The document discusses regional anesthesia techniques including central nerve blocks like spinal, epidural, and caudal anesthesia as well as peripheral nerve blocks. It provides detailed anatomy of the spinal column and spinal cord. It describes the techniques for performing spinal and epidural anesthesia including patient positioning, skin preparation, needle placement, and assessment of the block. Factors affecting the spread and level of the block are also discussed.

1. Regional Anesthesia
Central nerve block
 Spinal Anesthesia
 Epidural Anesthesia
 Caudal Anesthesia
Peripheral nerve block
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2. Spinal Anatomy
33 Vertebrae
◦ 7 Cervical
◦ 12 Thoracic
◦ 5 Lumbar
◦ 5 Sacral
◦ 4 Coccygeal
High Points: C5 & L5
Low Points: T5 & S2
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3. Cont…
• Vertebrae differ in shape and size at the various levels.
• The first cervical vertebra, the atlas, lacks a body and has
unique articulations with the base of the skull and the second
vertebra.
• The second vertebra,called the axis, consequently has atypical
articulating surfaces.
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4. Cont…
• All 12 thoracic vertebrae articulate with their corresponding
rib.
• Lumbar vertebrae have a large anterior cylindrical vertebral
body.
• A hollow ring is defined anteriorly by the vertebral body,
laterally by the pedicles and transverse processes, and
posteriorly by the lamina and spinous processes.
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5. Cont…
• The laminae extend between the transverse processes and
the spinous processes
• The pedicle extends between the vertebral body and the
transverse processes.
• When stacked vertically, the hollow rings become the spinal
canal in which the spinal cord and its coverings sit.
• The individual vertebral bodies are connected by the
intervertebral disks.
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6. Cont…
• Four small synovial joints at each vertebra, two articulating
with the vertebra above it and two with the vertebra below
adjacent to the transverse processes.
• The pedicles are notched superiorly and inferiorly, these
notches forming the intervertebral foramina from which the
spinal nerves exit.
• Sacral vertebrae normally fuse into one large bone, the
sacrum, but each one retains discrete anterior and posterior
intervertebral foramina.
• The laminae of S5 and all or part of S4 normally do not fuse,
leaving a caudal opening to the spinal canal,the sacral hiatus.
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7. Cont…
• The spinal column normally forms a double C, being convex
anteriorly in the cervical and lumbar regions.
• Ligamentous elements provide structural support, and,
together with supporting muscles, help to maintain the
unique shape.
• Ventrally, the vertebral bodies and intervertebral disks are
connected and supported by the anterior and posterior
longitudinal ligaments.
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8. Cont…
• Dorsally, the ligamentum flavum, interspinous ligament, and
supraspinous ligament provide additional stability.
• Using the midline approach, a needle passes through these
three dorsal ligaments and through an oval space between
the bony lamina and spinous processes of adjacent vertebra.
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9. Cont…
• The anterior and posterior nerve roots at each spinal level join
one another and exit the intervertebral foramina, forming
spinal nerves from C1 to S5.
• At the cervical level, the nerves arise above their respective
vertebrae,but starting at T1, exit below their vertebrae.
• As a result, there are eight cervical nerve roots, but only
seven cervical vertebrae.
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10. Cont…
• The cervical and upper thoracic nerve roots emerge from the
spinal cord and exit the vertebral foramina nearly at the same
level.
• But, because the spinal cord normally ends at L1, lower nerve
roots course some distance before exiting the intervertebral
foramina.These lower spinal nerves form the cauda equina
(“horse’s tail”.
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11. Cont…
• Therefore, performing a lumbar (subarachnoid) puncture
below L1 in an adult (L3 in a child) usually avoids potential
needle trauma to the cord; damage to the cauda equina is
unlikely, as these nerve roots fl oat in the dural sac below L1
and tend to be pushed away (rather than pierced) by an
advancing needle.
• An extension of the pia mater, the filum terminale, penetrates
the dura and attaches the terminal end of the spinal cord
(conus medullaris) to the periosteum of the coccyx
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12. Cont…
• The blood supply to the spinal cord and nerve roots is derived
from a single anterior spinal artery and paired posterior spinal
arteries.
