This document provides information on spinal anesthesia techniques. It begins with a brief history of spinal anesthesia dating back to 1885. It then covers topics such as indications, contraindications, preoperative evaluation, techniques, complications and their management. Specific details are provided on patient positioning, identifying anatomical landmarks, different needle approaches, administering anesthetic solutions and factors affecting spinal block height. The document aims to guide practitioners on safe and effective spinal anesthesia procedures.

1. Technique of SPinAL
AneSTheSiA indicATion
And conTrAindicATion
Guided by: Dr. Shubhada Deshmukh(M.D.)
Presented by: Dr.Anurag Giri

2.  Spinal anesthesiaisalso called asspinal block
or subarachnoid block (sab). SAB isaregional
anesthesiainvolving injection of alocal
anesthesiainto thesubarachnoid spacewhich
extendsfrom theforamen magnum to S2 in
adultsand S3 in children. Injection of LA below
LI in adultsand L3 in children helpsto avoid
direct traumato thespinal cord , (anesthetic
agentsactson thespinal nerveand not on the
substanceof thecord)
SPinAL AneSTheSiA

4.  Corning in 1885 , accidently administered
cocaineintrathecally.
 Quinckein 1891 , madeuseof spinal puncture
in diagnosis.
 August bier of Germany in 1898 , introduced the
techniqueof spinal anesthesia.
 Pitkin popularized themethod of introducing
agent'sintrathecally.
hiSTory

5.  Informed consent.
 Physical examination , history (past surgical ).
 Laboratory test.
 Premedication
Diazepam 0.1-0.2 mg/kg Po
midazolam 1-3 mg I/M
PreoPerATive evALuATion And
PrePArATion

6.  Used both aloneand in combination with either
GA or sedation.
 Lower limb orthopedic surgery on thepelvis,
femur , tibiaand ankle.
 Total hip replacement.
 Total kneereplacement.
 Lower limb vascular surgery.
4) indicATion of SPinAL
AneSTheSiA

7.  Hernia(Ingunial or epigastric).
 Haemorrhoidectomy , fistula, fissure.
 Nephrectomy and cystectomy in combination with GA.
 Transurethral resection of theprostateand transurethral
resection of thebladder tumors.
 Abdominal and vaginal hysterectomies
 Laproscopic assisted vaginal hysterectomies(LAVH)
combined with GA.
 Caesarean sections.

8.  ABSOLUTE
Patient refusal
Infection at thesiteof injection
Coagulopathy or other bleeding diathesis
Severehypovolemia
Increased intracranial pressure
Severeaortic stenosis
Severemitral stenosis
 Post traumatic vertibral injuries, myocardial infract.
conTrAindicATion

9. ∗ RELATIVE
∗ Sepsis
∗ Un co-operative patient
∗ Preexisting neurological deficit
∗ Stenotic valvular heart disease
∗ Severespinal deformity
∗ Spinal congenital anomalies
∗ Hypo tension
∗ Hyper tension
∗ Severeanaemia
∗ Shock(haemorragic,septic)
∗ Brain tumor

10. 4 Ps
Preparation
Position
Projection
Puncture
recoMMendATionS for SAfe
SPinAL TechniqueS

11. 1.Scrub handsaccording to aseptic surgical technique
2.Usesterileglows
3.Avoid contaminating blocking solutionswith solutionsused to
preparetheskin.
4.Useaseptic techniquewhen opening tray.
5.Clean theskin prior to needlepuncture.
6.Touch only sterilearticlesoncegloved.
7.Useintroducer prior to injection of small guagespinal needle.
8. Avoid repeated traumatic punctures.
9.Useapproved local anaesthetic agentsin standard concentration

12. ∗ Clean theskin surfacetwicewith betadineand twicewith spirit
using window techniquewith sterilegauze
cLeAninG And
drAPPinG

