Spinal anesthesia 1

Central neural blockade
Spinal Anaesthesia
By: Seid Adem
1

Course out line
• 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
2

Spinal cord anatomy
• 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
3

• 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.
4

Coverings of the spinal cord
• In the vertebral canal, the spinal cord is covered by three
membranes:
1. The dura mater
• Is the tough, outer, protective membrane
• This layer is the direct extension of the cranial dura mater
and extends as spinal dura mater from the foramen
magnum to S2
5

2. The arachnoid mater
 Is a very thin and transparent layer closely adhering to the
dura mater.
3. The pia mater
 Is a vascular membrane closely adhering to the spinal
cord.
 It invests the cord and sends septa into it
6

7
Fig-the spinal cord and the meninges

Compartments related to spinal meninges
• These are the
• subarachnoid,
• subdural and
• epidural spaces.
Subarachnoid space
• Found between the arachnoid and the pia mater
• Encompasses the CSF
8

• In the subarachnoid space are
– The CSF
– Spinal nerves
– A trabecular network between the two membranes
– Blood vessels that supply the spinal cord
• Although the spinal cord ends at the lower border of L1 in
adults, the subarachnoid space continues to S2.
9

Subdural space
• Is a potential one only; the arachnoid is in close contact
with the dural sheath and is separated from it only by a
thin film of serous fluid.
• The subdural space within the vertebral canal rarely enters
the consciousness of the clinician, unless it is the
accidental site of catheter placement during attempted
epidural analgesia or anaesthesia.
10

Epidural space
• Is that part not occupied by the dura and its contents
• It extends from the foramen magnum to end by the fusion
of its lining membranes at the sacrococcygeal membrane.
• It contains fat, nerve roots, blood vessels and lymphatic's.
11

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 fibers first.
• The sensory nerves, being of smaller diameter than the motor,
are blocked first.
13

14
Fig-the spinal cord in transverse section from a thoracic segment

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.
15

• Each spinal segment supplies specific region of skin and
number of muscle
o perineum – S1-S4
oInguinal region – L1
oUmbilicus – T10
oSub costal arch – T6-8
oNipple line – T3-T5
oSecond intercostal space – T2
oClavicle – C3-C4
16

• Segmental level of spinal reflexes
oEpigastric –T7-T8
oAbdominal –T9 & T12
oPlantar –S1 & S2
oKnee jerk –L2-L4
oAnkle jerk –S1 & S2
oAnal sphincter reflexes –S4-S5
17

CSF
• The CSF occupies the potential space between pia and
arachnoid mater
• Forms the volume of distribution for spinal anesthetic
agents to the spinal cord structures.
• Formation - CSF is formed in the choroids plexus in the
brain.
• 5o0ml/day and removed by arachinoid villi.
19

 CSF baths spinal cord ,caudal equina and brain
- contain 40-80 mg/dl glucose ,15-45mg/dl protein ,NA
,K ,Ca ,urea, bicarbonate ,Cloride
• Uses –it maintains physiologically stable environment and
buffering for CNS, biochemical function
20

• SA results from the delivery of anesthetic agents in to the
CSF or in to the sub Arachinoid space. It is one of the
simplest RA to perform and was 1st described in human by
august Bier in 1889.
• Indication ?
• SA is ideal for operation to lower extremities
22

1) Upper abdominal procedures with high spinal ,but today
lumbar and thoracic epidural technique is advanced with
heavy sedation or light GA
2) Lower abdominal procedures e.g. appendectomy
3) Gynecological procedures
 Dilation and curettage ,laparoscopy
 Cone biopsy ,tubal ligation ,ovarian Cystectomy
 Hysterectomy
4) Obstetric surgery
 Cesarean section
 Vaginal delivery, VVF ,UVP
23

5. Lower limb surgery
 Orthopedic ,vascular
 Amputations ,skin grafts
6) Urological procedures
 Trans urethral resections ,orchidectomy
 Cystoscopy ,penile implant open prostatectomy
7) Perineal and rectal surgery
 Bartholins cyst
 Rectal fissures/fistulae
8) Hernioraphies
24

Contra indication
o Patient refusal –explanation
o Uncorrected hypovolemia
oDehydration ,shock ,hypotension
oDiarrhea ,vomiting ,bleeding
o Infection at lumbar puncture site-local or systemic
o Coagulopathy -anti coagulated patient with heparin
,warfarin ,systemic coagulation problem.
25

o Anatomic factors that makes CSF access very difficult or
impossible kyphosis ,lordosis ,scoliosis
o Certain neurological disorders which may be exacerbated
by the pre operative stress or anesthesia and surgery.
o Elevated intracranial pressure ,progressive CNS disease
• Patient with fixed COP-heart block ,AV- block ,VHD
• Inadequate resuscitation drugs and equipment.
• Reluctant surgeon-unhappy to operate on awake patient or
relatively unskilled surgeon
26

