Regional Anesthesia

I. Definition

Regional anaesthesia involves the injection of local anaesthetic (LA) and sometimes other drugs (e.g. opioids)
targeted at a specific nerve(s) or nerve plexus to numb the area that the nerve innervates, including the spinal
cord and its nerve roots. (Julia Stone & William Fawcett, 2013)

II. Types
A. Central (Neuraxial) Blockade
Central blockade is the introduction of drugs into the CSF within the subarachnoid space or the
surrounding epidural space (epidural blockade).
Side effects of central blockade are hypotension (sympathetic block); nausea and vomiting
(hypotension, opiates); lower limb motor block; post dural puncture headache (more likely with
large needle, non- pencil-point tip, inadvertent Tuohy needle puncture of dura, young age), high block
can effect upper limb power and respiration (C35); loss of consciousness (total spinal); nerve
damage (rare).
Contraindications to central blockade include patient refusal, no i.v. access, severe CVS disease,
hypovolaemia, sepsis, LA allergy, coagulopathy (e.g. INR needs to be <1.5). Caution must be exercised
if there has been previous major spinal surgery or ongoing CNS disease. (Julia Stone & William
Fawcett, 2013)

1. Types of Central (Neuraxial) Blockade
a. Spinal Block
Spinal anesthesia is produced by injection of a local anesthetic drug into the subarachnoid space
creating a conduction blockade of the spinal nerves and resulting in a rapid, dense, and
predictable state of anesthesia.
Spinal anesthesia is an ideal choice for surgeries below the level of the umbilicus. Examples
include low abdominal, inguinal, genitourinary, gynecologic, rectal, and lower-extremity
surgeries. Spinal anesthesia is not widely used for upper abdominal procedures because of the
need for a very high level of block that may increase the risk of cardiovascular and respiratory
complications. A low spinal anesthetic or saddle block can be used for perineal or perianal
surgery
a.1 Physiologic Responses
Neural Blockade: Classically, the level of sympathectomy is said to be about two levels above
the sensory loss level, but more recent data suggest the degree of sympathetic blockade may be
at, below, or above the level of sensory loss.
Cardiovascular response: Cardiac sympathetic denervation and a decrease in heart rate, as well
as a decrease in cardiac contractility and cardiac output. Systemic effects include dilataion of
arteries and venous capacitance vessels, leading to decreased systemic vascular resistance;
decreased venous return; decreased cardiac output; and ultimately, hupotension. Spinal
blockade at lower levels produces less hemodynamic changes and is better tolerated by
hypovolemic patients, elderly patients, or those with cardiac disease.
Respiratory response: In healthy patients, spinal anesthesia has no major effects on ventilation,
even with a high spinal block. This is because spinal anesthesia does not alter the ventilatory
response to carbon dioxide. In addition, phrenic nerve function is usually pre- served. Spinal
anesthesia may cause paralysis of intercostal and abdominal muscles that may affect patients
with preexisting pulmonary disease and decrease their ability to cough. A high spinal level may
not be a good choice for patients with severe pulmonary disease.
Gastrointestinal response: Spinal anesthesia may cause nausea and vomiting in a significant
number of patients because of unopposed parasympathetic visceral activity. Consequently,
parasympa- tholytics (e.g., atropine, glycopyrrolate) and sympathomimetics (e.g., ephedrine,
phenylephrine) may be helpful in treating these symptoms. In addition, spinal anesthesia may
cause a decrease in hepatic blood flow proportional to the decrease in mean arterial blood
pressure.

