Spinal anaesthesia is a viable alternative to general anaesthesia in children. Compared to adults, children require a larger dose of long-acting local anaesthetic like bupivacaine due to higher CSF volume, but the duration of block is shorter, around 1 hour for infants. Adjuvants can prolong the block duration but must be preservative-free. Younger children generally do not experience hypotension from spinal anaesthesia unlike adults. It has been used successfully for procedures like hernia repair and myelomeningocele repair in neonates. The needle design does not significantly impact complications like in adults.

1. PAEDIATRIC SPINAL
ANAESTHESIA
JOURNAL FROM Best Practice & Research Clinical Anesthesiology
Section of Anesthesiology and Intensive Care, Department of Physiology &
Pharmacology, Karolinska Institute, Stockholm, Sweden
BY Dr.SANJITHA BANU AR
1ST YEAR PG
DEPT. OF ANAESTHESIA
MODERATOR: Dr.DEEPA

2. Introduction :
Spinal anaesthesia represents the first widespread major regional
anaesthetic technique to be used in children.
Spinal anaesthesia rapidly became popular because of its efficacy and safety
compared with the practice of general anaesthesia.
However the use of spinal anaesthesia in children decreased as the methods
for general anaesthesia improved, and there was also concern about the
potential serious complications following spinal anaesthesia in adults

3. Anatomical and physiological differences
between adults and neonates:
Dural Sac: Terminates at S3 and spinal cord at L3 vertebral
levels, at birth.
Adult level (S2 and L1 respectively) is not reached until 2nd
year of life.
Therefore, using a low approach (L4 - 5 or L5 -S1 ) to avoid
damage to spinal cord.
Intercristal line (Tuffier’s line) still remains a reliable landmark
similar to adults since in younger children, it passes through
L4-5/L5 –S1 .
Newborns have a narrow subarachnoid space (6-8 mm) and
low CSF pressure, requiring greater precision and avoidance of
lateral deviation.

4. CSF: Children require higher dose of local anesthetic (LA) drug due to
higher total CSF.
Neonates 10 ml/kg, infants and toddlers 4 ml/kg, adults 2
ml/kg and spinal CSF volumes (50% in children vs. 33% in adults).
Meninges: Highly vascular piamater and high cardiac output lead to
rapid re-absorption of LA and shorter duration of block in children.
Myelination: In children, endoneurium is loose, presenting little
barrier to drug diffusion, with faster onset and offset of block

5. Spine and Ligaments: Ligaments are less densely packed, and feel of loss of resistance is less marked.
Increased spine flexibility limits normal thoracic kyphosis and facilitates cephalad spread and higher level
of sensory block.
Laminae are cartilaginous, hence paramedian approach should be avoided.
CVS: Hemodynamic suppression following SA is absent in children due to a smaller peripheral blood pool,
immature sympathetic autonomic system, and compensatory reduction in vagal efferent activity.
Hence, preloading before SA is not a routine in children

6. • Respiratory system: High levels (T2-4) of block reduce outward
motion of lower ribcage, decrease intercostal muscle activity and may
lead to paradoxical respiratory movement in children.
• However, diaphragm compensates for loss of ribcage contribution in
most cases.

7. Documented
applications
of SA in
children:
Indication Reported applications
Infra umbilical *Lower limb — Amputations, closed reduction of hip, club foot repair, arthrogram, muscle
biopsy, tendon lengthening
*GI surgery — Herniorrhaphy, intestinal resections, colostomy, pyloric stenosis, hernia
*Urological — Urethroplasty, posterior urethral valve fulgurations,
circumcision, orchidopexy, vesicostomy, ureteral reimplant
*Abdominal Wall defects — Exostophia Vesicae
Supra umbilical Abdominal Wall defects — Gastroschisis
Thoracic — Cardiac, pulmonary, TOF, PDA ligation
Neurosurgery — Meningomyelocele, Teratoma
Spine surgery — Staged segmental scoliosis
Medical diseases Muco-polysaccharidosis (Morquis Syndrome), muscular dystrophy, Hurler-Scheies
syndrome, risk of malignant hyperthermia, broncho pulmonary dysplasia
Difficult airway Laryngo/tracheomalacia, subglottic stenosis, macroglossia, micrognathia
Premature/ term
neonates
Floppy baby syndrome, failure to thrive
Emergency Full stomach, intestinal obstruction, chest infection

8. Type of spinal
needle and
related
complications:
• Kokki et al. have found that both pencil-point and
cutting point needles can be used in children
with equal success.
• Spinal needle diameter appears to make no
difference.
• Needle design does not appear to influence
success rate or the occurrence of post-puncture
complications [transient neurological symptoms
(TNS) and post-dural puncture headache (PDPH)]
• TNS appear to only need symptomatic treatment,
e.g. analgesics. PDPH often resolves with
analgesics, fluid intake and bed rest. However, in
more severe cases, epidural blood patches are
warranted and effective in children.

