Spinal Anesthesia – Best below umbilicus

What is Spinal Anesthesia?

Spinal Anesthesia is a type of regional anesthesia in which you are given an injection in your lower back with a very fine needle, and a drug is injected into the cerebrospinal fluid (CSF). The CSF is a fluid that surrounds our brain and spinal cord. The drugs injected into the CSF at the level of your lumbar spine (lower back) block the nerves that leave the spinal cord at this level and produce rapid onset of anesthesia below the level of your umbilicus.

Spinal anesthesia, along with epidural anesthesia, combined spinal-epidural anesthesia and caudal block are all subtypes of neuraxial anesthesia. Neuraxial anesthesia means anesthesia in which the anesthetic drugs are administered in close proximity to the central nervous system structures like the spinal cord

How does it feel after getting spinal anesthesia?

After you are given spinal anesthesia, you will immediately start feeling numbness, tingling, or warmth in your legs. After 3-5 minutes, your legs will become heavy and you won’t be able to lift them up. The upper level of the sensory block will be titrated by your anesthesiologist, depending on the surgery planned.

You may remain awake during the surgery or your anesthesiologist may administer you some drug to make you sleep through the procedure. This is a light sleep and you can easily be awakened from this sleep.

Can all surgeries be done under spinal anesthesia?

No, all surgeries cannot be done under spinal anesthesia. Surgeries above your ribcage are generally done under general anesthesia (GA).

Spinal anesthesia is the best form of anesthesia for any surgery below your umbilicus. This means that most lower abdominal, pelvic, perineal, rectal, lower limb or spine surgeries can be done under spinal anesthesia. Although upper abdominal surgeries can also be done under spinal anesthesia, there is usually some discomfort and needs additional sedation or pain relief.

Some of the surgeries done under spinal anesthesia include:

• Orthopedic surgeries of the pelvis and lower limbs. For example, surgeries of the pelvic bones, femur, tibia, fibula, knee, ankle and foot.
• Hip and knee replacement surgeries
• Obstetric surgeries like cesarean section and hysterotomy.
• Gynecological surgeries like hysterectomy (removal of uterus), myomectomy (removal of fibroids from uterus), ovarian cystectomy (removal of ovarian cysts).
• Genito-urinary surgeries like Pyelolithotomy (removal of kidney stone), URS (removal of stone from ureters), TURP (Transurethral resection of prostate or Prostate surgery).
• Abdominal surgeries like appendicectomy, hernia repair.
• Perineal surgeries like hemorrhoidectomy, fistulectomy, anal fissure repair.
• Surgeries involving blood vessels of the legs (vascular surgeries).
• Although not the first choice, spinal anesthesia can be satisfactorily used for surgeries of the lumbar spine, like laminectomy and discectomy, microdiscectomy etc.

Preparation for spinal anesthesia

If you are having an elective surgery, you will be asked to:

• Have your last meal in the night by 10 pm and to come empty stomach the next morning, as a fasting of 8-10 hours is considered ideal for any procedure.
• You will be given certain medications which reduce acidity and anxiety to be taken on the night before surgery and may be in the morning too.
• You will be asked to stop taking any blood thinners or aspirin 5-7 days before your surgery, depending the particular drug being used. You will be asked to continue taking certain drugs without interruption till the morning of your surgery like medicines for your blood pressure, thyroid disorders, asthma, epilepsy etc. You may be asked to omit certain drugs on the morning of your surgery, like medicines for diabetes.
• In the hospital, you will be seen by an anesthesiologist which will take a detailed history, do a thorough physical examination and go through all your investigations. This is called Pre-anesthetic checkup and is done to check your fitness for surgery. It may be done a few days before surgery or on the day of your surgery, depending on the type of surgery (whether major or minor), presence of any previous medical conditions and the hospital policies.
• Once your anesthesiologist finds you fit for surgery, he will explain the choice of anesthesia for you. In this case, he will explain the procedure of spinal anesthesia and answer all your questions regarding the same.
• After this, you will be sent to operation theatre.

How is spinal anesthesia given?

