NEUROAXIAL BLOCK

IMAM SUDRAJAT, dr, SpAn, Msi

Med

Spinal, Epidural, and Caudal Anesthesia

General considerations

Preoperative assessment is similar to that for general

anesthesia.
The area where the block should be examined for potential
difficulties or pathology.
A history of abnormal bleeding and a review of the patient's
medications may indicate a need for additional coagulation
studies.
Patients should be given a detailed explanation of the
planned procedure, with risks and benefits.
As with general anesthesia, patients should receive
appropriate monitoring and have an IV line in place.
Oxygen, equipment for intubation and positive-pressure
ventilation, and drugs to provide hemodynamic support
should be available.

Contraindications to neuraxial anesthesia

Absolute

Patient refusal.
Localized infection at skin puncture site.
Generalized sepsis (e.g., septicemia, bacteremia).
Coagulopathy
Increased intracranial pressure.

Relative

Localized infection peripheral to regional technique site.

Hypovolemia.
Central nervous system disease.
Chronic back pain.

Spinal anesthesia

Spinal anesthesia involves administering local anesthetic into the subarachnoid space.

Anatomy
The spinal canal extends from the foramen magnum to the
sacral hiatus.
Three interlaminar ligaments bind the vertebral processes
together:
Superficially, the supraspinous ligament connects the
apices of the spinous processes.
The interspinous ligament connects the spinous processes
on their horizontal surface.
The ligamentum flavum connects the caudal edge of the
vertebrae above to the cephalad edge of the lamina below.
The spinal cord extends the length of the vertebral canal
during fetal life, ends at about L-3 at birth, and moves
progressively cephalad to reach the adult position near L-1 by
2 years of age. The conus medullaris, lumbar, sacral, and
coccygeal nerve roots branch out distally to form the cauda
equina. Spinal needles are placed in this area of the canal
(below L-2), because the mobility of the nerves reduces the
danger of trauma from the needle.

Table 16.1. Suggested

minimum cutaneous levels for
spinal anesthesia
Operative Site

Level

Lower extremities
T-12
Hip
T-10
Vagina, uterus
T-10
Bladder, prostate
T-10
Lower extremities with tourniquet
T-8
Testis, ovaries
T-8
Lower intraabdominal T-6
Other intraabdominal T-4

Spinal column curvatures that influence the spread of

anesthetic solutions.

The Advantages of Spinal Anaesthesia

Cost. Anaesthetic drugs and gases are costly and the latter often
difficult to transport.
Patient satisfaction. If a spinal anaesthetic and the ensuing surgery
are performed skilfully, the majority of patients are very happy with
the technique and appreciate the rapid recovery and absence of side
effects.
Respiratory disease. Spinal anaesthesia produces few adverse
effects on the respiratory system as long as unduly high blocks are
avoided.
Patent airway. As control of the airway is not compromised, there is a
reduced risk of airway obstruction or the aspiration of gastric contents.
Diabetic patients. There is little risk of unrecognised hypoglycaemia
in an awake patient.
Muscle relaxation. Spinal anaesthesia provides excellent muscle
relaxation for lower abdominal and lower limb surgery.
Bleeding. Blood loss during operation is less than when the same
operation is done under general anaesthesia.
Visceral tone. The bowel is contracted during spinal anaesthesia and
sphincters are relaxed although peristalsis continues. Normal gut
function rapidly returns following surgery.

Epidural anesthesia

Epidural anesthesia is achieved by introducing local anesthetics into the epidural space.

Anatomy. The epidural space extends from the base of the

skull to the sacrococcygeal membrane. Posteriorly, it is
bounded by the ligamentum flavum, the anterior surfaces
of the laminae, and the articular processes. Anteriorly, it is
bounded by the posterior longitudinal ligament covering the
vertebral bodies and

Subarachnoid and epidural spaces.

Pemeriksaan keadaan anestesi

Diagram dermatom

pin prick
alkohol

13

Obat dan alat

14

 Posisi : lateral kiri

Desinfektan : betadin alkohol
15

 Infiltrasi lidokain 2 %
Tusuk L

3-4

atau L

45

dengan jarum epidural no.18

16

Sasaran jarum

17

 Masukkan 2 3 ml obat anestesi lokal

18

Masukkan kateter epidural

19

Aspirasi, hasil (-) cabut jarum

20

 Fiksasi kateter
21

 Masukkan lagi 3 ml obat anestesi lokal,

observasi 5 menit
Dosis fraksional 3-5 ml
Interval waktu 5 menit
alternatif lain : infus kontinyu

22

Caudal anesthesia
Caudal anesthesia is obtained by placing local anesthetic into the
epidural space in the sacral region.
Anatomy. The caudal space is an extension of the epidural space. The
sacral hiatus is formed by the failure of the laminae of S-5 to fuse.
The hiatus is bounded laterally by the sacral cornua, which are the
inferior articulating processes of S-5. The sacrococcygeal membrane
is a thin layer of fibrous tissue that covers the sacral hiatus.