthetic systemic toxicity (LAST),
• which may affect the central nervous system (seizure and
unconsciousness) and the cardiovascular system (hypotension,
arrhythmias, depressed contractility, asystole)
• Local anesthetic may be injected directly into an epidural vein through
a needle or later through a catheter that has entered a vein
• ” Advanced cardiac life support should be initiated if cardiac arrest
occurs. Lipid emulsion, 20% 1.5-mL/kg bolus, should be given,
followed by a 0.25-mL/kg infusion
3.Sub dural injection
• Because of the larger amount of local anesthetic administered,
accidental subdural injection of local anesthetic during attempted
epidural anesthesia is much more serious than during attempted
spinal anesthesia
• The spinal subdural space is a potential space between the dura and
the arachnoid that extends intracranially, so local anesthetic injected
into the spinal subdural space can ascend to higher levels than when
injected into the epidural space.
• As with high spinal anesthesia, treatment is supportive and may
require intubation, mechanical ventilation, and cardiovascular
support.
4.Post dural puncture head ache
• Any breach of the dura may result in a postdural puncture headache
(PDPH) PDPH is believed to result from leakage of CSF from a dural
defect and subsequent intracranial hypotension
• Typically, PDPH is bilateral, frontal, retroorbital, or occipital and
extends into the neck.
• It may be throbbing or constant and associated with photophobia
and nausea.
• The hallmark of PDPH is its association with body position
• The pain is aggravated by sitting or standing and relieved or decreased
by lying down flat.
• The onset of headache is usually 12 to 72 h following the procedure;
• Factors that increase the risk of PDPH include young age, female sex, and
pregnancy
• Conservative treatment of PDPH involves recumbent positioning,
analgesics, intravenous or oral fluid administration, and caffeine
• . Keeping the patient supine will decrease the hydrostatic pressure, driving
fluid out of the dural hole and minimizing the headache
• Hydration and caffeine work to stimulate the production of CSF.
• Caffeine further helps by vasoconstricting intracranial vessels, as cerebral
vasodilation is thought to be a response to intracranial hypotension
secondary to the CSF leak
• An epidural blood patch is an effective and frequently used treatment for
PDPH.
• It involves injecting 15 to 20 mL of autologous blood into the epidural space
at, or one interspace below, the level of the dural puncture. It is believed to
stop further leakage of CSF by either mass effect or coagulation.
5.Backache
• As a needle passes through skin, subcutaneous tissues, muscle, and
ligaments, it causes varying degrees of tissue trauma.
• Bruising and a localized inflammatory response with or without reflex
muscle spasm may be responsible for postoperative backache
• Postoperative back soreness or ache is usually mild and self limited,
though it may last for a number of weeks
6. Meningitis and arachnoiditis
• Infection of the subarachnoid space can follow neuraxial blocks as the
result of contamination of the equipment or injected solutions or as a
result of organisms tracked in from the skin
7.Spinal or epidural hematoma
• Needle or catheter trauma to epidural veins often causes minor
bleeding in the spinal canal
• s, both insertion and removal of an epidural catheter can lead to
epidural hematoma formation
• Symptoms include sharp back and leg pain with motor weakness or
sphincter dysfunction, or both.
• When hematoma is suspected, magnetic resonance (MR) or
computed tomography (CT) imaging and neurosurgical consultation
must be obtained immediately.
• In many cases, good neurological recovery has occurred in patients
who have undergone prompt surgical decompression.
8.Epidural abscess
• Spinal epidural abscess (EA) is a rare but potentially devastating complication of
neuraxial anesthesia.
• Initially, symptoms include back pain that is intensified by percussion over the spine.
• Second, nerve root or radicular pain develops. The third stage is marked by motor
or sensory deficits or sphincter dysfunction. Paraplegia or paralysis marks the fourth
stage
• Once EA is suspected, the catheter should be removed (if still present) and the tip
cultured
• If suspicion is high and cultures have been obtained, anti-Staphylococcus coverage
can be instituted, as the most common organisms causing EA are Staphylococcus
aureus and S. epidermidis
• In addition to antibiotics, treatment of EA usually involves decompression
(laminectomy), though percutaneous drainage with fluoroscopic or CT guidance has
been used
9.Sheering of an epidural catheter
• There is a risk of neuraxial catheters sheering and breaking off inside
of tissues if they are withdrawn through the needle
• If a catheter breaks off within the epidural space, many experts
suggest leaving it and observing the patient.
• If, however, the breakage occurs in superficial tissues, the catheter
should be surgically removed.
10. Transient neurological symptoms
• It is referred to as transient radicular irritation (TRI), are characterized
by back pain radiating to the legs without sensory or motor deficits,
occurring after the resolution of spinal anesthesia and resolving
spontaneously within several days
• . It is most commonly associated with hyperbaric lidocaine (incidence
up to 12%), but it has also been reported with tetracaine (2%),
bupivacaine (1%), mepivacaine, prilocaine, procaine, and
subarachnoid ropivacaine
 CONCLUSION
• Neuraxial blocks can be performed as a single injection or with a catheter to
allow intermittent boluses or continuous infusions.
• Performing a lumbar (subarachnoid) spinal puncture below L1 in an adult (L3 in a
child) usually avoids potential needle trauma to the spinal cord.
• Differential blockade typically results in sympathetic blockade that may be two
segments or more cephalad than the sensory block, which, in turn, is usually
several segments more cephalad than the motor blockade.
• Major contraindications to neuraxial anesthesia include lack of consent,
coagulation abnormalities, severe hypovolemia, elevated intracranial pressure,
and infection at the site of injection.
• For epidural anesthesia, a sudden loss of resistance (to injection of air or saline)
is encountered as the needle passes through the ligamentum flavum and enters
the epidural space. For spinal anesthesia, the needle is advanced through the
epidural space and penetrates the dura–subarachnoid membranes, as signaled
by freely flowing cerebrospinal fluid.
• Epidural techniques are widely used for surgical anesthesia, obstetric analgesia,
postoperative pain control, and chronic pain management.
 REFERENCES
• Morgan and mikhael clinical anesthesiology
• Miller's Anesthesia 8th edition.
• Clinical anesthesia .Paul G Barash.
THANK YOU