• Severe HTN –it should be controlled before any anesthetic
is given
• Long surgery
• Uncooperative patient
• Allergy to local anesthesia
• psychosis
27

Structures penetrated by the lumbar puncture needle
Midline approach:
• Skin
• Subcutaneous tissue and fat
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Extradural space
• Dura mater and arachnoid mater
• Cerebrospinal fluid
28

Lateral approach:
• Skin
• Subcutaneous tissue
• Ligamentum flavum
• Extra dural space
• Dura mater and arachnoid mater
• Cerebrospinal fluid
29

• 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.
30

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.
31

• 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 swab holder.
- 2 syringes: 5ml and 2ml. These must be glass if in a pack to
be autoclaved.
32

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.
33

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.
34

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.
• Positioning is frequently the most poorly managed part of
the spinal technique
37

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.
39

• Drape the patient, preferably with a single "window"
• 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
40

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
41

• 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.
43

The spread of local anaesthetic in the subarachnoid
space is affected by
Patient characteristics
• Age
• Height
• Weight
• Gender
• Intra-abdominal pressure
• Anatomic configuration of the spinal column
• Position
44

Technique of injection
• Site of injection
• Direction of injection (needle)
• Direction of bevel
• Use of barbotage
• Rate of injection
45

Characteristics of the anesthetic solution
• Density
• Concentration
• Volume
• Vasoconstrictors
46

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.
• This is the recommended choice for spinal anaesthesia
• predictable in onset and distribution of anaesthesia.
47

• Dosage: Perineal surgery (saddle block) 1-1.5ml
• Prostatectomy, lower limb surgery 2.5ml
• Hysterectomy, appendicectomy 3 -3.5ml
Lignocaine 5% heavy
 Perineal surgery (saddle block) 1-1.5ml
 Prostatectomy, lower limb surgery 2ml
48

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.
49

• Respiration: the depth and rate of breathing should be
observed.
• The management of respiratory depression is discussed
later
• Color 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.
50

In the recovery area and the ward
• 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.
51

Practical problems during SAB
• The spinal needle feels as if it is in the right position but
no CSF appears.
 Wait at least 30 sec. then rotate needle 360⁰ and wait
for some time
 Still no CSF attach 2ml empty syringe and injection of
0.5-1ml of air to ensure the needle is not blocked then
use the syringe to aspirate whilst slowly withdrawing
the spinal needle ,stop as soon as CSF appears in the
syringe.
52

• Blood flows from the spinal needle
• wait a short time .
• if the blood becomes pinkish and finally clear ,all is well.
• if blood only continues to drip then it is likely that the
needle tip is in an epidural vein and it should be a little
further to pierce the dura.
• The patient complains of sharp ,stabbing leg pain.
– The needle has hit a nerve root because it has deviated laterally.
– Withdraw the needle and redirect it more medially away from the
affected site
53

• Wherever the needle is directed it seems to strike bone
 Make sure the patient is still properly positioned
,lumbar flexion and needle still in the middle line
 If patient is elderly and can not bend very much and
has heavily calcified intraspinous ligament, attempt
paramedian approach
54

• The patient complains of pain during needle insertion
 this suggests spinal needle is passing through either side of
ligaments –redirect your needle away from the affected side
of the pain to get back in to the midline or inject some LA
• The patient complains of pain during needle injection of the
spinal solution
–stop injection and change the position of the needle
• Assessing the block
55

COMPLICATIONS
Immediate complications
-Toxicity
Causes of toxic reactions
• The use of the drug in a dose greater than the safe maximum for that
drug.
• The accidental injection of the correct dose into a blood vessel. This
will result in a very high blood concentration.
• The use of the correct dose in a patient who is especially sensitive to
the drug.
57

• Symptoms, signs and emergency treatment of toxic reactions
Central nervous system (CNS)
• Stimulation – tinnitus, numbness, nystagmus, restlessness,
tremor, convulsions followed by
• Depression – depressed conscious level, coma
58

• Treatment
• Give oxygen
• Give sufficient diazepam or midazolam to control the
convulsion.
• Thiopentone may also be used in a small dose (e.g.
50 mg).
• If associated apnoea, give artificial ventilation with 100%
oxygen following intubation with a dose of suxamethonium
chloride.
59

• Cardiovascular system (CVS)
• Pulse – bradycardia, arrhythmias, cardiac arrest
• Blood Pressure –hypotension, cardiovascular collapse
Treatment:
- Give IV fluids.
- Give vasopressors and atropine, if necessary.
- Give oxygen by mask.
- Watch for and be ready to treat cardiac arrest.
60