Renal response: Spinal anesthesia tends to decrease renal blood flow as a result of arterial
hypotension. However, the kidneys autoregulate to maintain renal blood flow.
Neuroendocrine response: The bodys response to surgical trauma includes localized production
of inflammatory mediators and activation of somatic and visceral afferent nerve fibers. These
responses lead to an increase in the activity of adrenocorticotropic hormone, cortisol,
epinephrine, norepinephrine, vasopressin, and the renin angiotensinaldosterone system.
Spinal anesthesia suppresses part of this neuroendocrine response to a greater degree than
general anesthesia.
Thermoregulation: Spinal anesthesia inhibits normal thermoregulation. There is loss of heat due
to peripheral vasodilation as a result of sympathectomy.
a.2 Spinal Anesthetic Agents
The most common local anesthetics used for spinal anesthesia are lidocaine, tetracaine, and
bupivacaine.
Mepivacaine and ropivacaine, though more commonly used in peripheral nerve blocks or
epidural anesthesia, may be used for spinal anesthesia, although this is not a labeled use in the
United States.
Since procaine is associated with a slow onset and short duration of spinal anesthesia, it is
rarely used.
Chloroprocaine is not approved for spinal anesthesia and formerly was felt to be neurotoxic,
although it has been used successfully in some studies.
Lidocaine once was the most popular local anesthetic for spinal anesthesia, but its use has
declined significantly because of its association with transient neurologic symptoms.
Bupivacaine and tetracaine are popular choices for longer surgery.
While epinephrine has minimal effects on the duration of bupivacaine, epinephrine or
phenylephrine significantly prolong the duration of tetracaine anesthesia.
a.3 Preparation
Informed consent is an absolutely necessary part of patient preparation.
Physical Examination: Routine physical examination, including airway examination, is
performed prior to administering spinal anesthesia. Patients should be questioned about a
history of bleeding problems. The lumbar spine should be examined, and rash, infection, prior
lumbar surgery, or severe spine deformities should be documented if present. In addition, any
history of a neurologic condition or existing neurologic deficit should be documented.
Laboratory tests: If the patient reports a history of coagulopathy or easy bleeding and bruising,
then prothrombin time (PT), partial thromboplastin time (PTT), and platelet count may be
useful.
Premedication: Midazolam, 1 to 2 mg intravenously IV immediately, or diazepam, 5 to 10 mg
orally 1 hour prior to administering spinal anesthesia, may be used to allay the patients anxiety.
An opioid may be used to help relieve pain during patient positioning.
Intravenous preloading: Patients receiving spinal anesthesia must have an IV cannula placed.
Anesthesiologists commonly infuse 500 to 1000 mL of crystalloid fluid immediately before the
spinal anesthetic, to mitigate the effects of sympathectomy.
Monitoring: Blood pressure may fall precipitously following induction of spinal anesthesia.
Therefore, spinal anesthesia must be admin- istered in an environment in which the ASA
monitoring standards are achieved (see Chapter 24). Warning signs of falling blood pressure
include pallor, sweating, nausea, and feeling generally unwell.
Equipment: Spinal needles generally fall into two categories: those that cut the dura and those
designed to spread the dural fibers. The Whitacre and Sprotte needles have a rounded or pencil-
point tip, no cutting edges, and a side hole proximal to the tip. The QuinckeBabcock needle is
the traditional needle design. It is a cuttingtype needle with sharp edges, medium bevel
length, sharp point, and an end hole located on the cut bevel. Needle size and tip design have
been shown to correlate with the incidence of postdural puncture headache (PDPH). Smaller-
gauge needles (2527 G) have a lower incidence of PDPH than larger-gauge needles (22 G).
Pencil-point needles (e.g., Whitacre, Sprotte) have a lower incidence of PDPH com- pared with
cutting-type needles (e.g., Quincke) of similar or even smaller diameter.
a.4 Techniques
Landmarks: The iliac crests are palpated, and if a line is drawn at this level perpendicular to the
spinal column it will generally intersect the L45 interspace or the L4 body. However, imaging
studies indicate poor correlation between anesthesiologists landmark- predicted interspace and
the anatomically verified interspace. The injection site is then prepared with a skin antiseptic
and draped. If accidentally introduced into the spinal space, antiseptic solutions may cause
chemical meningitis. The skin is anesthetized at the level chosen using 1% lidocaine, and the
spinal needle is then inserted directly (Quincke needle), or through a larger introducer needle
(Whitacre or Sprotte needle).
Positioning: Spinal anesthesia can be administered in the sitting (Fig. 57.2), lateral decubitus, or
prone positions. The lateral decubitus and sitting positions are most commonly used. Oxy- gen
by face mask or nasal cannula may be administered, especially if a sedative has been given.
o The sitting position is a popular position for spinal anesthesia, and is also chosen when
low lumbar or sacral levels of anesthesia are needed. This position allows easier
identification of lumbar structures, especially in obese patients or patients with scoliosis.
The patient is positioned at the edge of the bed with the legs hanging or supported by a
foot rest. He or she is asked to bend forward and arch the lower back posteriorly
(reversing the lumbar lordosis); assuming this position allows opening of the
interspaces and easier access to the subarachnoid space. An assistant or a specially
designed support device then sup- ports the patient. Once the spinal injection is
performed, the patient is positioned for surgery. If a hyperbaric solution is used, spread
of the local anesthetic solution can be facilitated by tilting the operating table to the side
as needed, or to a Trendelenburg (head-down) position to increase cephalad spread of the
local anesthetic.
o The lateral decubitus position allows administration of more sedation and is less
dependent than the sitting position on a well-trained assistant. The patient is placed close
to the edge of the table in a comfortable position with a pillow underneath the head and
sometimes between the knees. The hips and knees are flexed and knees drawn up to the
chest. The neck is flexed toward the knees to provide maximum anterior flexion of the
spinal column. The hips and shoulders should be perpendicu- lar to the surface of the
table. If a hyperbaric solution is used, the surgical site is often placed dependently if the
planned surgery is unilateral. If the surgical site is placed nondependently, then a
hypobaric or isobaric anesthetic solution may be used.
o The prone position (Fig. 57.4) is usually reserved for patients undergoing rectal, perineal,
or lumbar surgery. The patient is placed in the desired position, often with jackknife
modification, and this position is maintained during surgery. Most often, the operative
site is caudad to the level of injection; there- fore, the prone position is well suited to the
use of hypobaric anesthetic solutions. An isobaric solution will also provide satisfactory
sacral anesthesia.
Approach: Lumbar puncture can be performed using either a midline or a paramedian approach.
o In the midline approach, the spinal needle is inserted and advanced between the upper
and lower spinal processes in the midline, taking into account the minimal cephalad
angulation of the spinal processes in the lumbar area (Fig. 57.5). If the needle is angled
and advanced correctly, it will pierce through the supraspinous and interspinous
ligaments, and then the ligamentum flavum. After entering the epidural space, it pierces
the dura to reach the subarachnoid space. At any time, bone may be encountered, and
this should be used as an indication as to where in the interspace the needle could be.
Superficial con- tact with bone usually indicates spinal process, whereas deeper contact
implies contact with the lamina. When the ligamentum flavum is encountered, there is an
increase in needle resistance, followed by decreased resistance (pop) when the
subarachnoid space is entered. The stylet is then removed. Correct position in the
subarachnoid space is confirmed by spinal fluid flowing through the needle hub.
o In some patients with difficult anatomy, such as kyphoscoliosis or severe arthritis, the
paramedian approach (Fig. 57.5) may be the technique of choice. In the presence of
severe scoliosis, the approach should be from the concave rather than the convex side of
the curvature. With this technique, the needle insertion point is approximately 11.5 cm
lateral and 11.5 cm caudal to the inferior edge of the superior spinal process of the
chosen interspace. A longer needle may be needed for this approach. The needle is
advanced with an angle of 10

