FACTORS AFFECTING LEVEL OF

BLOCK IN SPINAL AND EPIDURAL

ANESTHESIA
Dr. SHIKHA SHAH
 SPINAL ANESTHESIA
• Drug factors
1. Dose,
2. Baricity
3. Volume
4. Concentration
5. Temperature of injection
6. Viscosity
7. Additive other than opoids
• Patient factors
1. CSF volume
2. Advanced age
3. Pregnancy
4. Weight, height
5. Spinal anatomy
6. Intraabdominal pressure
7. Menopause
8. gender
• Procedure factors
1. Patient position
2. Epidural injection post spinal
3. Level of injection (hypobaric more than
hyperbaric)
4. Fluid currents
5. Needle orifice direction
6. Needle type
 DRUG FACTORS
Baricity :
• Baricity is defined as the ratio of the density
(mass/volume) of the local anesthetic solution
divided by the density of CSF, which averages
1.0003 ± 0.0003 g/mL at 37°C.
• Solutions that have the same density as CSF have
a baricity of 1.0000 and are termed isobaric.
• Solutions that are more dense than CSF are
termed hyperbaric, whereas solutions that are
less dense than CSF are termed hypobaric.
• solutions with a baricity <0.9990 can be expected
to reliably behave hypobarically in all patients.
• Hypobaric solutions are typically prepared by
mixing the local anesthetic solution with distilled
water.
• Solutions with a baricity of ≥1.0015 can be
expected to reliably behave hyperbarically.
Hyperbaric solutions are typically prepared by
mixing the local anesthetic in 5 to 8% dextrose.
• The baricity of the resultant solution depends on the
amount of dextrose added; however, dextrose
concentrations between 1.25 and 8% result in
equivalent block heights.
• Baricity is important in determining local
anesthetic spread and thus block height because
gravity causes hyperbaric solutions to flow
downward in CSF to the most dependent regions
of the spinal column, whereas hypobaric
solutions tend to rise in CSF.
• In contrast, gravity has no effect on the
distribution of truly isobaric solutions. Thus, one
can exert considerable influence on block height
by choice of anesthetic solution and proper
patient positioning.
• Spinal block can be restricted to the sacral and low
lumbar dermatomes (“saddle block”) by administering
a hyperbaric local anesthetic solution with the patient
in the sitting position or by administering a hypobaric
solution with the patient in the prone jackknife
position.
• Similarly, high thoracic to midcervical levels of
anesthesia can be reached by administering hyperbaric
solutions with the patient in the horizontal and
Trendelenburg positions or by administering hypobaric
solutions with the patient in a semisitting position.
• The sitting, Trendelenberg, and jackknife positions
have marked influences on the distribution of
hypobaric and hyperbaric solutions because these
positions accentuate the effect of gravity.
• While the patient is turned laterally, gravity has a
small but measurable effect on local anesthetic
distribution in that hyperbaric solutions will produce
a denser, longer lasting block on the dependent side,
while hypobaric solutions will have the opposite
effect.
• This makes hypobaric solutions ideal for unilateral
procedures performed in the lateral position (e.g.,
hip surgery).
• Hyperbaric solutions can be used to advantage for
unilateral procedures performed in the supine
position if the operative side is dependent during
drug injection and the patient is left in the lateral
position for at least 6 minutes.
Dose , volume and concentration
• Dose = volume x concentration
• Dose is most reliable determinant of local
anesthetic spread and thus the block height.
• Doses of hyperbaric 0.5% bupivacaine <10 mg
results in blocks that are approximately two
and one-half dermatomes lower than those
achieved with doses >10 mg.
Injection site
• The site of injection can have an important
effect on block height in some situations.
• By moving from the L3-4 to the L4-5
interspace means block height could be
reduced from T6 to T10 when using isobaric
0.5% bupivacaine.
 Patient factors
• Patient characteristics include height, weight,
age, sex , pregnancy , anatomic configuration
of the spine, and the CSF properties (volume
and composition).
• Within normal sized adults , patient height
does not seem to affect the spread of spinal
anesthesia. This is likely because the length of
the lower limb bones rather than the vertebral
column contributes most to adult height.
• The CSF volume is an important patient
related factor the significantly influences peak
block height and regression of sensory and
motor blockade.
• Lumbosacral CSF has a fairly constant pressure
of approximately 15cm of H2O but is volume
varies form patient to patient, in part because
of differences in body habitus and weight.
• The density of CSF is lower in women compared
with men, premenopausal compared with
postmenopausal women, and pregnant
compared with nonpregnant women.
• Advanced age is associated with increased block
height. In older patients, CSF volume decreases,
whereas its specific gravity increases. Further
nerve roots are more sensitive to local anesthetic
in the aged population.
• Gender affect block height by several
mechanism.
• CSF density is higher in males, thereby
reducing the baricity of local anestheic
solution and possibly limiting the extent of
cephalad spread.
• In the lateral position, the broader shoulders
of males relative to their hips make the lateral
position slightly more head up.
• The reverse is true in females who have a
slightly head down tilt in the lateral position
compared with males.
• Variations of spine may be an important
contributor to block height.
• Scoliosis makes insertion of the needle more
difficult, will have little effect on local
anesthetic spread if the patient is turned
supine.
• Kyphosis in a supine patient may affect the
spread of a hyperbaric solution.
• Spread of local anesthetic is enhanced by
changes in the lumbar lordosis during
pregnancy, as well as by the volume and
density of CSF, by twin pregnancies compared
with singletons, by intraabdominal pressure
increases and by a progestrone mediated
increase in neuronal sensitiviy.
 Procedure factors
• Combined with the baricity and local anesthetic
dose, patient position is the most important factor in
determining the block height.