• Respiratory system
• Respiratory depression, apnoea.
Treatment
- Clear airway
- Give oxygen by mask
- Assist or control ventilation
61

• Allergic phenomena (rare)
These may take the form of bronchospasm, urticaria,
hypotension, etc.
Reaction to vasoconstrictor drugs
Pallor, tachycardia, palpitation, hypertension.
62

Generally
• Stop administering the drug
• Get senior help/assistance
• Concentrate on airway, breathing and circulation (ABC)
• Provide oxygen by a face mask
• If unconscious, perform tracheal intubation
• If intubated, commence ventilation to ensure that patient does
not develop respiratory acidosis. (Acidosis worsens toxicity)
• Ensure adequate IV access and commence fluid resuscitation
63

• If patient develops seizures, treat with diazepam or small
doses of thiopentone or propofol
• If patient develops cardiac arrest, perform CPR. CPR may need
to be performed for a long time and may require multiple
trained assistants to take turns
• In a cardiac arrest, administer lipid emulsion (Intralipid ® ), if
available. Continue CPR throughout treatment with Intralipid
64

Lipid emulsion
• Give a bolus of 1.5 ml/kg IV over 1 minute, and
• Commence an infusion at 15 ml/kg/h If cardiac stability not
achieved. Then,
• Repeat bolus injection twice at 5-minute intervals, and
• Increase the infusion rate to 30 ml/kg/h
• Continue CPR and the intralipid infusion until a stable
circulation is established
• Maximum dose: 12 ml/kg (840ml)
65

For a 70 kg man:
Initial bolus: 100 ml of 20% Intralipid over 1 minute, and
Commence an infusion at 1000 ml/hr.
After 5 minutes: repeat bolus of 100 ml.
Maximum: 3 boluses in total and increase the infusion rate to
2000 ml/hr.
66

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
– The sympathetic nerves to the heart may be blocked.
67

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 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
68

• 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 atropine IV if the hypotension is associated with a
bradycardia
• Always exclude and treat aorto-caval compression in
obstetric patients
69

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.
70

Nausea and vomiting
 Due to a variety of causes.
 Always attempt to find out the cause.
 It may be associated with any of the following:
• Hypotension
• Hypoxia.
• Traction on the nerve endings by the surgeon.
• Morphine or pethidine given as pre-medication.
• Nervousness, fear,
71

Treatment
 Treat the cause.
-The main cause of nausea is hypotension.
- Re-assurance.
- Encourage deep breathing.
- Metoclopramide (Maxalon) 10 mg IV or IM.
- Ondansetron 4 mg. IV
-Scopolamine
72

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.
73

Total spinal
 Complete spinal block is caused by local anaesthetic
interfering with the normal neuronal function in the
cervical spinal cord and brain stem.
• 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
74

• 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.
75

Treatment
• is supportive until the spinal wears off:
- Ventilation with facemask or LMA.
- Tracheal intubation and IPPV (with sedation).
- Treat hypotension with fluid +/– vasopressor.
• Early recognition is vital as block progression may be
mitigated (reverse trendelenberg/head raised) or serious
cardio-respiratory compromise avoided.
76

FEATURE MANAGEMENT
Bradycardia Vagolytics eg. atropine
Hypotension Sympathomimetics eg.
ephedrine, adrenaline
Vasopressors eg. metaraminol,
phenylephrine Fluid boluses
Leg elevation
Respiratory dysfunction Oxygenation Intubation and
ventilation
Loss of consciousness Secure airway , supportive
measures
77

Shivering
Post-anesthetic shivering is spontaneous, involuntary , rhythmic ,
oscillating, tremor-like muscle hyperactivity that increases metabolic heat
production after general or regional anesthesia.
The probable mechanisms could be decrease in core body temperature
secondary to:
– sympathetic block;
– peripheral vasodilatation;
– Increased cutaneous blood flow, which leads to increased heat loss
through skin;
– cold temperature of operation theatre; rapid infusion of cold IV fluids;
and effect of cold anaesthetic drugs upon the thermo sensitive
receptors in the spinal cord
78

Management
Two approaches in the management of PAS:
1) Non-pharmacological methods and
 minimising redistribution of heat;
(ii) cutaneous warming during anaesthesia: Passive
insulation/Active warming
(iii) internal warming
79

Later complications
PDPH
• Post-partum headache is the complaint of headache and neck or
shoulder pain in the first 6 weeks
• Not all post headache is PDPH, and as anaesthetists are asked to
review patients often, it is important to be aware of the
differential diagnoses
80

