Prof. Mridul M. Panditrao adds another presentation to his collection. This is another Faculty lecture that was delivered at International conference on pain ... ISSPCON 2014, at Mumbai/Bombay, 7th Feb to 9th Feb 2014.

1. Difficult Spine:
My views

2. Prof. Mridul M. Panditrao
Consultant
Department of Anesthesiology and Critical Care
Public Hospital Authority’s Rand Memorial Hospital
Freeport, Grand Bahama,
Commonwealth of The Bahamas

3. “Two conditions are, therefore,
absolutely necessary to produce
Spinal anesthesia:
Puncture of the Dura Mater and
sub-arachnoid injection of an
anesthetic agent!”
Gaston Labat,
1922
„Father‟ of modern regional anesthesia

4. INTRODUCTION

5. INTRODUCTION
Neuraxial Blockade!
Historical:
• James Leonard Corning: 1885; first performed neuraxial blockade (epidural) in
healthy male volunteer
• August Bier: 1899; first clinical Spinal anesthesia
• Fidel Pagés (Spanish military surgeon): 1921; "single-shot" lumbar epidural
anesthesia
Spinal anesthesia has enjoyed a long history of success and
has already celebrated a centennial anniversary (1999)!
•Wulf HF: “The centennial of spinal anesthesia.” Anesthesiology 1998; 89:500–6

6. Neuraxial Blockade!
A well-planned, skill oriented and reasonably
successful modality of anesthesia.
• Anesthesiologists master spinal anesthesia early during training:
(90% technical success rate) after only 40–70 supervised
attempts!!!!
• However, once adequate proficiency has been achieved
• It is one of the easiest techniques to perform and get adequate
results.
•Kopacz DJ, Neal JM, Pollock JE: The regional anesthesia “learning curve”: What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth
1996; 21:182–90
•Konrad C, Schupfer G, Wietlisbach M, Gerber H: “Learning manual skills in anesthesiology:” Is there a recommended number of cases for anesthetic procedures?
AnesthAnalg 1998; 86:635–9

7. Caution!
Even in expert hands, a well-executed „spinal block‟ may „fail‟!
• It is an unusual/awkward situation
• Especially, when the operator with adequate skill level encounters……..
1.
2.
3.
Difficulty in achieving the lumbar puncture
Inadequate/ complete lack of free flow of the CSF
Inadequate block: ???? Wrong : place/ drug/ dose/
concentration/volume
One has to analyze, the exact etiology of the failure!!

8. • Once the avoidable causes/technical reasons have been
eliminated or when it is impossible even to achieve the
„lumbar puncture‟ then it is termed as truly
“Difficult Spine!!’
Thus it is a interplay of various factors, which ultimately culminate in to
a „Unsuccessful/Difficult‟ or „Inadequate/Failed spinal‟
Fettes, PDW, Jansson J-R and Wildsmith JAW Failed spinal anaesthesia: mechanisms, management, and
prevention. BJA 2009;102 (6): 739–48

9. Definitions:
“Difficult Spine”:
• An anticipated or un-anticipated
• Failure of introduction of the needle
• Getting „wet tap‟ or free flow of CSF
• Multiple attempts at lumbar puncture
• Subsequent consequences/ problems
It can be one of the etiological factors of failed spinal!

10. Definitions:
“Failed/Inadequate spinal”:
• In spite of
• a successful lumbar puncture,
• satisfactory flow of CSF and
• injection of correct concentration/volume/ dose
• unanticipated, complete (failed) or
• incomplete/ patchy/ lower than required level of the
sub-arachnoid (or even epidural) block

11. Etiopathogenesis:
• Failed Spinal:
If one is circumspective, about the factors involved in this
process, four set of factors need to be considered:
• Operator
• Patient
• Equipment
• Miscellaneous

12. Etiopathogenesis
Operator factors!
•
Skill level/ experience & thorough knowledge of the anatomy
• more chances of failure in the hands of less experienced/ novices.
•
Proficiency/ practice of the Technique: how frequently on daily basis
the anesthesiologist, is performing the block?
• Even in the hands of so called „experts‟/ mature operators there can be
failure, if they have not been practicing the skill for some time in recent
past
• In fact this can be a major factor for these techniques falling in serious
disrepute and not being practiced, because of development of a „vicious
cycle‟.

