CHAPTER 19

SPINAL ANAESTHESIA

Outline:

Anatomy

The spinal pack

Technique

The spread of the analgesic solution

Drugs and doses

Care of the patient under spinal anaesthesia

Complications:
Immediate
Later

Indications for spinal anaesthesia

Contraindications

Advantages

Disadvantages of spinal anaesthesia

Extradural block

7
ANATOMY

The vertebral column consists of:

7 cervical
12 thoracic
5 lumbar
5 sacral
4 or 5 coccygeal vertebrae

A typical lumbar vertebra consists of

• A body which bears and transmits weight.
• An arch composed of a pedicle and a lamina. The pedicle is notched
both inferiorly and superiorly to form part of the intervertebral
foramen.
• 2 upper and 2 lower articular processes, arising from the junction of the
pedicles and the laminae.
• A spinous process.
• Transverse processes.

8
 Lateral

Fig 19.1
A lumbar vertebra

Antero–superior

Intervertebral disc
This is a fibro-cartilaginous disc that exists between two vertebrae.
In the centre is the nucleus pulposus. Surrounding this is the annulus
fibrosus. Above and below this is a thin plate of cartilage.
If the spinal needle penetrates the nucleus pulposus it could herniate
and cause chronic backache.

9
 Fig 19.2 Cross–section of the vertebral column at lumbar level

The vertebral canal

This is bound in front by the vertebral bodies and the intervertebral disc.
Behind, by the spines, are the supraspinous and interspinous ligaments on
the sides by the pedicles, the laminae and the ligamentum flavum. There
are two bony deficiencies or "openings" in the vertebral column which will
enable a needle to be introduced into the vertebral canal.
• At the site of the intervertebral foramina. This is difficult. The nerves
leave through this foramen.
• Posteriorly between the laminae. Half the posterior wall of the
vertebral column is made up of bone (the laminae) and half by
ligaments.

10
 Vertebral ligaments
• Supraspinous ligaments extend from the tip of one spine to another.
• Interspinous ligaments extend between two adjacent spines.
• Ligamenta flava extend from one lamina to another lamina. They are
composed of yellow elastic fibres. Half of the posterior wall of the
vertebral canal is composed of bone (i.e. laminae) and half of
ligaments (ligamenta flava).
• The posterior longitudinal ligament connects the posterior aspects of
the bodies of the vertebrae.
• The anterior longitudinal ligament connects the front aspects of the
bodies of the vertebrae.

The curvature of the vertebral column

There are four curves in the vertebral column: 2 curves are convex
anteriorly, in the cervical and lumbar regions and 2 curves are concave
anteriorly, in the thoracic and sacral regions. These curves determine the
spread of local analgesic solution.

Fig 19.3 The curves of the vertebral canal

11
The spinal cord
The spinal cord is the continuation of the brain and occupies the vertebral
canal. It extends from the upper border of the first cervical vertebra (the
atlas) to the upper border of the second lumbar vertebra.
In the foetus, the spinal cord occupies the whole of the vertebral canal.
However, the vertebral canal grows faster than the spinal cord and at birth
the cord terminates at L3.
In the adult, the spinal cord occupies the upper two-thirds of the vertebral
canal. It is 45cm long and ends in the conus medullaris, from the apex of
which the filum terminale descends to the coccyx. Spinal puncture above L2
may result in cord damage.

Coverings of the spinal cord

These are three in number:
• The dura mater is strong and fibrous and ending at the lower border of
S2, it is separated from the bony wall of the vertebral column by the
extradural space. The dural fibres are longitudinal and this must be
remembered when introducing the spinal needle. Ensure the bevel
faces upwards (in the lateral position of lumbar puncture), so that the
fibres are not divided but separated.
• The arachnoid mater is a very thin and transparent layer closely
adhering to the dura mater.
• The pia mater is a vascular membrane closely adhering to the spinal
cord. It invests the cord and sends septa into it.

The cerebrospinal fluid

The cerebrospinal fluid occupies the space between the pia mater and the
arachnoid mater. This space is called the subarachnoid space. The local
anaesthetic is deposited into it during spinal anaesthesia.

Spinal segments
The cord is divided into segments by the spinal nerves that leave it. Each
segment gives off an anterior root and a posterior root. Each anterior root
fuses with the corresponding posterior root at the intervertebral foramen.