• A 10 degree head up tilt can reduce the spread of

hyperbaric solutions without hemodynamic
compromise.
• A saddle block where only the sacral nerve
roots are anesthetized can be achieved by
using a small dose of hyperbaric local
anesthetic while the patient remains in the
sitting position for up to 30mins.
• The specific needle type and orientation of
the orifice may affect block quality.
• With hypobaric solutions, cephalad alignment of the
orifice of Whitacre, but not Sprotte, needles
produces greater spread.
• When directing the needle orifice to one side and
using hyperbaric anesthetic , a more marked
unilateral block is achieved again when using a
whitacre , rather than a Quincke needle.

• The level of injection affects block height.

• Even when the difference is only one
interspace more cephalad, the block height is
greater when using isobaric bupivacaine.
• The injection of local anesthetic or even into
the epidural space after a spinal anesthetic
increases the block height.
 Epidural anesthesia
• The epidural space is a collapsible, distensible
reservoir through which drugs spread and are
removed by diffusion, vascular transport, and
leakage.
• Spread of anesthetic within the epidural
space, and subsequent block height, is related
to a variety of factors.
• Drug factors
1. Volume
2. Dose
3. Concentration
4. Additives
• Patient factors
1. Elderly age
2. Pregnancy
3. Weight, height
4. Pressure in adjacent body cavities
• Procedure factors
1. Level of injection
2. Patient position
3. Speed of injection
4. Needle orifice direction
Drug factors
• The volume and total mass of injectate are the
most important factors.
• As a general principle, 1 to 2ml of solution
should be injected per segment to be blocked.
• Additives such as bicarbonate, epinephrine,
and opioids influence onset, quality and
duration of analgesia but they do not affect
spread.
Patient factors
• There is stronger correlation with age and
block height.
• In elderly less volume is required.
• The reasons include decreased leakage of local
anesthetic through intervertebral foramina,
decreased compliance of the epidural space in
the elderly result in greater spread or an
increased sensitivity of the nerves.
• Only extremes of patient height influence
local anesthetic spread in the epidural space.
• Weight is not well correlated with block
height.
• In pregnant patients, less local anesthetic is
required to produce the same epidural space
of anesthesia.
Procedure factors
• Level of injection is the most important factor
that affects epidural block height.
• In upper cervical region , spread is mostly
caudal.
• In midthoracic region , spread is equally
cephalad and caudal.
• And in the low thoracic region, spread is
primarily cephalad.
• After lumbar epidural, spread is more
cephalad than caudal.
• The total number of segments blocked is less
in the lumbar region compared with thoracic
levels.
• Patient position also affect spread of lumbar
epidural injections, with preferential spread
and faster onset to the dependent side in the
lateral decubitus position.
• The sitting and supine position does not affect
block height.
• The head down tilt position does increase
spread in obstetric patients.
• Needle bevel direction and speed of injection
do not appear to influence the spread of
injection.
THANK YOU