Spinal anesthesia: Technique
- Alexander M DeLeon, MD
Alexander M DeLeon, MD
- Assistant Professor in Anesthesiology
- Northwestern University
- Cynthia A Wong, MD
Cynthia A Wong, MD
- Professor of Anesthesia
- University of Iowa Healthcare
Spinal anesthesia is a type of neuraxial anesthesia; local anesthetic (LA) is injected into cerebrospinal fluid (CSF) in the lumbar spine to anesthetize nerves that exit the spinal cord. Spinal anesthesia is most commonly used for anesthesia and/or analgesia for a variety of lower extremity, lower abdominal, pelvic, and perineal procedures.
This topic will discuss the relevant anatomy, techniques, and management of spinal anesthesia. Indications, contraindications, preoperative evaluation, physiologic effects, and complications of spinal anesthesia are discussed separately.
Techniques for other types of neuraxial anesthesia, including epidural and combined spinal-epidural, are discussed separately. (See "Overview of anesthesia and anesthetic choices".)
Spinal anesthesia is performed by placing a needle between the lumbar vertebrae and through the dura to inject anesthetic medication. Anatomy of the bony spine and vertebrae are discussed in more detail separately (figure 1 and figure 2). (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Anatomy'.)
Anatomy related specifically to the performance of spinal anesthesia is discussed here.
- Saifuddin A, Burnett SJ, White J. The variation of position of the conus medullaris in an adult population. A magnetic resonance imaging study. Spine (Phila Pa 1976) 1998; 23:1452.
- Broadbent CR, Maxwell WB, Ferrie R, et al. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia 2000; 55:1122.
- Margarido CB, Mikhael R, Arzola C, et al. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Can J Anaesth 2011; 58:262.
- DAVIS H, KING WR. Densities of cerebrospinal fluid of human beings. Anesthesiology 1954; 15:666.
- Chin KJ, Perlas A, Chan V, et al. Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology 2011; 115:94.
- Longbottom J, Clegg I, Bhatia K. Should ultrasound of the spine be mandatory before performing a lumbar central neuraxial block? Br J Hosp Med (Lond) 2014; 75:178.
- Lim YC, Choo CY, Tan KT. A randomised controlled trial of ultrasound-assisted spinal anaesthesia. Anaesth Intensive Care 2014; 42:191.
- American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010; 112:530.
- Tsen LC, Hepner DL. Needles used for spinal anesthesia. Expert Rev Med Devices 2006; 3:499.
- Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 2012; 32:916.
- Gnaho A, Nguyen V, Villevielle T, et al. Assessing the depth of the subarachnoid space by ultrasound. Rev Bras Anestesiol 2012; 62:520.
- Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 1991; 72:275.
- Horlocker TT, McGregor DG, Matsushige DK, et al. Neurologic complications of 603 consecutive continuous spinal anesthetics using macrocatheter and microcatheter techniques. Perioperative Outcomes Group. Anesth Analg 1997; 84:1063.
- Tao W, Grant EN, Craig MG, et al. Continuous Spinal Analgesia for Labor and Delivery: An Observational Study with a 23-Gauge Spinal Catheter. Anesth Analg 2015; 121:1290.
- McKenzie CP, Carvalho B, Riley ET. The Wiley Spinal Catheter-Over-Needle System for Continuous Spinal Anesthesia: A Case Series of 5 Cesarean Deliveries Complicated by Paresthesias and Headaches. Reg Anesth Pain Med 2016; 41:405.
- Greene NM. Distribution of local anesthetic solutions within the subarachnoid space. Anesth Analg 1985; 64:715.
- Khaw KS, Ngan Kee WD, Wong M, et al. Spinal ropivacaine for cesarean delivery: a comparison of hyperbaric and plain solutions. Anesth Analg 2002; 94:680.
- Chambers WA, Edstrom HH, Scott DB. Effect of baricity on spinal anaesthesia with bupivacaine. Br J Anaesth 1981; 53:279.
- Zaric D, Pace NL. Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics. Cochrane Database Syst Rev 2009; :CD003006.
- McDonald SB, Liu SS, Kopacz DJ, Stephenson CA. Hyperbaric spinal ropivacaine: a comparison to bupivacaine in volunteers. Anesthesiology 1999; 90:971.
- Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011; 55:267.
- Dahl JB, Jeppesen IS, Jørgensen H, et al. Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology 1999; 91:1919.
- Liu S, Chiu AA, Carpenter RL, et al. Fentanyl prolongs lidocaine spinal anesthesia without prolonging recovery. Anesth Analg 1995; 80:730.
- Belzarena SD. Clinical effects of intrathecally administered fentanyl in patients undergoing cesarean section. Anesth Analg 1992; 74:653.
- de Oliveira GS Jr, Balliu B, Nader A, McCarthy RJ. Dose-ranging effects of intrathecal epinephrine on anesthesia/analgesia: a meta-analysis and metaregression of randomized controlled trials. Reg Anesth Pain Med 2012; 37:423.
- Elia N, Culebras X, Mazza C, et al. Clonidine as an adjuvant to intrathecal local anesthetics for surgery: systematic review of randomized trials. Reg Anesth Pain Med 2008; 33:159.
- Sakura S, Sumi M, Sakaguchi Y, et al. The addition of phenylephrine contributes to the development of transient neurologic symptoms after spinal anesthesia with 0.5% tetracaine. Anesthesiology 1997; 87:771.
- Maehara Y, Kusunoki S, Kawamoto M, et al. A prospective multicenter trial to determine the incidence of transient neurologic symptoms after spinal anesthesia with phenylephrine added to 0.5% tetracaine. Hiroshima J Med Sci 2001; 50:47.
- Morrison AP, Hunter JM, Halpern SH, Banerjee A. Effect of intrathecal magnesium in the presence or absence of local anaesthetic with and without lipophilic opioids: a systematic review and meta-analysis. Br J Anaesth 2013; 110:702.
- Tawfik MM, Hayes SM, Jacoub FY, et al. Comparison between colloid preload and crystalloid co-load in cesarean section under spinal anesthesia: a randomized controlled trial. Int J Obstet Anesth 2014; 23:317.
- Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth 2010; 57:24.
- Loubert C. Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development. Can J Anaesth 2012; 59:604.
- Rocco AG, Raymond SA, Murray E, et al. Differential spread of blockade of touch, cold, and pinprick during spinal anesthesia. Anesth Analg 1985; 64:917.
- Russell IF. A comparison of cold, pinprick and touch for assessing the level of spinal block at caesarean section. Int J Obstet Anesth 2004; 13:146.
- Nor NM, Russell IF. Assessing blocks after spinal anaesthesia for elective caesarean section: how different questions affect findings from the same stimulus. Int J Obstet Anesth 2013; 22:294.
- PREOPERATIVE EVALUATION
- Preparation for spinal anesthesia
- Positioning for spinal procedure
- Preprocedure ultrasonography
- Aseptic technique
- Choice of spinal needle
- - Midline approach technique
- - Paramedian approach technique
- Spinal injection
- Post-injection positioning
- Continuous spinal
- Choice of spinal drugs
- - Baricity
- - Local anesthetics
- - Adjuvants
- MANAGEMENT AFTER SPINAL INJECTION
- Hemodynamic management
- Assessment of level of block
- Sedation during spinal anesthesia
- SUMMARY AND RECOMMENDATIONS