Overview
Spinal anesthesia involves the injection of local anesthetic and/or opioids into the subarachnoid space to provide anesthesia and analgesia for surgical procedures below the level of injection. It is a form of neuraxial anesthesia that blocks sensory, motor, and autonomic function.
Spinal anesthesia is a cornerstone of regional anesthesia practice, providing excellent surgical anesthesia and post-operative analgesia. It offers advantages over general anesthesia including reduced blood loss, better post-operative outcomes, and preservation of consciousness. Mastery of this skill is essential for anesthesia practice.
Learn more in our comprehensive RxDx Anesthesia Course
Indications
Hip, knee, foot, and ankle procedures
Surgical anesthesia for cesarean delivery
Transurethral procedures, cystoscopy
Hysterectomy, pelvic procedures
Anal, rectal, and perineal procedures
Appendectomy, hernia repair
Lower extremity vascular procedures
Lower extremity orthopedic procedures
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, spine anatomy, neurological examination), equipment check (spinal needle, local anesthetic, monitoring), informed consent, and understanding the anatomy of the subarachnoid space and surrounding structures.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, perform neurological examination, check coagulation status, and obtain informed consent. Position patient in sitting or lateral position.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing contraindications
- Poor positioning
💡 Pro Tip:
Always check coagulation status and perform thorough neurological examination before procedure.
Step 2: Equipment Preparation
Prepare spinal needle, draw up local anesthetic, prepare sterile field, and ensure adequate monitoring.
⚠️ Common Mistakes to Avoid:
- Incomplete equipment check
- Wrong local anesthetic concentration
- Poor sterile technique
💡 Pro Tip:
Use appropriate local anesthetic concentration and volume for the planned surgery.
Step 3: Sterile Technique
Perform sterile preparation with antiseptic solution, drape the area, and maintain strict aseptic technique throughout the procedure.
⚠️ Common Mistakes to Avoid:
- Inadequate sterile technique
- Poor skin preparation
- Contamination
💡 Pro Tip:
Maintain strict aseptic technique to prevent meningitis or epidural abscess.
Step 4: Needle Insertion
Insert spinal needle through skin, subcutaneous tissue, and ligaments until CSF flow is obtained.
⚠️ Common Mistakes to Avoid:
- Wrong needle angle
- Too deep insertion
- Poor technique
💡 Pro Tip:
Use midline approach and advance needle slowly. CSF flow confirms subarachnoid space.
Step 5: CSF Confirmation
Confirm CSF flow, aspirate to ensure proper needle position, and prepare for local anesthetic injection.
⚠️ Common Mistakes to Avoid:
- False CSF flow
- Blood contamination
- Poor aspiration
💡 Pro Tip:
Always confirm clear CSF flow before injection. Blood indicates epidural space puncture.
Step 6: Local Anesthetic Injection
Inject local anesthetic slowly, monitor for complications, and remove needle.
⚠️ Common Mistakes to Avoid:
- Rapid injection
- Wrong dose
- Needle movement during injection
💡 Pro Tip:
Inject slowly over 10-15 seconds. Monitor for signs of high spinal or toxicity.
Step 7: Block Assessment
Assess block level, monitor for complications, and position patient appropriately.
⚠️ Common Mistakes to Avoid:
- Inadequate monitoring
- Poor block assessment
- Wrong positioning
💡 Pro Tip:
Monitor block level every 5 minutes initially. T4 level is adequate for most procedures.
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Post-procedure Care
Post-procedure care includes monitoring for complications (hypotension, respiratory depression, post-dural puncture headache), assessment of block level, management of side effects, and documentation of the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Post-dural puncture headache | 1-3% | Severe headache, worse on sitting/standing, photophobia, nausea | Bed rest, hydration, caffeine, epidural blood patch | Use small-gauge pencil-point needles, proper technique |
| Hypotension | 20-40% | Decreased blood pressure, dizziness, nausea, bradycardia | IV fluids, vasopressors, Trendelenburg position | Preload with IV fluids, monitor blood pressure closely |
| High spinal | 1-2% | Respiratory depression, bradycardia, loss of consciousness | Airway management, vasopressors, supportive care | Proper dose calculation, slow injection, monitoring |
| Failed block | 3-8% | Inadequate anesthesia, patchy block, patient discomfort | Supplement with local anesthetic, convert to general anesthesia | Proper technique, adequate dose, correct positioning |
| Back pain | 5-15% | Localized back pain, tenderness at insertion site | Analgesics, time, reassurance | Gentle technique, proper positioning, adequate analgesia |
| Neurological complications | <0.01% | Paresthesia, weakness, bowel/bladder dysfunction | Neurological consultation, MRI, monitoring | Proper technique, avoid multiple attempts, patient selection |
Clinical Pearls
Always check coagulation status before spinal anesthesia - safety first.
Use pencil-point needles - they reduce post-dural puncture headache.
Confirm CSF flow before injection - clear, colorless fluid is essential.
Monitor for complications continuously - especially in the first 30 minutes.
Document procedure details including level, complications, and outcomes.
Practice sterile technique religiously - meningitis is devastating.
Be prepared for high spinal - have airway equipment ready.
Check block level regularly - inadequate block requires supplementation.
Use appropriate local anesthetic dose - higher dose for longer procedures.
Spinal anesthesia provides excellent post-operative analgesia.