• The anterior spinal artery is formed from the vertebral artery
at the base of the skull and courses down along the anterior
surface of the cord.
• The anterior spinal artery supplies the anterior two-thirds of
the cord, whereas the two posterior spinal arteries supply the
posterior one-third.
• The posterior spinal
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13. Spinal Cord
– Adult
• Begins: Foramen Magnum
• Ends: L1
– Newborn
• Begins: Foramen Magnum
• Ends: L3
– Terminal End: Conus Medullaris
– Cauda Equina: Nerve group of lower dural sac
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14. Saggital Sections
• Supraspinous
Ligament
– Outer most layer
• Intraspinous Ligament
– Middle layer
• Ligamentum Flavum
– Inner most layer
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15. Cont…
Epidural Space
• Space that surrounds the spinal meninges
Ligamentum Flavum
– Binds epidural space posteriorly
• Widest at Level L2
• Narrowest at Level C5
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16. Spinal Meninges
Dura Mater
◦ Outer most layer
◦ Fibrous
Arachnoid
◦ Middle layer
◦ Non-vascular
Pia
◦ Inner most layer
◦ Highly vascular
Sub Arachnoid Space
◦ Lies between the
arachnoid and pia
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17. Spinal Technique
Preparation & Monitoring
◦ EKG
◦ NBP
◦ Pulse Oximeter
Patient Positioning
◦ Lateral decubitous
◦ Sitting
◦ Prone (hypobaric
technique)
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18. Spinal Technique
• Midline Approach
– Skin
– Subcutaneous tissue
– Supraspinous ligament
– Interspinous ligament
– Ligamentum flavum
– Epidural space
– Dura mater
– Arachnoid mater
• Paramedian or Lateral Approach
• Same as midline excluding supraspinous & interspinous
ligaments, 2 cm lateral to the inferior aspect of the superior
spinous process of the desired level.
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19. Cont…
Anatomy.
The skin
Subcutaneous fat
The supraspinous ligament
The interspinous ligament
The ligamentum flavum
The epidural space
The dural sac.
The subarachnoid space
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20. Spinal Anesthesia Levels
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21. Spinal Anesthesia
• Indications & Advantages
– Full stomach
– Anatomic distortions of upper airway
– TURP surgery
– Obstetrical surgery (T4 Level)
– Decreased post-operative pain
– Continuous infusion
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22. Spinal Anesthesia
• Contraindications
– Absolute:
• Refusal
• Infection
• Coagulopathy
• Severe hypovolemia
• Increased intracranial pressure
• Severe aortic or mitral stenosis
– Relative:
• Use your best judgment
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23. Spinal Anesthetic Agents
Only preservative-freelocal anesthetic solutions are used.
Addition of vasoconstrictors (α-adrenergic agonists,
epinephrine (0.1–0.2 mg)) and opioids enhance the quality
and/or prolong the duration of spinal anesthesia.
Vasoconstrictors seem to delay the uptake of local anesthetics
from CSF and may have weak spinal analgesic properties.
Opioids and clonidine can likewise be added to spinal
anesthetics to improve both the quality and duration of the
subarachnoid block.
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24. Cont…
• Hyperbaric bupivacaine and tetracaine are two of the most
commonly used agents for spinal anesthesia.Both are
relatively slow in onset (5–10 min) and have a prolonged
duration (90–120 min).
• Although both agents produce similar sensory levels,spinal
tetracaine more consistently produces motor blockade than
does the equivalent dose of bupivacaine.
• Addition of epinephrine to spinal bupivacaine prolongs its
duration only modestly.
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25. Cont…
• Lidocaine and procaine have a relatively rapid onset (3–5 min)
and short duration of action (60–90 min).
• Their duration is only modestly prolonged by vasoconstrictors.
• Although lidocaine spinal anesthesia has been used
worldwide, some experts no longer use this agent because of
the phenomenon of transient neurological symptoms and
cauda equina syndrome (CES)
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26. Pre-operative Visit.
Patients should be told about their anaesthetic during the
pre-operative visit.