12
Spinal nerves
There are 31 pairs of spinal nerves each arising by the fusion of the anterior
and posterior nerve root. The anterior root is motor (i.e. it supplies the
muscles). The posterior root is sensory.
The nerve roots are blocked by the analgesic solution during spinal
anaesthesia. The analgesic solutions block the finest fibres first. The
sensory nerves, being of smaller diameter than the motor, are blocked first.

Fig 19.4 A typical spinal nerve

13
 Fig 19.5 The segmental cutaneous nerve supply of the body

14
 Segmental Levels
The following areas are supplied by the segmental
areas of the spinal cord mentioned below:

Perineum S1-4
Inguinal Area L1
Umbilicus T10
Xiphisternum T8
Nipple T4-5
Clavicle C3-4

15
Structures penetrated by the lumbar puncture needle
Midline approach:
• Skin
• Subcutaneous tissue and fat
• Muscles
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Extradural space
• Dura mater and arachnoid mater
• Cerebrospinal fluid

Fig 19.6 Path of needle during lumbar puncture

Lateral approach:
• Skin
• Subcutaneous tissue
• Muscles
• Ligamentum flavum
• Extra dural space
• Dura mater and arachnoid mater
• Cerebrospinal fluid

16
 Average depth penetrated by the spinal needle is 4 to 5 cm. This is
greater
in the obese patient.
The spinal cord ends at the upper border of L2. Therefore make sure the
lumbar puncture is done below this level, or else the cord may be damaged.
In the elderly patient the supraspinous ligament may be calcified and the
lateral approach may be easier.

THE SPINAL PACK

This is a collection of items to be kept ready for spinal anaesthetics.
The following list is an example of a basic spinal set but the contents may
vary from hospital to hospital.
All sterile
− 1 fenestrated drape or 4 towels.
− 2 bundles of gauze swabs.
− 2 gallipots and 1 kidney dish.
− 1 spinal needle with stilette gauge 22 and/or 25G/27G, plus
introducer (19 gauge needle).
− 1 23G hypodermic needle (skin analgesia).
− 1 18G hypodermic needle (for drawing up LA).
− 1 ampoule file.
− 1 swab holder.
− 1 ampoule local anaesthetic.
− 2 syringes: 5ml and 2ml. These must be glass if in a pack to be
autoclaved.
Several such bundles should be kept in theatre, with the date of autoclaving
marked on the seal and every unused pack re-autoclaved every week at a
pressure of 20psi for half an hour. Most local anaesthetics can be autoclaved
but should be discarded if the solution is discoloured.
Amethocaine (Pontocaine, Tetracaine) must not be re-autoclaved.
Chemical sterilisation is very dangerous. Never use needles or syringes
soaked in spirit or any other antiseptic solution. It is ineffective and can
cause neurological damage. Autoclave (or boil if altitude is less than 1000
metres).

17
TECHNIQUE OF SPINAL ANAESTHESIA
• Wash the patient's back (shave it if necessary).
• Check the blood pressure and leave the cuff on. Apply ECG and pulse
oximetry monitoring, if available.
• Put in an indwelling needle or start an intravenous infusion if
necessary.
• Make sure the following are available in the theatre before proceeding
with the spinal anaesthesia:
− Vasopressors (ephedrine or metaraminol)
− Atropine
− Oxygen
− A gas machine or a means of ventilating the patient
− Suction
• Select either the lateral or sitting position for the patient.
Lateral Position
Place the patient on his side, right or left. The buttocks and the
shoulders should be parallel to the edge of the table. The nurse stands
in front of the patient and places one hand behind the patient's neck
and the other hand behind the patient's knees. The back is arched to
open up the intervertebral and the interlaminar spaces.

Fig 19.7 Patient in lateral position for lumbar puncture

18
 Fig 19.8

Sitting position
The patient sits on the table. He is instructed to arch his back like a cat or to
"push out" his back. The feet are placed on a stool, arms folded across the
chest and the head flexed. A nurse supports the patient.

Fig 19.9

19
With the patient in an appropriate position
• Scrub as for a surgical operation. Wear a sterile gown and gloves.
• Swab the patient. Use a fresh swab each time and discard it after use.
Swab the lumbar spine from above downwards three times. Betadine
solution or any other antiseptic that is used to prepare the site of
surgery in theatre can be used.
• Open the pack.
• Draw up the drugs. In the 2ml syringe, draw up the drug to be injected
into the spinal space. In the 5ml syringe, draw up the drug for local
infiltration of the skin. If using bupivacaine a 5ml syringe is needed
and great care must be taken to identify the contents of each syringe.
• Drape the patient, preferably with a single "window" drape or with 4
drapes, 2 vertical and 2 horizontal, leaving a square in the lumbar
region uncovered.
• Sit on the stool so that the site of the lumbar puncture is at eye level.
• Choose the site of injection:
− Feel for the highest point of the iliac crest. This passes through
the body of the 4th lumbar vertebra or the interspace between
4th and 5th lumbar vertebrae.
− Choose the widest space between 2 spines with the above point
as a guide. It does not matter exactly at which level entry is
made, provided it is at or below the space between L2 and L3.