13. ∗NEEDLES
∗Thestandard spinal needle-
∗ThreepartsHub , cannula, stylet
∗Pointsof cannulaearebeveled and havesharp edgeCannulaemadeof stainlesssteel
should bestiff, flexibleand resistant to breakage.
∗Sizes- 16 G to 30 G
∗Length- 3.5 to 4 inches
∗NEEDLES CLASSIFIED
∗1. Standard bevelled with cutting edges-
∗ Quincke,Babcock or Pitkin
∗2. Pencil point needlewith conical point with no cutting edges- Sprotte, Greene.
SPinAL AnASTheSiA Technique

14. • Large IV cannula
• IV fluids immediately before the spinal
• The volume of fluid given will vary with age and extent of
block
• Ideally – 10ml/kg
• Crystalloids like Ringerlactate , 0.9% normal saline are
used
• Now co-loading.
INTRAVENOUS PRELOADING

15. ∗ L.P. ismost easily performed when thereismaximum flexion of
lumbar spine.By thisligamentsget stretched and spaceisopen
POSITIONS

16. ∗ TWO ASPECTS
∗ 1. Spinal canal should beon horizontal plane
∗ 2. Operator should fix hisor her gazeon thehorizontal plane.
POSITIONING
∗ Flexed lateral position- back should beparallel to theedgeof the
table, kneesareflexed on theabdomen, neck flexed.
∗ Jack knifeposition
LATERAL POSITION

19. ∗ Theanatomic midlineisoften easier to aproach when thepatient is
in sitting position .Patient sit with their elbowsresting on their
thighsor bedsidetableor they can hug apillow. Flexon of spine
miximizesthetarget areabetween adjacent spinousprocessesand
bringsthespinecloser to skin surface
SITTING POSITION

21. ∗ Thisposition isused for anorectal proceduresutilising ahypobaric
anasthetic solution
PRONE POSITION

22. • Vertebral Spinousprocessesand theiliac crests
• Spinousprocessesclearly definethemidline
• Linedrawn between theiliac crests- intercristineor Tuffier’s
linecrossesthe4th
lumber vertebrae.
LANDMARK

23. ∗ Thedepression between thespinousprocessof thevertibraaboveand
below thelevel to beused ispalpated.Thiswill bethemiddleentry
site.
∗ Thespinousprocesscoursedownwardsfrom thespinetowardsthe
skin so theneedlewill bedirected cephalad
∗ Thesubcutaneoustissuegivesfeeling of littleresistanceto the
needle,after that needlewill enter thesupraspinousand infraspinous
ligamentsfelt asan increasein tissuedensity .
∗ Astheneedlemeetstheligamentum flavam an increasein resistanceis
encountered and on piercing it, lossof resistancecan befelt .The
needleisadvanced through theepidural spaceand penetratesthedura
(2nd
resistance) and subarachnoid membraneassignaled by free-
flowing CSF.
MIDLINE APPROACH

24. USE OF AN
INTRODUCER
•Concept of Introducer was that of
Lincoln Size.
•Modifications- Pitkin and by Lundy.
• Purpose- Spinal needle can be
inserted to the depth of the
interspace without touching the
skin, subcutaneous tissues and
ligaments.
• Grasping and stabilising

25. OBJECTIVES OF INTRODUCER
∀↓Infection
∀↓ Contamination
•Facilitate introduction of Spinal
needle.
•Minimize introduction of skin and
tissue fragments
•Avoid development of SAB
epitheliomas and epidural tumors.

26. ∗ Theparamedian approach may beselected if SAB isdifficult(severe
arthritisor prior LSspinesurgery) Theskin wheal for theparamedian
approach israised 2cm lateral to theinferior aspect of thesuperior
spinousprocessof thedesired level.Theneedleisdirected and
advanced at a10-25degreeangletowardsthemidline
PARAMEDIAN/ LATERAL
APROAch