• When you are in the operation theatre, first a monitor will be attached to your body and your vital parameters (heart rate, blood pressure, oxygen saturation) will be checked.
• The anesthesiologist or Anesthesia technician will insert a venous cannula in one of the veins of your hand or arm and start an intravenous line.
• After this, you may be turned to one side (lateral decubitus position) or made to sit up on the side of operating table (sitting position). In either case, you will be asked to bend completely, so that your spine becomes C-shaped and your lumbar intervertebral spaces open up. An assistant will help you to bend so as to make a C-shaped curve of your spine.
• Then your anesthesiologist will insert a very fine needle in the space between the lumbar vertebrae in your back, and inject the anesthetic drug into a space called subarachnoid space which contains the cerebrospinal fluid (CSF). The CSF is present in and around your brain and spinal cord. The anesthetic drugs injected in the CSF at lumbar level temporarily blocks all nerves at and below this level for 3-4 hours, providing excellent anesthesia for any surgery below your umbilicus.

It’s very important to stay still and not move during the procedure as this procedure is dependent on good positioning. You will only feel a slight prick, just like a pinch. It’s not painful; so do not get anxious and do not move. Movement can disturb the anatomy and the needle may not go into the right track.

What are the benefits of spinal anesthesia?

Spinal anesthesia is one of the most extensively studied and the most commonly performed procedures in anesthesia. It offers many advantages over general anesthesia (GA):

• It offers distinct advantage over general anesthesia as it avoids airway instrumentation required for general anesthesia, with lesser chances of sore throat or chest infection.
• It avoids the effect of drugs on the whole body, thereby having lesser systemic side effects.
• The patient can remain awake during the procedure.
• Lesser incidence of nausea, vomiting, and other side effects associated with general anesthesia.
• Early return of oral intake and bowel function.
• Benefits of good muscle relaxation with lesser bleeding for the surgeon.
• Pain relief continues in the postoperative period, unlike general anesthesia where pain relief ends immediately when the patient wakes up.
• Avoids the risks of general anesthetic drugs in high-risk populations like in patients with chronic kidney disease, liver disease, hypertension, old age etc.
• Much more cost-effective as compared to general anesthesia.
• Quicker recovery and shorter hospital stay as compared to GA.
• Spinal anesthesia is the choice of anesthesia in cesarean section as all pregnant patients are considered full stomach and are high risk of aspiration in GA. Moreover, pregnant patients have varying degrees of airway edema and a more difficult airway as compared to general population.

What are the complications of spinal anesthesia?

Spinal anesthesia is extremely safe with a very low complication rate in experienced hands. However, following are some complications that can occur with spinal anesthesia:

• You will not be able to feel or move your legs for about 3-6 hours after the surgery. This is not technically a complication; some patients just don’t like not being able to feel their legs.
• Low backache: Many patients complain of low backache after spinal anesthesia and some even refuse to get spinal anesthesia due to fear of low backache, even though it could have been the most appropriate anesthesia for them. However, it is a myth and the incidence of low backache following spinal anesthesia has been found to be comparable to that of general anesthesia. Some causes of backache after surgery may include surgical positioning, prolonged duration of surgery, muscle spasm due to prolonged bed rest in fixed positions, inability to turn to one side etc.
• Peripheral nerve injuries: The incidence of severe or permanent nerve injuries after spinal anesthesia is very low. When they occur, they may manifest as sensory loss like persistent loss of sensation or persistent paresthesias in localized areas, and rarely with motor loss like foot drop.
• Spinal headache: Some patients have a headache on the second or third day of their surgery due to spinal anesthesia. This complication is very infrequent nowadays as the needles used for spinal anesthesia are very thin and the postoperative protocols are excellent. These include nursing flat in bed for 24 hours, liberal intravenous fluids and painkillers.
• Infection: If due aseptic precautions are not observed, infection of a covering of the brain (meninges), can occur and is called meningitis. This is a serious complication but fortunately very rare now due to use of disposable equipment and good anesthesia care by qualified and trained anesthesiologists.
• Hematoma: Injury to any blood vessel during the needle puncture can cause a hematoma around the nerves in the back, leading to weakness in the legs. With extremely fine needles used nowadays, this complication is also very infrequent.
• Spinal anesthesia leads to a fall in heart rate and blood pressure. These are physiological effects of the sympathetic blockade caused by the spinal anesthesia. These are easily correctable with drugs and your anesthesiologist will take care of it, as and when needed.

Carry home message

Spinal anesthesia is a type of regional anesthesia which offers excellent surgical conditions for any surgery below the umbilicus. It offers significant advantages over general anesthesia and should be preferred in all cases where it is feasible and not contraindicated. Most of the myths associated with spinal anesthesia have no rational basis and should not deter you from opting spinal anesthesia.

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