PATHOGENESIS
CSF leakage into the epidural space via a tear in the dura.
CSF loss leads to a reduction in intracranial pressure and
downward traction on pain-sensitive intracranial
structures(veins, meninges and cranial nerves) resulting in a
headache that is classically worse in the upright position.
The fall in intracranial pressure may also cause compensatory
cerebro-vascular venodilation and this may contribute to the
development of the headache
81

Differential diagnosis
Infective: Meningitis, Encephalitis
Pharmacological/Metabolic:
Dehydration and Caffeine withdrawal
Vascular: Migraine, Cerebral vein thrombosis,
Cerebral infarction, Subdural haematoma &
Subarachnoid haematoma
82

A history and examination should be performed taking
account of the timing of the headache in relation to the
neuraxial procedure, the nature of the headache as
well as other symptoms and signs.
In the case of a headache following a spinal procedure,
PDPH is more likely following dural puncture with a
larger gauge ‘cutting’ tipped needle or after multiple
attempts, increasing the chance of a CSF leak.
83

Classic features of the headache caused by dural puncture:
Headache is often frontal-occipital.
Most headaches do not develop immediately after dural
puncture but 24-48 hours after the procedure with 90% of
headaches presenting within 3 days.
The headache is worse in the upright position and eases when
supine.
It is relieved by increasing abdominal pressure.
Associated symptoms: neck stiffness, photophobia, tinnitus,
visual disturbance and cranial nerve palsies
84

• The incidence of spinal headaches is related to the size of
the needle
85
Needle size
Incidence of
headaches
20G
22G
25G
26G
10–20%
8–15%
2–5%
<1%

Factors That May Increase the Incidence of Post–spinal
Puncture Headache
Age Younger more frequent
Gender Females > males
Needle size Larger > smaller
Pregnancy More when pregnant
Dural punctures (no.) More with multiple punctures
86

• 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.
87

Management
Conservative Management: Most post-dural puncture
headache will resolve spontaneously.
Conservative management has traditionally involved bed
rest and fluids though there is little evidence to support
either of these measures.
Simple analgesia should be instituted in all patients with
PDPH; regular paracetamol and non-steroidal anti-
inflammatory medications may control symptoms
adequately
88

Caffeine:
Caffeine was first reported as a treatment for PDPH in
1949.
Caffeine is a central nervous system stimulant and is
thought to influence PDPH by inducing cerebral
vasoconstriction.
Doses from 75 – 500 mg have been investigated and
caffeine has been administered orally, intramuscularly and
intravenously.
Caffeine is associated with adverse events including
cardiac arrhythmias and seizures
89

• Epidural blood patch (EBP) after observation that patients
blood spinal tap at lumbar puncture were less likely to
develop PDPH.
• the first epidural blood patch was performed in 1960 by
the American surgeon, Dr James Gormley.
• Just 2 ml of the patient’s blood was injected during the
first epidural blood patch and the headache was relieved.
90

Epidural blood patching involves injection of autologous
blood into the epidural space.
It remains one of the few proven treatments of PDPH
The resulting blood clot may have a “patch effect” on the
dural tear while the volume of blood transfused into the
epidural space raises intracranial pressure and reduces
ongoing CSF leak.
91

EBP should be performed by two personnel, one an
experienced anaesthetist, the other competent in taking
a volume of blood from the arm.
Both should employ full aseptic precautions.
Contraindications to EBP include:
- Sepsis,
- Coagulopathy and
- Patient refusal.
92

EBP is likely to be most effective if performed at least 24
hours after the onset of PDPH.
Volumes of between 20-60mls of blood have been
used.
Optimal volume is unknown but current
recommendations suggest 10 to 20ml should be
injected
93

If the patient reports discomfort in the back during the
procedure the injection should be stopped.
The patient should lie flat for 1-2 hours after the procedure.
There is no evidence that bed rest for longer than this time is
beneficial.
94

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)
95

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.
96

The advantage of spinal anesthesia over GA
• Minimal cost
• Patient satisfaction
• Reduced Respiratory disease- as long as high blocks are
avoided
• Patent AW
• Muscle relaxation
• Minimal bleeding
97

• Simple technique
• Splanchnic blood flow-increased blood flow to the gut ,so
reduce incidence of anastomotic dehiscence
• Post op analgesia
• Prevent production of stress hormone-stress free
• Avoids risk of difficult intubation and its complication
• Increase feto-maternal bond
98

• Decrease neonatal depression due to drugs
• DM-gut functions rapidly return to oral feeding and
insulin
• Less post op. deep vein thrombosis and pulmonary
embolism
• Decreased risk of air way obstruction or aspiration of
gastric contents
99

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Spinal anesthesia 1