Technique for Midline approach (This is the most common approach)

The patient is positioned as described. The interspace between L3 and L4
or L4 and L5 is identified. Make a skin weal, then insert the spinal needle in
the interspace at right angles to the skin.
Once through the ligament there is a distinct loss of resistance. The needle
is advanced slightly forwards, to pierce the dura mater and the stilette
should be removed to check for flow of cerebrospinal fluid through the
needle. If the flow is poor, replace the stilette, rotate the needle gently, push
it forwards or withdraw it slightly.
Always replace the stilette before advancing the needle, or skin or other
tissue may be introduced into the CSF when the local anaesthetic
solution is injected. Remember that unless the flow of cerebro spinal fluid
is free, the block will not be satisfactory.

20
 Fig 19.10 Removal of stilette and flow of CSF
The same approach, i.e. lateral or midline, can be used in the sitting
position. The beginner is advised to commence spinal anaesthesia using a
22G needle. Once experience is gained a 23G needle and later a 25G
needle can be used. The use of a 23G or 25G needle would necessitate the
use of a 19G hypodermic needle as an introducer. Ensure the introducer is
not inserted too deep as it may pierce the dura.
Using a 25G needle may require aspiration of CSF into the syringe.

Fig 19.11 Midline and lateral approach

21
Technique for the lateral approach
Note the space between L3 and L4 or L4 and L5 spines in the midline.
Raise a skin weal at the selected interspace using a 23 gauge needle and
1 ml of lignocaine 0.5%.
Hold the lumbar puncture needle by the hub. With the patient in the lateral
position the needle is inserted 1cm above the midline between two spines.
It is directed inwards at an angle of 25 degrees to the midline. Once
through the ligament there is a distinct loss of resistance. The needle is
advanced slightly forwards, to pierce the dura mater and the stilette should
be removed to check for flow of cerebrospinal fluid through the needle. As
for the midline approach if the flow is poor, replace the stilette, rotate the
needle gently, push it forwards or withdraw it slightly. Always replace the
stilette before advancing the needle, or skin or other tissue may be
introduced into the CSF when the local anaesthetic solution is injected.
Remember that unless the flow of cerebrospinal fluid is free, the block will
not be satisfactory.

Once the space has been identified and a free flow of CSF obtained
• Inject the drug, place a sterile swab over the site of injection and hold it
in place with a piece of strapping. After the injection some of the drug
is fixed to the nervous tissue and some is absorbed into the venous
plexuses. Position the patient in such a way as to get the desired block.
• Remember a minimum of 10 minutes fixation time is required after
injection.
• A blood stained CSF should clear after 5 or 6 drops. If it clears,
proceed, if not, repeat at another interspace.

THE SPREAD of the ANALGESIC SOLUTION

The vertebral column if viewed from the side has a concavity in the thoracic
region maximal at the 6th thoracic vertebra and a convexity in the lumbar
region maximal at the third lumbar spine. At the usual site of injection most
of the anaesthetic "rolls" down the lumbar curve. This is of little use for
abdominal surgery where the thoracic segments must be anaesthetized, so
when the patient is placed on the back, a slight head down tilt is employed
to help the distribution to the thoracic segments. In women there is a
natural tilt, because the female pelvis is broad and the shoulders are narrow.

22
The spread of local anaesthetic in the subarachnoid space is affected by
• Posture.
• The specific gravity of the solution in relation to CSF, i.e. whether the
solution is lighter or heavier than CSF. This is really determined by
what is added to the local anaesthetic solution. If the solution is heavier
than CSF it tends to sink.
• The volume of the local anaesthetic solution injected.
• Speed of injection. With a fine needle it is difficult to inject fast
enough to affect the spread of the drug.
• Barbotage: the aspiration of CSF into the syringe and then injection
into the spinal space.
• Changes in pressure and volume of CSF during pregnancy reduce the
volume of local anaesthetic required.
• Age. Smaller doses of local anaesthetic are needed with advanced age.
• The interspace chosen for injection. The higher the interspace the
higher the spread of LA.