to 15

off the sagittal plane and 45

cephalad. If the lamina
is contacted, the needle is redirected and walked off the lamina in a slight medial and
cephalad direction. With this approach, the interspinous ligament has been bypassed and
the needle encounters the ligamentum flavum before entering the spinal space.
o The lumbosacral approach (Taylor approach) is useful in patients who have had lumbar
spine fusions. The point of needle insertion is about 1 cm caudal and 1 cm medial from
the posterior superior iliac spine. In this technique, a 5-inch spinal needle is directed
upward, medially, and anteriorly at an angle that approximates the angle of the dorsal
aspect of the sacrum. The needle is then advanced so that its point enters the lumbosacral
space between the sacrum and the last lumbar vertebra at the L5S1 interspace
a.5 Factors affecting Spinal Block
In the past, numerous factors were thought to affect the spread of spinal local anesthetic,
including the patients body habitus, technique of injection, characteristics of the spinal fluid,
and the anesthetic solution. In clinical practice, only baricity, patient posture, and perhaps total
dose of anesthetic have any important effects.
o The baricity of a local anesthetic solution refers to the density of the solution compared
with the density of human CSF. Hyperbaric solutions contain glucose and have a specific
gravity greater than 1.008 and therefore tend to migrate toward dependant areas.
Hypobaric anesthetic solutions have a specific gravity less than 1.003 and are prepared
by mixing local anesthetic with preservative-free water. Hypobaric anesthetic solutions
tend to move opposite the dependant areas. Isobaric anesthetic solutions (specific gravity
same or close to CSF) will stay near the site of injection, with minimal spread.
o At extremes of height, the level may vary modestly, although this may be the result of
altered spinal curves rather than height per se. Controlling the position of the most
dependent point in the spine by patient positioning or tilting the bed can influence this
distribution.
o It may seem logical that a greater dose or volume of solution would block more spinal
segments, but there is little evidence that this is true. The effect of baricity so
overwhelms other effects, including dose, that the small effect that may be caused by the
drug dose is clinically meaningless. Isobaric injections may show some modest dose or
volume dependency, and any block will be more intense and last longer when a larger
dose is used.
a.6 Adverse Effects of Spinal Anesthesia
Cardiovascular effects: The most common cardiovascular effects after spinal anesthesia are
hypotension and bradycardia. Cardiac arrest (asystole) is a rare but more serious complication.
o Hypotension, the most common complication of spinal anesthesia, is the result of venous
and arterial vasodilation from sympathectomy, resulting in reduced venous return,
cardiac output, and systemic vascular resistance. Hypotension, if severe, should be
treated with appropriate administration of IV fluids and careful administration of
vasoactive drugs, such as ephedrine (510 mg IV bolus) or phenylephrine (4080 ug IV
bolus).
o Bradycardia is caused by widespread sympathetic blockade, leading to unopposed vagal
tone. Bradycardia during spinal anesthesia may be associated with hypotension and
hypoxemia, but also may occur independently. Consequently, severe or symptomatic
bradycardia should be treated aggressively with glycopyrrolate, atropine, or ephedrine.
Epinephrine should be used if other agents are not effective.
Neurologic effects: Aseptic meningitis is usually benign and presents within 24 hours of spinal
anesthesia. Clinically, nuchal rigidity and photophobia may be present, accompanied by a fever.
CSF cultures are negative for bacteria but may show abundant polymorphonuclear leukocytes.
Infectious meningitis should always be in the list of differential diagnoses and needs to be ruled
out, especially if fever is present. Aseptic meningitis requires only symptomatic treatment and
usually resolves within a few days. Postdural puncture headache (PDPH) is thought to be
caused by persistent CSF leak through the dural puncture site. Age (young > older), gender
(female > male), the size and type of the needle, orientation of the bevel (parallel >
perpendicular to the long axis of the body for cutting needles), and pregnancy all are risk factors
for developing PDPH. Transient neurologic symptoms (TNS) were first described in 1993 and
originally termed transient radicular irritation. It presents with pain in the lower back, limbs,
buttocks, thighs, or calves after uncomplicated spinal anesthesia. The pain may last for 5 to 10
days. There are no associated motor or sensory deficits with TNS. Somatosensory evoked
potential, electromyography, and nerve conduction studies do not show any abnormalities. TNS
