PREDICTING DIFFICULT

NEURAXIAL BLOCK

Dr Divesh Arora

Consultant Anesthesiologist
 INTRODUCTION
Anticipated technical difficulty can influence the
anesthesiologist’s decision to perform neuraxial block.

Multiple attempts at needle placement might lead to:*

•Patient discomfort
•Higher incidence of spinal hematoma
•PDPH
•Trauma to neural structures
*Horlocker TT et al. A retrospective review of 4767 consecutive spinal
anesthetics:CNS complications. Anesth Analg 1997;84:578-84
• Limited work has been carried out to
predict difficult neuraxial block

• Scoring system to predict difficult

neuraxial block ?

• Reliability of the predictive factors and

scoring systems
 FACTORS PREDICTIVE OF
DIFFICULT NEURAXIAL BLOCK
• Age
• Sex
• Weight
• BMI
• Body habitus
• Spinal bony landmarks
• Spinal bony deformity
• Previous spine surgery
• Radiological characteristics of vertebrae
 PATIENT
CHARACTERISTICS
• Age: degenerative
changes, osteophytes

• Sex: Osteoarthritis
and lordosis more
prevalent in females

• BMI:Distribution of fat
 Body Habitus*

• Normal
• Thin
• Muscular
• Obese
*Sprung et al. Predicting the difficult neuraxial block: A prospective
study. Anesth Analg 1999;89:384-9.
 Spinal Bony Landmarks*

• Grade I: Spinous processes visible

• Grade II: Spinous processes not visible but
palpable
• Grade III: Spinous processes not visible
and not palpable
• Grade IV: No Landmarks
*Chien I et al. Spinal process landmark as a predicting factor for
difficult epidural block. Kaohsiung J Med Sci Nov
2003;19(11):563-8
SPINAL BONY DEFORMITY

LORDOSIS SCOLIOSIS
KYPHOSIS ANKYLOSING
SPONDYLITIS
 Previous Spine surgery

• Post operatively
anatomical as well
as degenerative
changes occur in
spine
• Limited spread of LA
due to adhesions
• X Ray spine is of
value
Radiological Characteristics of
Vertebrae

• Presence / Absence
of osteophytes
• Ligament
Calcification
• Narrow Intervertebral
spaces
• Spinal bony deformity
• Identification of the
entry point
• Skin crease serves
as a landmark
• Approximate depth
of epidural /
subarachnoid space
 DIFFICULTY SCORE FOR
NEURAXIAL BLOCK *
0 1 2 3

Age(yr) 20-40 41-60 >60 ---

BMI(Kg/m2) <22 22-27 27-34 >34

Spinal Bony Clear Unclear --- ---

Landmarks
Spinal Bony No Yes --- ---
Deformity
Radiology Of Easy Difficult --- ---
Vertebrae

*Atallah et al. Development of a difficulty score for spinal anesthesia. Br J Anaesth 2004;92:354-60
 TECHNICAL DIFFICULTY

• Each new skin puncture is counted as a

new attempt
• Redirection of needle in the ligaments
• Change of intervertebral space
• Time required for the completion of
procedure
• Patient Discomfort
 RELEVANT STUDIES
Sprung et al. Predicting the difficult neuraxial
block: A prospective study. Anesth Analg
1999;89:384-9.

• BMI weakly related

• Quality of landmarks correlates best
• Patient characteristics not associated with difficulty
 Filho et al. Predictors of successful
neuraxial block: A prospective study. Eur
J Anaesthesiology 2002 June;19(6):447-51

• Anatomical landmarks, Patient positioning,

Experience of Anesthetist are independent
predictors of success.

• Patient characteristics are minor predictors.

Chien I et al. Spinal process landmark as a
predicting factor for difficult epidural block.
Kaohsiung J Med Sci Nov 2003;19(11):563-8

• Spinal landmark grading system is

valuable.

• Deformed spinal anatomy and body

habitus correlates with the number of
attempts required.
 OUR EXPERIENCE
• High volume joint replacement unit
• CSE is the mainstay anesthesia
technique
• X Ray lumbosacral spine is routinely done
• Prospective study on this topic is being
conducted by our unit
• Detailed analysis is yet to be completed
• Age: younger the better
• Sex: more difficult in females
• BMI: Distribution of fat is more
important
• Spinal bony landmarks palpation in
conjunction with radiological
characteristics of spine correlates with
technical difficulty
• Deformity of spine increases the
number of attempts
 How To Make Difficult
Neuraxial Block Successful
As the quality of anatomical landmarks cannot
be changed special attention should be given
to the following:
• Explanation of the procedure to the patient
• Proper patient positioning
• Experience of anesthesia provider
• Paramedian or taylors approach
USE OF C ARM
USE OF USG
 CONCLUSION

Examination of patients back for the:

• Quality of landmarks
• Spinal deformity
And radiology of spine are the most reliable
methods of determining the ease or
potential difficulty in performing the
neuraxial block