Fig 19.12 The effect of the curvature of the vertebral column on the
spread of local anaesthetic

23
DRUGS AND DOSAGES FOR FIT ADULTS

Bupivacaine 0.5% plain (Marcaine)

2.5-3 ml may be used in the sitting or lateral position for lower limb and
lower abdominal surgery.
Bupivacaine 0.5% hyperbaric
Heavy or hyperbaric bupivacaine is a 0.5% solution mixed with 80mg/ml
dextrose. (SG 1.026)
This is the recommended choice for spinal anaesthesia and is the most
predictable in onset and distribution of anaesthesia.
Dosage: Perineal surgery (saddle block) 1-1.5ml
Prostatectomy, lower limb surgery 2-2.5ml
Hysterectomy, appendicectomy 3-3.5ml
Lignocaine 5% heavy
Perineal surgery (saddle block) 1-1.5ml
Prostatectomy, lower limb surgery 2ml
Amethocaine (pontocaine, tetracaine)
This may be used as crystals dissolved in CSF. It could also be used as a
1% solution dissolved in 10% glucose.
10-15 mg is normal for lower abdominal surgery, depending on the patient
and the preparation used.
The maximum intrathecal dose is 20mg.

Never use a spinal anaesthetic for upper abdominal surgery.

For older patients (above 55 years of age)

• Start an intravenous infusion before the spinal.
• Give a minimum dose.

For Caesarean section (see also Obstetric anaesthesia Chapter 21)

Lignocaine 5% 1.2-1.5ml
Bupivacaine 0.5% heavy 2-2.5ml
Amethocaine 10mg (1ml)

Adrenaline in local anaesthetic solutions.

The advantages and disadvantages of the use of adrenaline, with the local
anaesthetic, for spinals are considered with Obstetric anaesthesia in Chapter
21. The practice is not recommended.

24
CARE OF THE PATIENT UNDER SPINAL ANAESHESIA
In the operating theatre
• Check the blood pressure every minute for the first 5 minutes and
every 5 minutes thereafter. Record it on the anaesthetic chart. The
treatment of hypotension is discussed later.
• Monitor the pulse rate every minute for the first 5 minutes and every
5 minutes thereafter. If the pulse rate slows and if this is associated
with a fall in blood pressure atropine may be required.
• Respiration: the depth and rate of breathing should be observed. The
management of respiratory depression is discussed later.
• Colour or oximetry: Pallor or cyanosis require urgent attention.
• Observe the general condition of the patient carefully. Sweating,
nervousness, nausea, dry retching, should be noted and appropriately
treated.

In the recovery area and the ward

If otherwise stable a patient can be returned to the ward when there are
signs of the spinal anaesthesia beginning to wear off.
The following vital signs should be observed for four hours after the return
of the patient to the ward or as long as the spinal is still effective (i.e. as
long as the patient is paralysed).
• Record blood pressure every 10-15 minutes for the first hour and
half-hourly thereafter.
• Record pulse every 10-15 minutes for the first hour and half-hourly
thereafter.
• Record SaO2 or observe colour every 10-15 minutes.
• Observe respiration rate and depth every10-15minutes.
• Level of consciousness
• Position: Patients are usually nursed lying flat for the first 6 –12 hours
but may ambulate if a fine needle has been used.

25
COMPLICATIONS
The complications of spinal anaesthesia can be immediate or late.
Immediate complications
Cardiovascular system
There may be a fall in blood pressure. This is usually seen in the first
twenty minutes and could be explained by several mechanisms.
• Sympathetic blockade resulting in vasodilation of the peripheral blood
vessels. This causes a fall in venous return and a drop in blood
pressure.
• The sympathetic nerves to the heart may be blocked. These nerves
increase the rate of contraction of the heart. A block of the cardiac
sympathetic nerves results in bradycardia and a fall in the cardiac
output.
Treatment of hypotension. In the event of a fall in blood pressure,
exclude other causes e.g. blood loss, packs in the abdomen.
If hypotension occurs:
− Tilt the table head down. This increases venous return. This
must only be done if the spinal is 'fixed', otherwise the legs
could be elevated, manually or by raising the lower half of the
table.
− If blood pressure falls below 90mm Hg, increase IV fluids
(Hartmann’s solution). Infuse 500ml rapidly.
− If blood pressure falls below 80mm Hg give ephedrine 5mg IV
and repeat if necessary or aramine (Metaraminol) 0.25 - 0.5 mg
IV in increments.
− Give oxygen by mask.
− Give 0.3mg of atropine IV if the hypotension is associated with
a bradycardia. Do not give aramine (Metaraminol) if the pulse
rate is less than 60 as it causes a reflex bradycardia. This dose
of 0.3mg atropine could be repeated if necessary until a dose of
0.6mg has been given.
− Always exclude and treat aorto-caval compression in obstetric
patients.
Respiratory system.
The breathing may become slow and shallow, perhaps as a result of the
intercostal nerves being blocked by the spinal anaesthesia. The breathing
may actually stop owing to paralysis of the respiratory centre after a total
spinal (see below). If respiratory depression occurs, the patient must be
given oxygen by mask first. If the respiratory excursions are inadequate,
assist respiration using a mask. If still inadequate, intubate the patient and