9. Choice of local
anaesthetic
and block
duration:
• Compared with adults, neonates and
infants are reported to have both an
increased amount of cerebrospinal fluid
(CSF), a higher rate of CSF turnover, and
increased absorption of the injected local
anesthetic.
• Consequently, the amount of local
anesthetic that is required to produce an
adequate spinal block is drastically higher
in infants (0.5-1.0 mg bupivacaine/kg)
than in adults (usually 0.1-0.2 mg
bupivacaine/kg).

10. Choice of
local anaesthe
tic and
block duration:
• Thus, spinal anesthesia with bupivacaine
or levobupivacaine can be performed with
a dose of 1 mg/kg for newborns and
infants and a dose of 0.5 mg/kg in older
children (>1 year of age)
• large doses of local anaesthetics are used
compared with doses in adults, the
duration of the block is usually much
shorter than in adults (approximately 60
min in neonates and infants)
• Therefore, to extend the duration of the
block by using an adjuvant may be useful
in neonates and infants.

11. Adjuvants to
prolong the
duration:
The duration of spinal block can be
prolonged by use of clonidine (1
mcg/kg), thereby increasing the
duration from 60-90 min in neonates
without any apparent side effects.
Other drugs for prolongation of spinal
blockade is by the addition of fentanyl,
morphine or adrenaline to the local
anaesthetic .

12. Haemodynamic
response:
• Neuraxial blocks in adults are frequently
associated with a drop in systemic blood pressure
that often requires intervention.
• Younger children (<6 years) receiving spinal,
caudal or epidural blocks usually do not display
any significant change in blood pressure.
• Children between 6 and 10 years, there is a linear
drop in blood pressure that will plateau at about
a 30% drop in systolic blood pressure
• In children >10 years of age (similar to adults)
• Thus, no special precautions are needed in
younger children.
• If problems occur in older children, volume
replacement and intravenous titrated doses of
ephedrine can be used.

13. In myelo
meningocele
repair
• The use of spinal anaesthesia has also
been suggested in neonates scheduled for
myelomeningocele repair.
• Blood pressure was well preserved during
the procedure but because of the short
duration of action, supplemental spinal
injection by the surgeon was needed in
about half the patients.
• spinal anaesthesia can be safely used for
meningomyelocele repair as an alternative
to general anaesthesia

14. Use of spinal
anaesthesia to
modify the
neuroendocrine
stress response in
association with
major paediatric
surgery:
• Wolf and co-workers have shown that the
use of combined spinal/epidural (CSE)
anaesthesia with an indwelling epidural
catheter can modify the neuroendocrine
stress response following
major abdominal and thoracic surgery
compared with epidural- or opioid-based
analgesia.
• Intra operatively, both adrenaline and nor-
adrenaline levels were considerably lower
with CSE followed by epidural compared
with opioid-based analgesia.

15. Summary:
• Spinal anaesthesia is a viable alternative to
general anaesthesia in neonates, infants and
older children.
• A considerably larger dose of a long-acting local
anaesthetic (typically bupivacaine) is required in
younger children compared with adults.
• The duration of block is age-dependent and
considerably shorter than in adults. The typical
duration of plain bupivacaine in infants is
approximately 1 h.
• To prolong the duration, various adjuvant drugs
can be used. However, these must be
preservative-free to avoid potential
neurotoxicity.

16. Summary:
• Compared with the general
inhalation anaesthesia, the use of
spinal anaesthesia in the setting of
inguinal hernia repair (one of the most
common surgical procedures in infants) is
associated with better preservation of
blood pressure.
• Spinal anaesthesia can be useful even
in paediatric outpatients.
• Regards success rate and PDPH, needle
design does not appear to play as
important a role as in adults

17. Thank you