It is important to explain that although spinal anaesthesia
abolishes pain, they may be aware of some sensation in
the relevant area, but it will not be uncomfortable and is
quite normal.
They must be reassured that, if they feel pain they will be
given a general anaesthetic.
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27. Premedication
- not always necessary, but if a patient is apprehensive,
a benzodiazepine such as 5-10 mg of diazepam may be
given orally 1 hour before the operation.
Other sedative or narcotic agents may also be used.
Anticholinergics such as atropine or scopolamine
(hyoscine) are unnecessary
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28. Preparation for Lumbar Puncture
1 . spinal needle.
2 . Introducer
3 . 5ml syringe for the spinal anaesthetic solution.
4 . 2 ml syringe for local anaesthetic to be used for skin
infiltration.
5 . selection of needles for drawing up the local
anaesthetic solutions and for infiltrating the skin.
6 . gallipot with a suitable antiseptic for cleaning the skin,
eg chlorhexidine, iodine, or methyl alcohol.
7 . Sterile gauze swabs for skin cleansing.
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29. Cont…
8 . sticking plaster to cover the puncture site.
The local anaesthetic to be injected intrathecally should be
in a single use ampoule.
Never use local anaesthetic from a multi-dose vial for
intrathecal injection.
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30. Pre-loading.
The volume of fluid given will vary with the age of the
patient and the extent of the proposed block. A young, fit
man having a hernia repair may only need 500 mls.
Older patients are not able to compensate as efficiently
as the young for spinal-induced vasodilation and
hypotension and may need 1000mls for a similar
procedure. If a high block is planned, at least a 1000mls
should be given to all patients. Caesarean section
patients need at least 1500 mls.
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31. Cont…
The fluid should preferably be normal
saline or Hartmann's solution.
-Colloids like hetasrach, dextran, can be
used.
-5% dextrose is readily metabolised and so
is not effective in maintaining the blood
pressure.
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32. Position
1. Lateral ( Lt lateral )
2. Sitting
3. Prone
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34. Assessing the Block.
 The patient is unable to lift his legs from the bed, the
block is at least up to the mid-lumbar region.
 It is unnecessary to test sensation with a sharp needle
 Test for a loss of temperature sensation using a swab
soaked in either ether or alcohol.
 The patient can be gently pinched with artery forceps or
fingers on blocked and unblocked segments
 Surgeons and patients should be reminded that when a
block is successful, a patient may still be aware of touch
but will not feel pain.
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35. Factors Affecting Spread Of Local Anesthetic:
• 1- Baricity; (heavy-Isobaric)
• 2-Position
• 3-Volume injected
• 4-Level of Injection
• 5-Concentration Of local anesth
• 6- Speed Of injection
• 7-Abdomial pressure (asites-pregnancy-
tumours) .
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36. • In the horizontal supine
position ,hyperbaric local
anesthetic solutions injected at
the height of the lumbar
lordosis (circle) flow down the
lumbar lordosis to pool in the
sacrum and in the thoracic
kyphosis.
• Pooling in the thoracic
kyphosis is thought to explain
the fact that hyperbaric
solutions produce blocks with
an average height of T4-6.
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37. Problems With Spinal Block
• 1-NO block at all…………………… .. ..
• 2-Block is one sided………… … ……. …
• 3-Block is not high enough…… … ….
• 4-Block is too high…………………………..
• 5-Nausea &Vomiting…………… . ….. ......
• 6-Shivering………………………… ….. .
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38. Epidural anesthesia
• produces a reversible loss of sensation and motor function
much like a spinal with the exception that local anesthetic is
placed within the epidural space.
• Larger doses of local anesthetic are required to produce
anesthesia when compared to a spinal anesthetic.
• Doses must be monitored to avoid toxicity.
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39. Cont…
• An epidural catheter allows the versatility to extend the
duration of anesthesia beyond the original dose by the
administration of additional local anesthetic.
• Epidural catheters may be left in place for postoperative
analgesia.