26
control respiration.

27
Nausea and vomiting
Nausea and vomiting could be due to a variety of causes. Always attempt
to find out the cause. It may be associated with any of the following:
• Hypotension. Always check the patient's blood pressure, if there is
nausea or vomiting.
• Hypoxia.
• Traction on the nerve endings by the surgeon.
• Morphine or pethidine given as pre-medication.
• Nervousness, fear, etc.
Treatment
− Treat the cause. The main cause of nausea is hypotension. (See
above for treatment.)
− Re-assurance.
− Encourage deep breathing.
− Phenergan IV slowly (if the patient's blood pressure is within
normal limits) or IM.
− Metoclopramide (Maxalon) 10 mg IV or IM.
− Ondansetron 4 mg. IV.
Broken needle
A broken needle is a serious complication. Never apply force when
inserting a needle into the subarachnoid space. If a needle does break
leave the proximal part of the needle in place. Insert another needle along
the tract. The patient must be X-rayed and the needle must be removed as
soon as possible.
Total spinal
This may occur accidentally. If a "total spinal" occurs, it means that either
an excessive dose of local anaesthetic has been given or, because of faulty
positioning, the injected drug has affected the spinal nerves at a higher than
expected level. It may follow the accidental injection into the subarachnoid
space of drugs intended for epidural block. Occasionally the cause is not
obvious.
The results of a total spinal are:
• The blood pressure falls. If this is severe a cardiac arrest may result.
• Respirations become shallow and may even cease.
• The patient becomes cold and blue.
Treatment is supportive until the spinal wears off:
− Ventilation with facemask or LMA.
− Tracheal intubation and IPPV (with sedation).

28
− Treat hypotension with fluid +/– vasopressor.

29
 Systemic reaction to the injected local anaesthetic
It is rare for the local anaesthetic injected into the subarachnoid space to be
absorbed in such quantities into the blood stream as to produce toxic effects.
It may be associated with the following:
• A high dose of local anaesthetic.
• Accidental injection of a local anaesthetic into a blood vessel.
• Rapid absorption, perhaps because of an increased vascularity of the
meninges.
• Decrease in the rate of breakdown of the local anaesthetic, e.g. in liver
disease.

Later complications
Headache
There are many explanations given. The most widely accepted is that the
leakage of CSF through the hole in the dura mater lowers the pressure in the
subarachnoid space. This results in traction on the blood vessels etc.
Features of a spinal headache
• The spinal headache is different from any the patient has experienced
before.
• It is worse on sitting up. It is relieved by lying down.
• External stimuli, such as light and noise, make the headache worse.
• The headache is mainly at the back of the head (occipital) and is
associated with pain down the neck.
• It is relieved by increasing abdominal pressure.

The incidence of spinal headaches is related to the size of the needle.

Needle size Incidence of headaches
20G 10–20%
22G 8–15%
25G 2–5%
26G <1%

Prevention
− Use a fine needle.
− Make sure the fibres of the dura mater are divided and not cut by
adjusting the bevel of the needle.
− Avoid multiple punctures.
− Nurse the patient flat for 6 hours post-operatively.
− Avoid coughing and straining post-operatively.

30
31
Treatment
− Reassurance
− Frequent long drinks
− Sedation and analgesia
− IV infusion if not contraindicated
− Epidural "blood patch" (see more advanced text books)

Backache
Treatment
− Small pillow under the lumbar region
− Sedation
Prevention: Avoid traumatic punctures.

Retention of urine
Treatment
− Nursing measures and stand patient out of bed if possible.
− If retention persists, catheterise.