28. ∗ Thisisavery useful method in casesof spinefusion, arthritic spine,
opisthotones, skin infection in thelumbar region , or in other
conditionsin which theusual approach isdifficult or impossible.
∗ Largest interspaseL5-S1.
∗ A skin wheal is made1cm medially and 1cm below thelowest
prominenceof theposterior-superior spine. A 12-cm , needleis
directed upward , medially and forward at an angleof about 50degree,
approximating forward at an anglethat thedorsal aspect of thesacrum
makeswith theskin. Theneedlethen isadvanced so that it’spoint
entersthelumbosacral spacebetween thesacrum and thelast lumbar
vertebra. Asthespaceisentered , thereusually an immediateflow of
CSF , although gentleaspiration may benecessary.
Taylor Technique

30. The spinal needle feels as if it is in the right position but no CSF
appears. Wait at least 30 seconds, then try rotating theneedle90
degreesand wait again. If thereisstill no CSF, attach an empty 2ml
syringeand inject 0.5-1ml of air to ensuretheneedleisnot blocked then
usethesyringeto aspiratewhilst slowly withdrawing thespinal needle.
Stop assoon asCSF appearsin thesyringe.
Blood flows from the spinal needle. Wait ashort time. If theblood
becomespinkish and finally clear, all iswell. If blood only continuesto
drip, then it islikely that theneedletip isin an epidural vein and it
should beadvanced alittlefurther to piercethedura.
The patient complains of sharp, stabbing leg pain. Theneedlehas
hit anerveroot becauseit hasdeviated laterally. Withdraw theneedle
and redirect it moremedially away from theaffected side.
PracTical Problems

31. The patient complains of pain during needle insertion. This
suggeststhat thespinal needleispassing through themuscleon either
sideof theligaments. Redirect your needleaway from thesideof the
pain to get back into themidlineor inject somelocal anaesthetic.
Whereverthe needle is directed, it seems to strike bone. Make
surethepatient isstill properly positioned with asmuch lumbar flexion
aspossibleand that theneedleisstill in themid-line. It might bebetter
to attempt aparamedian approach to thedura.

32. PrinciPles in aDminisTraTinG
anaesTheTic
soluTions
Main aim of anaesthetists is to secure anaesthesia of
• Sufficient duration
• Sufficient Height.
STOUT’S PRINCIPLES FORSPREADOFSOLUTIONS
Height of anaesthesia is
1. Directly proportional to concentration of thedrug
2. Inversely proportional to rapidity of fixation
3. Directly to speed of injection
4. Directly proportional to thevolumeof fluid.
5. Inversely proportional to spinal fluid pressure.
6. Directly proportional to specific gravity for hyper baric solution.

33. FacTors PosTulaTeD To be relaTeD To sPinal
anaesTheTic blocK heiGhT
PATIENTCHARACTERISTICS
• Age, Height, Weight, Intraabdominal pressure, position, anatomic
configuration of spinal column.
TECHNIQUEOFINJECTION
• Siteof injection, direction of injection, rateof injection.
CHARACTERISTICS OFSPINALFLUID
• Volume, Pressure, density.
CHARACTERISTICS OFANAESTHETIC SOLUTIONS
• Density, Amount, Concentration, temperature, volume.

34. ∗ This is the technique of stirring up to increase
turbulence , mixing of injected solutions and
increasing the distribution in the subarachnoid space.
The technique first was described by Bier and consists
of the injection of the anesthetic solution into the
subarachnoid space, immediate withdrawal of a
portion of the solution and reinjection. This may be
repeated. The to-and-fro movement agitates the
injectate in the spinal fluid, and the currents mix the
agent more completely and carry the agent more
extensively and to higher levels. Caution must be
observed and each operator must learn the results of
his barbotage
barboTaGe

35. PaTienT FacTors
AGE
• Spinal spacebecomesmaller with ↑ age- distribution greater.
OBESITY
• Increaseintra-abdominal pressure
• increasepressurein epidural space.
• Decreasesubarachnoid space
PREGNANCY
• Increaseintra-abdominal pressure
• Increasevolumeof epidural venousplexus- Small subarachnoid
spaces.