is more common after the lithotomy position, in obese patients, and in outpatient operations.
Although TNS may develop after injection of any local anesthetic, the highest incidence has
been found after administration of lidocaine. There is no association of TNS with gender, age,
needle type, difficulty with block placement, or paresthesia during needle placement. The first
line of therapy is patient reassurance and analgesics such as COX inhibitors if the pain is
severe. Nerve damage is a rare complication of spinal anesthesia, with an incidence of fewer
than one in 10,000 cases. Spinal nerve roots may be damaged directly from the needle contact,
and this is usually preceded by paresthesias or pain during placement. Under no circumstances
should the needle be advanced or injection continued if the patient complains of pain or
paresthesia. Meningitis may rarely follow spinal anesthesia, particularly if there is a breach of
sterile technique or if the patient has severe untreated bacteremia. The incidence is estimated to
be approximately one in 50,000. Oral commensal organisms have been isolated in some cases,
implying the source may be the anesthesiologists mouth. Careful attention to sterile
precautions, including universal use of a mask and sterile gloves, pretreatment of patients with
suspected bacteremia with appropriate antibiotics, and vigilance for signs of meningitis
followed by aggressive treatment, can help minimize morbidity. Spinal hematoma is a
potentially devastating complication that if left untreated, may result in a partial or permanent
neurologic deficit. The most common site is the epidural space, however subdural and
subarachnoid hematomas are also documented. High spinal or total spinal anesthesia is a
serious anesthetic complication caused by depression of cervical spinal cord and brainstem
function due to high cephalad spread of local anesthetic. It has a variable presentation and may
present with tingling of the fingers, indicating spread of local anesthetic to the C7T1 level. The
patient may complain of nausea, followed by hypotension, bradycardia, difficulty breathing,
and respiratory depression. If the anesthetic spreads to C35, apnea may occur as a result of
blockade of the phrenic nerve (diaphragm). Treatment is supportive, involving IV fluids and
pressors to maintain the blood pressure and heart rate, and adequate oxygenation (face mask or
tracheal intubation) for respiratory support.
Respiratory effects: Dyspnea is described as an unpleasant sensation of difficulty breathing. This
complication has been seen frequently after spinal anesthesia. It results from loss of intercostal
muscle pro- prioception and the inability of patients to sense chest wall movements. Motor
blockade of the abdominal and intercostal muscles may have a negative impact on coughing.
Patents with preexisting pulmonary problems such as chronic obstructive pulmonary disease are
more severely affected. Reassurance and confirmation of adequate ventilation are essential.
Apnea may result from a high spinal and direct blockade of C35 (phrenic nerve) or severe
hypotension. Hypotension may lead to impaired medullary blood flow and hypoxemia of the
ventilatory center and may be perceived as chest heaviness.
Other effects: Backache may occur in up to 40% of patients after a lumbar puncture and may last
for 1 to 2 weeks. The pain may be related to periosteal trauma from multiple attempts or
stretching of the muscles or ligaments associated with muscle relaxation, TNS, or a spinal
hematoma. It is important to remember that the back- ache may not be related to the spinal
injection. Usually, the pain is not severe or debilitating. Application of heat, rest, and mas- sage
therapy are usually sufficient. Urinary retention is common after spinal anesthesia and is caused
by blockade of the sacral nerve roots S24. The loss of bladder tone may lead to bladder
distention. Considering that sacral autonomic fibers are among the last to recover fol- lowing a
spinal anesthetic, bladder distention may be signif- icant, and catheterization may be needed. If
a longer spinal anesthetic is planned, it might be prudent to insert a bladder catheter to avoid
problems with bladder distention. Bladder dis- tention, if not recognized postoperatively, may
be associated with hemodynamic changes such as hypertension and tachy- cardia or
bradycardia. Blockade of higher sympathetic efferent fibers (T5L1) may result in an increase
in sphincter tone, again producing urinary retention. Nausea and vomiting may occur after a
spinal anesthetic as a result of hypotension, administration of opioid in the spinal solution or IV,
sympathectomy itself (leading to unopposed vagal tone), or surgical stress. Hypotension should
be treated, and antiemetics such as ondansetron may be administered.