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40. Advantages
• Easy to perform (though it takes a bit more practice than
spinal anesthesia)
• Reliable form of anesthesia
• Provides excellent operating conditions
• The ability to administer additional local anesthetics
increasing duration
• The ability to use the epidural catheter for postoperative
analgesia
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41. Cont…
• Return of gastrointestinal function generally occurs faster
than with general anesthesia
• Patent airway
• Fewer pulmonary complications compared to general
anesthesia
• Decreased incidence of deep vein thrombosis and pulmonary
emboli formation compared to general anesthesia
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42. Disadvantages
• Risk of block failure
• Onset is slower
• Risk of complications
• Risk for infection
• Continuous epidural catheters should not be used on the
ward if the patient’s vital signs are NOT closely monitored.
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43. Factors Affecting Height of Epidural
Blockade
• Volume of local anesthetic- 1-2 ml of local anesthetic per
dermatome
• Age- A 20 year old vs 80 year old
• Height of the patient-The shorter the patient the less local
anesthetic required.
• Gravity
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44. Epidural Needles
• The standard epidural needle is typically 17–18 gauge,3 or 3.5
inches long, and has a blunt bevel with a gentle curve of 15–
30° at the tip.
• The Tuohy needle is most commonly used.
• The blunt, curved tip theoretically helps to push away the
dura aft er passing through the ligamentum flavum instead of
penetrating it.
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45. Epidural Catheters
• Placing a catheter into the epidural space allows for
continuous infusion or intermittent bolus techniques.
• In addition to extending the duration of the block, it may
allow a lower total dose of anesthetic to be used.
• Typically, a 19- or 20-gauge catheter is introduced through a
17- or 18-gauge epidural needle.
• The catheter is advanced 2–6 cm into the epidural space.
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46. Epidural Anesthesia
 Test Dose: 1.5% Lido with Epi 1:200,000
◦ Tachycardia (increase >30bpm over resting HR)
◦ High blood pressure
◦ Light headedness
◦ Metallic taste in mouth
◦ Ring in ears
◦ Facial numbness
◦ Note: if beta blocked will only see increase in BP not HR
 Bolus Dose: Preferred Local of Choice
◦ 10 milliliters for labor pain
◦ 20-30 milliliters for C-section
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47. Epidural Anesthesia
• Distances from Skin to Epidural Space
– Average adult: 4-6cm
– Obese adult: up to 8cm
– Thin adult: 3cm
• Assessment of Sensory Blockade
– Alcohol swab
• Most sensitive initial indicator to assess loss of
temperature
– Pin prick
• Most accurate assessment of overall sensory block
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48. Caudal Anesthesia
• It is used to provide peri and post operative analgesia
in adults and children.
• It may be the sole anaesthetic for some procedures,
or it may be combined with general anaesthesia.
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49. Caudal…..
• Caudal epidural anesthesia is a common regional
technique in pediatric patients.
• It may also be used for anorectal surgery in adults.
• The caudal space is the sacral portion of the epidural
space.
• Caudal anesthesia involves needle and/or catheter
penetration of the sacrococcygeal ligament covering
the sacral hiatus that is created by the unfused S4
and S5 laminae.
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50. Caudal…..
• The hiatus may be felt as a groove or notch above
the coccyx and between two bony prominences, the
sacral cornua.
• Its anatomy is more easily appreciated in infants and
children.
• The posterior superior iliac spines and the sacral
hiatus defi ne an equilateral triangle.
• Calcification of the sacrococcygeal ligament may
make caudal anesthesia difficult or impossible in
older adults.
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51. Caudal…..
• Within the sacral canal, the dural sac extends
to the first sacral vertebra in adults and to
about the third sacral vertebra in infants,
making inadvertent intrathecal injection more
common in infants.
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52. Cont….
• In children, caudal anesthesia is typically combined with general
anesthesia for intraoperative supplementation and
postoperative analgesia.
• It is commonly used for procedures below the diaphragm,
including urogenital, rectal, inguinal, and lower extremity
surgery.
• Pediatric caudal blocks are most commonly performed after the
induction of general anesthesia.
• The patient is placed in the lateral or prone position with one or
both hips flexed, and the sacral hiatus is palpated.