13. Etiopathogenesis: Operator Factors
• The „approach‟ used:
• Conventionally the midline approach especially in
L3-L4 interspace - The intercristal line or Tuffier‟s line
• Lateral or para-median approaches, especially in heavily calcified
midline ligaments
• inherently more complex techniques
• need again excellent knowledge of anatomy,
• acquired skill and
• continued practice
•Lee JA, Atkinson RS. Sir Robert Macintosh’s Lumbar Puncture and Spinal Analgesia. Edinburgh: Churchill Livingstone, 1978

14. Etiopathogenesis: Operator Factors
• The angle of needle insertion used
• advisable to insert the needle, cephalad angle/bevel pointed upwards.
• even with adequate patient position; if
Incorrect angle
of insertion and
inadequate depth
of insertion
free flow of the
CSF is not
achieved
„failure‟ of the
block.

15. Etiopathogenesis
Patient factors!
• Un-informed, unwilling so logically uncooperative patients will
always be a hindrance in performing a successful block.
• Use of local infiltration : reluctance to use pre-block local anesthetic
infiltration, especially before sub-arachnoid block.
• The excuses which are given for this are,
• „Anyway it is just question of one prick, so how does it matter?‟
• „Infiltration will distort the local anatomy, mask the landmarks and make my
entry more difficult.‟
• „I am quite confident/ skilled enough to do the block in first attempt, why
should I bother about additional injections?‟

16. Etiopathogenesis: Patient Factors
No matter
• what proficiency level one may be able to boast about,
• that leaving aside all the ego rides/ excuses or any issues,
• one must use the local infiltration both intradermally as well
subcutaneously,
• making sure that the adequate volume/ concentration of Local
anesthetic is used
• so as not to mask the landmarks, but to provide the analgesia, for
the entire passage of the needle
http://www.frca.co.uk/article.aspx?articleid=100449

17. Etiopathogenesis
Equipment factor!
• The needles:
• smaller gauge of the needle is better
• A pencil-point should be used if possible.
• However, in some of the elderly patients, or strong muscular adult males it is
very difficult to introduce and smoothly pass the 27 G pencil-point needle.
• The drugs: multiple factors
• wrong drug, wrong concentration, wrong dose, wrong volume,
• even the wrong connection between the needle and syringe, thus loss/ leaking
of the drug
• Improperly stored, ineffective drug preparation
• Baricity of the drug also plays a significant role in final distribution/ spread of
the drug and level, density and uniformity of the block (Non-patchyness).

18. Etiopathogenesis: Equipment factor!
• The adjuvants:
• the physical (precipitation/ change of pH)
• chemical (Mixture of acidic and basic drugs producing an
ineffective salt)
• idiosyncratic ( The formation of a newer salt/ molecule leading to
unanticipated, rarely toxic actions).

19. Etiopathogenesis
Miscellaneous factors: „Resistance to Local Anesthetics!!!!!!‟
• Controversial area
• Unexplainable, recurring yet unproven factors
Various proposed hypotheses
• genetic predilection like redhead persons, especially females
• mutation in the receptor for the action of Local anesthetics, the Sodium channels
on the nerve fibers,
• pathological conditions like Ehlers Danlos syndrome
• even the history of previous scorpion bite.
•Panditrao MM, Panditrao MM, Khan MI, Yadav N. Does scorpion bite lead to development of resistance to the effect of local anaesthetics? Indian J Anaesth 2012; 56:575–8.
•Panditrao MM, Panditrao MM, Sunilkumar V, Panditrao AM. Can repeated scorpion bite lead to development of resistance to the effect of local anesthetics? Maybe it does! CRCM. 2013; 2, 179-82
•http://www.biomedcentral.com/1471-2253/4/1.
•Hoppe J, Popham P. Complete failure of spinal anaesthesia in obstetrics. Int J ObstetAnes 2007; 16:250-5.
•Panditrao MM, Panditrao MM, V. Sunilkumar, Panditrao AM. Effect of previous scorpion bite(s) on the action of intrathecal bupivacaine: A case control study. Indian J Anaesth 2013;57:236-40.

20. Difficult spine
• Situations are rarer
• but have a very predictable outcome  „the failure‟.

21. Concentrate upon the factors
• Patient factors
• Operator Factors
• Miscellaneous

22. Patient Factors
 Demographic Profile:
(a) Age: The extremes of age
•
•
•
•
Age related changes - elderly patients: calcification/ossification
Consequences of osteoporosis
Degenerative disc disease
Decreased CSF volume
(b) Sex:
• Female spine - more challenges
Pronounced lordosis, More subcutaneous fat.