36. INTRAABDOMINAL PRESSURE
• Changesresulting from direct pressureof increased intra-abdominal
pressureon epidural and subarachnoid spaces.
• Collateral flow through epidural venousplexusexpand- SA spacesmall
SPINALCURVATURE
• Abnormal curvaturehavean effect on technical aspects
• Changesthecontour of Subarachnioid space
RATEOFINJECTION
• Slow injections- low levels
• Rapid injections- high level

37. CHARACHTERISTICS OF ANAESTHETIC
SOLUTIONS
∗ AMOUNTOFDRUG
•Increaseamount- increaseDuration
∗ EFFECTOFTEMPERATURE
•DecreaseTemperature- increaseBaricity
charachTerisTics oF
anaesTheTic soluTions

38. DENSITY /SPECIFIC GRAVITY ANDBARICITY
• Density of any solution istheweight in gramsof 1 ml of thesolution at a
standard temperature. Density variesinversely with temperature.
• Specific gravity isthedensity of asolutionscompared in aratio with the
density of water.
• Baricity isaratio comparing thedensity of onesolution to another.
• Density of normal human. CSF at 370
C is1.0001 to 1.0005
• Specific gravity of spinal fluid 1.003 to 1.008
ISOBARIC SOLUTIONS
• Densitiesbetween 0.9998 and 1.0008
• Solutionsaremixed with physiological saline
• Solutionswith out added glucose
• Bupivacaine, ropivacaine, levobupivacaine
• Spread not influenced by position

39. HYPOBARIC SOLUTIONS
• Baricity lessthan 0.9998 at 370
C
• Prepared by diluting with distilled water
HYPERBARIC SOLUTIONS
• Solutionsat 370
c with baricity greater than 1.0008
• Madeby addition of 5-9.5% dextrose.

40. Problems with the block
No apparent sab at all. If after10 minutes the patient still has full
powerin the legs and normal sensation, then the block has failed
probably because the injection was not intrathecal. Try again.
The sab is one-sided oris not high enough on one side. lie the patient
on the side that is inadequately blocked fora few minutes and adjust
the table so that the patient is slightly "head down".
sab not high enough. tilt the patient head down while they are supine
(lying on the back), so that the solution can run up the lumbar
curvature. Flatten the lumbarcurvature by raising the patient's knees.
Block too high. The patient may complain of difficulty in breathing or
of tingling in the arms orhands. Do not tilt the table "head up".

41. ∗ CLASSIFIED INTO:
∗ Singleinjection technique
a)Hyperbaric
b)Isobaric
c)Hypobaric
Continuousinjection method
a)Intermittant or fractional
b)Differential block
c)Continuousdrip
Segmental method
sPiNAl ANAsthesiA techNiQUe

42. 1. Procaine-Anaesthetic solution used isprocainemixed each 50mg of
procainecrystal with each 1ml of CSF
∗Dosage-For lower extremitiesand perinium 50-100mg
For lower abdomen 100-150 mg
For upper abdomen 150-200mg
2. Lidocaine dextrose-Premixed solution is available lidocaine
5% in 5% dextrose orlidocaine 5% in 7.5% dextrose to a
volume of 2.5ml or50mg/ml of lidocaine.
∗Dosage-Forlowerextremities and periniom 40-60mg
Forlowerabdominal 75mg .
For
upper abdominal 100-150mg
hYPerbAric

43. ∗ 3. Bupivacaine dextrose- An optimal concerntration of
bupivacaine is 0.5% in 5% dextrose
∗ Dosage-Forlowerextrimities and perinium 1.5 -2.5ml(7.5
-12.5mg of bupivacaine)
∗ 1.5ml will provide level of T10. 2ml will provide
level of T8
∗ Forlowerabdomen 2.5ml-3.0ml(12.5-
17.5mg)3.0ml provides anesthesia to T6 level
∗ Forupperabdomen (high spinal) 3.5 to 4.5 ml
(17.5-25mg) 4ml will provide anasthesia usually upto T4
level
∗ 4. Teracainedextrose- Rarely used in practice