b. Epidural Block
This involves the placement of a catheter into the epidural space, followed by continuous or intermittent
drug administration. It is used for analgesia during labour as well as during surgery and for
postoperative analgesia. Positioning is as for a spinal block. (William Fawcett & Julian Stone)
A Tuohy needle is advanced towards the epidural space, with continuous or intermittent pressure
applied to a saline-filled syringe attached to the distal end of the needle. As the ligamentum flavum is
breached there is a sudden loss of resistance. An epidural catheter is threaded down the needle, which is
then removed and discarded.
b.1 Lumbar Technique
The spinal cord terminates at L1 in most adults and L3 in most children. Therefore, there is less
risk of damage to the spinal cord by placing an epidural block in the lumbar region.
b.2 Thoracic, cervical, and caudal epidural anesthesia
Thoracic epidural anesthesia is most often used, in addition to general anesthesia, for
procedures in the thoracic and high abdominal regions.
An alternative approach to the epidural space for procedures in the rectal, perineal, genital,
inguinal, and lower abdominal region is the caudal approach. single-shot epidural anesthetic or
a catheter to provide continuous infusion may be used. This technique is used more commonly
in children, because the sacral hiatus is more often patent in children than in adults.
a.3 Spinal Epidural Block
Combined spinalepidural (CSE) block is when both procedures are performed at the same time, either
as a needle through needle technique or as two separate procedures at different vertebral levels. It has
the advantage of rapid onset (spinal) and the ability to supplement with the epidural component as the
spinal anaesthetic wears off (e.g. post- operative analgesia or prolonged surgery).
The injected drugs act directly on the spinal cord and nerve roots, blocking sensory, motor and
autonomic nerve transmission. LA and opiates given together have a synergistic effect.
Repeated syringe aspiration on injecting LA is important to prevent inadvertent intravenous injection.
Nerve damage is rare but the issue should be discussed with the patient.