23. Patient Factors
(c) Weight:
• Both underweight as well as overweight
• Underweight patients - the skin &subcutaneous tissue: tougher/ loose,
due to absence of subcutaneous fat
• Practically very difficult to puncture them with „pencil point needles‟
• Entry point does not remain precise, in relation with the underlying
structures, especially in midline approach
• Overweight/ obese patients: Entire anatomy distorted, the skin
landmarks and the entry point are practically never well correlated
with deeper structures.
(d) Height:
Shorter patients - almost all the structures in the back are compressed

24. Patient Factors
Anatomical variations: Developmental anomalies
• Pathological processes of spine
• Kyphosis,
• Scoliosis
• epidural cysts called „Tarlov Cysts‟
Cause difficulty in lumbar puncture as well as failed blocks.
•Hoppe J, Popham P. Complete failure of spinal anaesthesia in obstetrics. Int J ObstetAnesth 2007; 16: 250–5
PophamPA.Anatomical causes of failed spinal anaesthesia may be commoner than thought. Br. J. Anaesth. 2009; 103: 459. doi:10.1093/bja/aep217

25. Patient Factors
Abnormalities of the spine: These truly are the causes of “Difficult Spine”
• Spinal stenosis
• Osteoporotic compression fractures
• Degenerative spondylolisthesis
• Adult scoliosis
• Degenerative disc disease
• Ankylosing Spondylitis
 Although many other conditions exist, most of these disorders are in fact not
entirely separate entities but rather disease states along a continuum
Many of these conditions overlap in their presence and presentation in any
one individual.

26. Operator Factors
„Not so gentle handling of the patient‟:
• while positioning/keeping them still
• Anxious patient tends to be scared and un-co-operative
• sitting or lateral, the patient has to be exposed: very agitated, especially
females
• If the patient has already a painful condition, for which they are on
Operation table, like, lower limb fractures or intra-abdominal pathologies

27. Operator Factors
For adequate co-operation
• very gentle and careful handling of the patient
• maximum, physical, emotional as well as moral support
• patience on part of the anesthesiologist
• avoidance of transference
• A very humane, conscientious as well as caring attitude needs to be
developed.
• It would be very useful and imperative to give a combination of an
anxiolytic like midazolam along with an analgesic, especially in the
presence of pre-operative painful condition.

28. Operator Factors
Miscellaneous Factors:
• Assistance: while positioning, the role of the assistant in achieving and
maintaining the patient in the correct position cannot be
underestimated
• Positioning: Sitting or Lateral

29. Operator Factors
Positioning:
Conventionally, Sitting position has lesser degree of difficulty
• midline is properly maintained
• the landmarks are easier to locate
• patient less likely to be rotated or laterally flexed.
• Over-enthusiastic assistants - too much forward bending of the back
Space available for the needle tip‟s progress hampered
Correct position would be to keep the back straight
• Resultant sympathetic blockade – aggravated
Enhanced gravity-induced peripheral blood pooling - significant
hypotension.
•Fredman B, Zohar E, Rislick U, Sheffer O, Jedeikin R. Intrathecalanaesthesia for the elderly patient: the influence of the induction position on peri operative haemodynamic
stability and patientcomfort. Anaesth Intensive Care 2001; 29: 377-82.

30. Operator Factors: Positioning
Lateral position
• Elderly pre-medicated patients
• Compared to the sitting position, the lateral position may cause
less hypotension.
• The identification of anatomical landmark is difficult
• May be practically very difficult to assume it, with lower limb
painful pathologies like fractures/ Trauma

31. Prevention
• Pre-operative identification/confirmation
• Thorough history taking:
• Especially of any previous spine surgery,
• previous difficult/ failed spinal blocks
• any family history of similar instances.
• The pre-operative examination
• Examination of vertebral column, especially thoraco-lumbar spine, to
rule out abnormalities of spine, like kypho/scoliosis, any spinal
diseases/ degenerative conditions.
• If situation warrants then one may have to opt for imaging studies,
from radiological examination to CT, if required.