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53. • After sterile skin preparation, a needle or intravenous
catheter (18–23 gauge) is advanced at a 45° angle cephalad
until a pop is felt as the needle pierces the sacrococcygeal
ligament.
• The angle of the needle is then flattened and advanced.
• Aspiration for blood and CSF is performed, and, if negative,
injection can proceed.
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54. cont…
• A dosage of 0.5–1.0 mL/kg of 0.125–0.25% bupivacaine (or
ropivacaine), with or without epinephrine,can be used.
• Opioids may also be added (eg, 50–70 mcg/kg of morphine),
although they are not recommended for outpatients because
of the risk of delayed respiratory depression.
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55. Indications
• Anaesthesia and analgesia below the umbilicus
• Obstetric analgesia :For the 2nd stage or instrumental
deliveries.
• Care should be taken as the foetal head lies close to the site of
injection and there is real risk of injecting local anaesthetic
into the foetus.
• Chronic pain problems relating to lower limbs and lower
abdominal pains.
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56. Contraindications
• Infection near the site of the needle insertion.
• Coagulopathy or anti coagulation.
• Pilonidal cyst
• Congenital abnormalities of the lower spine or meninges,
because of the unclear or impalpable anatomy.
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57. • The caudal epidural space is
the lowest portion of the
epidural system and is
entered through the sacral
hiatus.
• The sacrum is a triangular
bone that consists of the five
fused sacral vertebrae (S1-
S5).
• It articulates with the fifth
lumber vertebra and the
coccyx.
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58. • The sacral hiatus is a defect in
the lower part of the posterior
wall of the sacrum formed by
the failure of the laminae of S5
and/or S4 to meet and fuse in
the midline.
• The sacral canal is a
continuation of the lumbar
spinal canal which terminates
at the sacral hiatus.
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59. Caudal Anesthesia
• Anatomy
– Sacrum
• Triangular bone
• 5 fused sacral vertebrae
• Needle Insertion
– Sacrococcygeal membrane
– No subcutaneous bulge or
crepitous at site of injection
after 2-3ml
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60. Technique
Prepared as for general anaesthesia:
1.NPO
2. Prepare all appropriate equipment for resuscitation
3. Follow aseptic technique
4. semi-prone position
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61. 5) The landmarks are palpated.
The sacral hiatus and the
posterior superior iliac
spines form an equilateral
triangle pointing inferiorly.
6)The sacral hiatus can be
located by first palpating
the coccyx, and then sliding
the palpating finger in a
cephalad direction until a
depression in the skin is felt.
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62. 7) Once the sacral hiatus is
identified the area above is
carefully cleaned with
antiseptic solution, and a 22
gauge cannula or needle is
directed at about 90 degree
to skin and inserted till a
"click" is felt as the sacro-
coccygeal ligament is
pierced.
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63. Cont…
 Care should be taken not to insert the needle too far
as the dura lies at or below the S2 level in the child.
 (8) The needle should be aspirated looking for either
CSF or blood.
 The injection should never be more than 10 ml/30
seconds
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64. Caudal Anesthesia
• Post Operative Problems
– Pain at injection site is most common
– Slight risk of neurological complications
– Risk of infection
• Dosages
– commonly used drugs-Lignocaine 1% and
Bupivacaine 0.25%.
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65. Complications
a. IV or IO injection-: may lead to grand mal seizures and/or cardio-
respiratory arrest.
b. Dural puncture:-total spinal block will occur if the dose for a
caudal block is injected into the subarachnoid space
c. Perforation of the rectum
d. Sepsis.
e. Urinary retention.
f. Haematoma
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66. Axillary Block
• Position
– Head turned away
from arm being
blocked
– Abduct to 90º
– Forearm is flexed to
90º
– Palpate brachial artery
for pulse
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67. Axillary Block
• Advantages
– Provides anesthesia for forearm & wrist
– Fewer complications than a supraclavicular block
• Limitations
– Not for shoulder or upper arm surgery
– Musculocutaneous nerve lies outside of the
sheath and must be blocked separately
• Complications
– Intravascular injection
– Elevated bleeding time increases risk for
hematoma
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68. Axillary Block
• Dosing
– Lidocaine 1% 30-40ml
– Etidocaine 1% 30-40ml
– Bupivacaine 0.5% 30-40ml
• Note 40ml is most common dose
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69. Wrist Block
Radial nerve block
• To block the branches of the
radial nerve, make an injection
along the radial artery’s lateral
border 2 cm proximal to the
wrist .