B. Nerve Plexus Blockade
The two main ways of locating the targeted nerve are to use a nerve stimulator or ultrasound. Either
technique can be used or both together. Although rare, inadvertent intravenous injection of LA and/or
LA toxicity are recognized complications. Full resuscitation facilities, including drugs and equipment to
perform tracheal intubation, must be available whenever a nerve block is performed.
Repeated syringe aspiration on injecting LA is important to prevent inadvertent intravenous injection.
Nerve damage is rare but the issue should be discussed with the patient.

1. Nerve stimulator
The needle is attached to a variable electrical current. It is initially set to 12 mA with a frequency of 1
2 Hz. As the nerve is approached, a motor response in the muscles supplied by the nerve is elicited. The
current is reduced as the nerve is approached, aiming to produce the best motor response at the lowest
current. When the correct needle position is achieved, muscle twitch will usually disappear at a current
of 0.20.3mA (threshold). If twitches persist down to a very low amperage, it suggests intraneural
placement and the needle should be resited. The injection should be pain free if pain does occur, the
injection must be stopped and the needle repositioned. Twitches disappear as the LA is injected, due to
the conductive properties of the LA.
2. Ultrasound
Advantages are direct vision of the needles entire length and tip throughout all stages of needle
advancement as well as seeing the spread of LA as it is given. Other potential advantages include:
o higher success rate
o quicker to performquicker onset of block
o smaller doses of anaesthetic used
o less pain in performing
o increased patient satisfaction.
3. Some common nerve blocks
Interscalene block provides surgical anaesthesia to shoulder, upper arm and forearm. The upper,
middle and lower trunks of the brachial plexus are blocked as they lie in the interscalene groove
(between the scalenus anterior and scalenus medius), within a fascial sheath. The groove is located at
the level of C6 (corresponding to the cricoid cartilage) at the lateral border of the sternocleidomastoid.
Axillary block is used for surgery of the elbow, forearm and hand. It blocks the radial (C5T1), ulnar
(C7T1), median (C6T1) and musculocutaneous (C57) nerves high in the axilla, lateral to the
pectoralis minor. The nerves lie within a fascial sheath with the axil- lary artery and vein (the latter is
not always within the sheath).
Femoral nerve block is used for surgery of the anterior thigh, knee and quadriceps tendon. The
femoral nerve (L24) is the largest branch arising from the lumbar plexus. It is located lateral to the
femoral artery, in the inguinal crease, just distal to the inguinal ligament. Stimulation of quadriceps
(patella twitch) indicates correct needle placement. If used in combination with a sciatic nerve block,
total anaesthesia distal to the mid thigh is produced.
Popliteal block affects the sciatic nerve (L4S3) proximal to its bifurcation into the common peroneal
nerve (L4S2) and the tibial nerve (L4S3). It provides anaesthesia below the knee, excluding that
supplied by the saphenous nerve (a terminal branch of the femoral nerve). The injection is at the apex of
a triangle where the popliteal crease is the base and the sides are composed of the tendons of biceps
femoris (lateral) and semitendinosus and semimembranosus (medial).

III. Advantages and Disadvantages of Regional Anesthesia
1. Advantages of central blockade are:
avoidance of GA in at-risk patients, e.g. severe respiratory disease, difficult intubation, diabetic,
myopathies, pregnant, malignant hyperthermia;
good postoperative analgesia;
avoids sedation/nausea and vomiting, e.g. by morphine;
reduction in pulmonary thromboembolism due to sympathetic block;
reduced blood loss;
reduced stress response to surgery

2. Disadvantages
Takes longer to initiate than GA, but may save time post-operatively
Extra equipment necessary
GA still possible
Additional skill required
Management of awake and lightly sedated patients