32. MANAGEMENT
“The true difficult spine is truly difficult to manage!”
• The „confirmed difficult spine may need mustering of all the skill,
experience and knowledge,
• even in terms of the team approach,
• advanced equipment,
• even assistance of radiological colleagues.
• Plan for suitable modification
• CT/ Ultra sound guided technique
• Not possible to use any one of the above techniques, then General
Anesthesia
The classical examples of difficult situation are as follows:

33. Previous spine surgery :
Spine surgery: a relative contraindication to neuraxial anesthesia.
*
Although it is generally accepted, as well as reported by some authors
• Post-operative spinal stenosis and other degenerative changes
• Presence of chronic pain making the patients reluctant to allow the needle insertion.
• The post-operative anatomical changes make the insertion of needle difficult, which has to
be inserted through the unfused areas.
• Evidence: it may be possible to do spinal in these patients more successfully, as compared to
epidural.
But there is an increased incidence of post spinal neurological deficit.
•*Harlocker TT, Wedel DJ Epidual and spinal anesthesia after a major spine surgery In Paul G. Barash, Bruce F. Cullen, Robert K. Stoelting, Michael Cahalan, M.
Christine Stock. Eds.Clinical Anesthesia 6thEdn. Lippincott WilliamsWolters Kluwer Health2009;1381
•Bajaj P. Regional Anaesthesia in the Patient with Pre-Existing Neurological Dysfunction. Indian J Anaesth. 2009 April; 53(2): 135–138. PMCID: PMC2900096

34. Pathological conditions causing severe structural changes:
Ankylosing Spondylitis (AS):Bamboo Spine, Bechterew's syndrome/
Marie-Strümpell disease
• Autoimmune seronegative, painful chronic inflammatory disease of the
axial skeleton
• with variable involvement of peripheral joints and nonarticular structures
• and intermittent exacerbations („flares‟) and quiescent periods.
• Spine and sacroiliac joints (spondyloarthropathy) - eventually fusion and
rigidity of the spine („bamboo spine‟)
• Cervical spine, especially atlanto-occpital joint, Temporo-mandibular
joint also affected, resulting in difficult airway management.
•http://en.wikipedia.org/wiki/Ankylosing_spondylitis,

35. Management: Ankylosing Spondylosis
• Difficult cases
• Insertion of needle via midline approach – impossible
(Calcified Ligamentum Flavum)
• Paramedian approach
• Modifications: Taylor‟s approach
• L5-S1 interspace
• Spinal needle inserted in a cephalo-medial direction through a skin
wheal raised 1 cm medial and 1 cm caudal to the lowermost
prominence of the posterior superior iliac spine.
•Jindal P, Chopra G, Chaudhary A, Rizvi AA, and Sharma JP. Taylor's approach in an ankylosing spondylitis patient posted for percutaneous nephrolithotomy: A challenge for
anesthesiologists Saudi J Anaesth. 2009 Jul-Dec; 3(2): 87–90. doi: 10.4103/1658-354X.57879. PMCID: PMC2876933
•Thota RS, Sathish R, Patel R, Dewoolkar L. Taylor's approach for combined spinal epidural anesthesia in post-spine surgery: A case report. Int J Anesthesiol. 2006;10:2.

36. Management: Pathological Conditions
Rheumatoid Arthritis (RA):
• Generalized arthropathy
• Mainly centered around the cervical spine
• Atlanto-axial as well as sub-axial joint
• General anesthesia is practically very difficult
• Recommended to try the regional techniques as the priority
• cases where the lumbar and thoracic spines are involved, in the
disease process, the spinal and epidural anesthesia may be technically
difficult or impossible*
•
*Fombon FN, Thompson JP. Anaesthesia for the adult patient with rheumatoid arthritis. Contin Educ Anaesth Crit Care Pain (2006) 6 (6): 235-239. doi: 10.1093/bjaceaccp/mkl049

37. Management: Pathological Conditions
Degenerative Disc Disease (DDD):
• Natural processes and conditions brought about by the general ageing &
wear/tear upon the spinal discs
• The secondary effects that this has upon associated spinal structures.
• Epidural injections of local anesthetics and steroids, under image guidance.
One may try the blind technique,
but the challenges, of positioning, pain, and
complete obliteration of landmarks can lead to difficulty!
http://www.spinal-foundation.org/Conditions/Disc-Degeneration. Degenerative Disc Disease or Disc Degeneration (Spondylosis).

38. Conclusion
• The spinal/epidural are well established, accepted and reliable/ trust
worthy techniques
• Especially in experienced and knowledgeable hands
• In spite of celebrating the centenary, there are, instances of „failure‟
• One has to differentiate between a „failure‟ which in actuality may be
due to an avoidable or technical causes from a „true difficult spine‟.

39. Conclusion
• Meticulous, planned and multidisciplinary handling.
• The challenge is when, we come across an „unanticipated difficult
spine‟.
• In these situations, the true skill, knowledge and experience and
• most importantly, the „team approach are the only available weapons
in the hands of anesthesiologists to overcome these challenges!!

40. Thank You!!