Sepsis or infection
This may take various forms. All of them are serious.
• Extra dural abscess
• Meningitis (inflammation of the coverings of the brain and spinal cord)
• Encephalitis (inflammation of brain and spinal cord)
• Radiculitis (inflammation of nerve roots)

Meningism
This is an irritation of the meninges without actual infection. It presents
like a meningitis and is diagnosed on a normal CSF tap. It is due to
introduction of irritants into the subarachnoid space during the tap.

Paralysis of the cranial nerves

This is a rare occurrence.
The 6th cranial nerve (which is the longest) is the most vulnerable. The
paralysis of this nerve presents usually as double vision, between the 5th
and 11th post-operative day. It may be associated with headaches. It occurs
in 1 in 300 patients. The cause of cranial nerve palsies is most likely due to
the loss of CSF and traction on the unsupported brain.
Treatment: Dark glasses with a patch on the outer third of the glass over
the affected eye may help. Fifty percent of patients recover within 1 month.
Surgery must be performed to correct the double vision if recovery does not
occur in 2 years.
32
INDICATIONS FOR SPINAL ANAESTHESIA
• Routine anaesthetic for surgery below the umbilicus in the fit patient.
• In a patient with a full stomach a spinal anaesthetic is safer than a
general from the point of view of aspiration of stomach contents. If
possible all patients should still be fasted according to the guidelines
whatever type of anaesthetic is planned.
• Patients who have a contraindication or relative contraindication to a
general anaesthetic e.g. acute respiratory tract infection, known
difficult intubation / airway, severe liver or renal disease.
• In situations in which oxygen is available but must be conserved.
Remember that oxygen must be available for a spinal anaesthetic
to be given.
• In situations where cost is an important factor.

CONTRAINDICATIONS TO A SPINAL ANAESTHETIC

• Local infection over the site of injection.
• Raised intracranial pressure.
• Young children.
• Unco-operative patients and patients with chronic headaches.
• Very ill patients, e.g. those with reduced blood volumes as from:
− Bleeding from any site.
− Dehydration.
− Shock.
− Uncorrected hypotension from any cause.
− Heart disease, e.g. unstable angina or recent myocardial
infarction, severe aortic stenosis.
• Deformed backs (relative contraindication as may be more
difficult but may be worth trying).
• Disorders of blood clotting.
• Multiple sclerosis.
• Enlarged prostate in which the surgery performed is not on the
prostate. The spinal anaesthetic is sometimes associated with retention
of urine. This would be more likely in patients with an enlarged
prostate (relative contraindication).

33
ADVANTAGES OF SPINAL (AND EPIDURAL) ANALGESIA
• Simple technique. Epidural analgesia is a slightly more difficult
technique than spinal and requires special needles.
• Cheap. The cost of drugs and equipment for a spinal is much less than
for general anaesthesia.
• Safe. The patient is not exposed to a multiplicity of drugs, e.g.
IV drugs, inhalational agents and relaxants. There is minimal danger
of aspiration and airway obstruction.
• Minimal interference with physiological functions as the patient is
conscious and breathing spontaneously.
• Good operating conditions, for instance, for intra -abdominal surgery
below umbilicus:
− Relaxed abdomen.
− Good analgesia.
− Reduced bleeding.
• No explosion risks.
• Fewer post-operative chest complications.

DISADVANTAGES
• Patient acceptability. Not all patients accept being awake.
• The procedure is not without complications. These have been
discussed in detail.

EPIDURAL BLOCK
This is not discussed in detail. Please see other anaesthetic textbooks.
The local analgesic solution is deposited outside the dura mater. The local
anaesthetic acts on the nerve roots.

Advantages of an EDB over a spinal

• No postoperative headache. However if the dura is punctured the
incidence of headache is far higher, as a thicker needle is used.
• Less danger of infection in the CSF as the dura is not punctured.

34
Disadvantages compared with a spinal
• Technically the EDB is a little more difficult. The "end point",
indicating the needle is in the epidural space, depends on the detection
of the negative pressure. The "end point" in the spinal is CSF.
• Time taken to insert an EDB is a little longer than for a spinal.
• The onset of analgesia after an EDB is slower.
• A large volume of local anaesthetic is used for an EDB. This makes it
more expensive and it increases the danger of toxic reactions.
• Accidental injection into the subarachnoid space of a large volume of
local anaesthetic can be very dangerous.

It is recommended that provided there are no contraindications, for surgery

below the level of the umbilicus, a spinal anaesthetic can be used as the
standard method of anaesthesia.

35