• Then extend the injection
dorsally over the border of the
wrist
• Injection of 5 to 7 mL of local
anesthetic is usually sufficient.
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70. Ulnar nerve block
Ulnar artery pulsation as a
landmark for the ulnar nerve
block at the wrist; however,
the ulnar pulse is difficult to
appreciate in many patients.
A practical approach is to insert
the block needle just proximal
to the ulnar styloid process.
After aspiration to confirm that
the needle is not within the
ulnar artery,inject 3 to 5 mL of
local anesthetic.
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71. Median nerve block
Identify the tendons of the flexor
palmaris longus and flexor
carpi radialis by flexing the
wrist during palpation.
Insert the needle between the
tendons 2 cm proximal to the
wrist flexor crease,posteriorly
towards the deep fascia
Inject 3 to 5 mL of local
anesthetic while withdrawing
he needle.
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72. Ankle Block
• Blockade of 5 Nerves
– Tibial nerve
• Largest
• Heal & medial side sole of foot
– Superficial perineal nerve
• Branch of common perineal
• Dorsal (top) portion of foot
– Saphenous nerve
• Branch of femoral nerve
• Medial side of leg, ankle, & foot
– Sural nerve
• Branch of posterior tibial nerve
• Posterior lateral half of calf, lateral side of foot, & 5th toe
– Deep perineal nerve
• Continuation of common perineal nerve
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73. Ankle Block…
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74. Ankle Block…
Tibial Nerve.
• located posterior to the posterior
tibial artery at the level of the
medial malleolus.
• Palpate the artery and insert the
needle passing posterior to the
artery.
• A nerve stimulator can be used
to help localize the nerve. The
needle will typically contact the
medial malleolus; after this
contact occurs, slightly withdraw
the needle.
• Inject 3 to 5 mL of local
anesthetic
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75. Ankle Block…
Deep Peroneal Nerve
This nerve runs lateral to the
dorsalis pedis artery at the
level of the foot.Palpate the
artery and insert the needle
lateral to the artery.
If bone is contacted, withdraw
the needle slightly before
injecting 2 to 4 mL of local
anesthetic
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76. Ankle Block…
Superficial Peroneal Nerve
Inject a subcutaneous wheal of
local anesthetic (5 mL) from
the anterior border of the
tibia to the lateral malleolus
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77. Saphenous Nerve
Inject a subcutaneous wheal
of local anesthetic (5 mL),
directing it posteriorly from
the tibial ridge to the
medial malleolus
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78. Ankle Block…
Sural Nerve
Insert the needle between the
Achilles tendon and the
lateral malleolus, and
subcutaneously infiltrate 5
mL of local anesthetic along
this course
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79. Regional Anesthesia in the Anticoagulated Patient
• Basic Labs:
– Platelet counts >50,000 (minimum), prefer >100,000
– Prothrombin time (PT) & Partial thrombin time (PTT)
– Thrombin time
– Hemoglobin & Hematocrit
– Bleeding time
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80. Regional Anesthesia in the Anticoagulated Patient
• Heparin:
– IV discontinue 4 hours prior to block
– SQ can block one hour prior to dose
– Do not D/C cath until 4 hours after heparin D/C’d & obtain
normal lab values
• LMWH:
– Stop 10 days prior to surgery
– Post op D/C cath 2 hours prior or 10 hours after first dose
6/14/2023 80
Prepared By FB

81. Regional Anesthesia in the Anticoagulated Patient
• NSAIDS:
– May be safe for regional block
– Ideal to stop 5 days prior to surgery
• ASA:
– Stop 7-10 days prior to surgery
6/14/2023 81
Prepared By FB