44. ∗ 1.Dibucaine-Anasthetic solution 1:1000 or 0.1% dibucainesolution is
used.To makethissolution minimum 1vol. of 0.5% dibucainein a
buffered phosphatesodium chloridesolution with 4vol. Of CSF.
∗ For lower extrimitiesand perinium 0.5 to 1ml
∗ For lower abdomen 1to 1.5 ml
∗ For upper abdomen 1.5 to 2ml
∗ 2. Bupivacaine isobaric-0.5% bupivacaine solution in isotonic
saline.
∗ Forlowerextrimities and perinium 1-2mlof bupivacaine
achieved level upto T10 -T12
∗ Forlowerabdomen 2.5 -3.0ml level upto T8 – T6.
∗ Forupperabdomen 3.5-5.0ml level upto T6-T4.
isobAric

45. ∗ 1.Tetracainein distilled water 0.1% tetracainehydrochloridesolution
iscommonly used.
∗ Hypobaric tetracaine(naphanoid) crystallinepowder in asterile
ampoulecontaining 20mg of tetracaineisdissolved in steriledistilled
water for injection
∗ Dosage-For lower extremitiesand perinium 5-10mg
∗ For lower abdomen 10-15mg
∗ For upper abdomen 15-20mg
∗ 2. Dibucainehypobaric-Anasthetic sloution dibucaine1;1500 in 0.5%
salineeach 1.5ml contains1mg of dibucaine.
∗ Dosage-For lower extremitiesand perinium 5-10ml
∗ For lower abdomen 10-15ml
∗ For upper abdomen 15-20 ml
hYPobAric

46. ∗ inserting acatheter into thesubarachnoid spaceincreasestheutility
of spinal anesthesiaby permitting continuousor repeated drug
delivery in order to expand thelevel or duration of spinal block dural
punctureisdonewith an epidural needle. After thesubarachnoid
placement of theneedleand ascertaining freeflow of csf ,thecatheter
isthreaded 2-3 cm in to thesubarachnoid space.thecatheter should
never bepulled back in to theneedleshaft becauseof therisk of
shearing thecatheter off into thesubarachnonid space
∗ If thecatheter needsto beremoved both needleand catheter should be
removed asaunit . 18 G epidural needle&20 G epidural catheter are
used
∗ Stimulation of nerveroot by thecatheter tip ispainful and catheter can
enter subarachnoid vessel
coNtiNUoUs iNJectioN methoD

47. ∗ Sensation of temperature- Ice, Alcohol
∗ Sensation of Pin-prick – Blunt tipped / Forcep
∗ Motor power – Bromage scale
0 – No motor block
1 – Can flex knee, move foot, but cannot raise leg
2 – Can move foot only
3 – Cannot move foot or knee
Testing of Effect

48. ∗ Sedation only isrecommended in infantsolder than 6-8 weeks.
∗ Conceptual ageof 48weeksor moreto permit quiteand safefor
spinal tap.
∗ Generally thepreterm neonateor infant of aconceptual agelessthan
48 weekswill not need sedation but clinical judgement will
determinetheneed.
∗ Ketamine1-2mg/kg with atropine15-20 micro gram /kg
∗ Midazolam 50-100 micro gram/kg.
sPiNAl ANAsthesiA iN iNFANts
AND chilDreN

49. Thelateral position ispreferred with thetabletilted and thehead up at
100degreeto faster filling of thelumber subarachnoid space.
Thesitting position may also beused.
Thepunctureat L3 –L4 vertibrainterspacefor children of 1-18yrsand
L5 for infants.
Thespinal needledirected perpendicular to planeof theback.
A standard 24-26G needleisused.
Dosage-Minimum vol. of 0.2ml isnecessary in thepreterm or newborn
infant
Infant under 3000gm requiresthelargest dosesbecauselarger vol. of
CSF and absorption dosesupto 0.6mg/kg may begiven to infant of 2-
3kg of weight
For infant over 3kg thedoseisstablised at 0.35 mg/kg upto 1yr of age.
PositioN

50. ∗ After administration of spinal anasthesiaiv linemay beeasily
started in afoot vein becauseof venousdilatation. Monitoring of
pulse,BPand Oxygen saturation isan additional standard.
moNitoriNg

51. THANKS ALL