Spinal

Spinal anesthesia in orthopedic surgeries presents challenges, especially concerning the choice of anesthetic agents and their adjuncts, which affect analgesia quality and potential side effects. This study was conducted with the aim of determining the effects of intrathecal bupivacaine, meperidine and magnesium sulfate on hemodynamic parameters, onset and duration of sensory/motor block in spinal anesthesia in patients with lower limb fractures.

This double-blind, randomized clinical trial included 130 patients who were candidates for planned lower limb orthopaedic surgery. They were divided into four groups: 1: bupivacaine 10 mg, 2: meperidine (1 mg/kg), 3: bupivacaine 10 mg + magnesium sulfate of 100 mg, and 4: meperidine (1 mg/kg) + magnesium sulfate with (100 mg). Parameters measured included hemodynamic status and sensory and motor block onset and duration. The level of sensory block was assessed via the pinprick sensation method, while the Bromage scale was used to evaluate motor block.

No clinically significant differences in hemodynamic parameters were observed across the groups. The onset of sensory block (P value= 0.235), onset of motor block (P value= 0.097), and duration of motor block (P value= 0.135) were statistically similar across the groups. However, significant differences were found in the duration of the sensory block (P value= 0.035). Magnesium sulfate increased the duration of motor block in the meperidine group (80.93 ± 30.28 minutes). However, it reduced the duration in the bupivacaine group (75.23 ± 38.56 minutes) Motor block onset was prolonged in groups receiving magnesium sulfate, with a significant difference between the meperidine and meperidine with magnesium sulfate groups (CI = 1.10 to 12.52, P value = 0.04).

The intrathecal drugs used did not produce significant side effects, suggesting that they can be used interchangeably... However, magnesium sulfate, as an adjuvant, did not enhance the length or quality of the block in spinal anesthesia when used with meperidine and bupivacaine.

Post-dural puncture headache (PDPH) is the most common complication following spinal anesthesia among parturients undergoing cesarean section surgery. The purpose of this study was to evaluate the effectiveness of acetaminophen and caffeine in preventing PDPH.

This double-blind, randomized clinical trial was conducted on 96 obstetric women, who were candidates for elective cesarean section. Following the randomization of participants into two groups, participants in the intervention group received tablets of acetaminophen (500 mg)+caffeine (65 mg), and participants in the control group received placebo tablets orally 2 hours before spinal anesthesia induction and then every 6 hours after surgery up to 24 hours. All parturients were evaluated for frequency and intensity of PDPH every 6 hours until 24 hours after surgery and then 48 and 72 hours after surgery. Overall satisfaction during the first 72 hours of postpartum was evaluated. The data were analyzed using SPSS software. P<0.05 was considered statistically significant.

Participants in the intervention group were 70% less likely to experience PDPH after spinal anesthesia (OR=0.31 P=0.01, 95% CI [0.12-0.77]). They also experienced significantly milder headaches 18 hours, 48 hours, and 72 hours later. Participants in the intervention group reported higher levels of satisfaction at the end of the study (P=0.01). No side effects related to the intervention were reported.

Prophylactic administration of acetaminophen+caffeine decreases 70% the risk of PDPH and significantly attenuates pain intensity in obstetric patients who underwent spinal anesthesia for cesarean section.

Prolonged predelivery time in cesarean-section (C-section) may be associated with worse neonatal outcomes such as lower umbilical cord acid-base profile. This study investigated the association between surgical and anesthetic predelivery time intervals and neonatal acidosis in pregnant women delivering via C-section under spinal anesthesia.

This cross-sectional study was conducted on 70 pregnant women candidates for elective cesarean C-section, referred to Yas Hospital.

Umbilical artery pH<7.3 was observed in 27 (38.6%) out of 70 included participants. The study variables including maternal age, hypertension, and gestational diabetes were not associated with umbilical pH level. 1-minute Apgar scores were linearly associated with pH (β: 0.170, 0.100 to 0.239, p-value<0.001). Among all evaluated surgical and anesthetic intervals, induction of spinal anesthesia to delivery (β: -0.008, -0.012 to -0.004, p-value<0.001), and skin incision to uterine incision interval (β: -0.006, -0.009 to -0.002, p-value=0.002) interval time had a significant linear association with PH.

The duration of induction of spinal anesthesia to delivery and skin incision to the uterine incision in non-emergent C-sections is linked to lower neonatal umbilical pH which shows the importance of optimizing the timing of elective C-section surgeries and reducing the risk of neonatal acidosis for obstetricians and anesthesiologists.

 Spinal anesthesia is considered to be the safest method of anesthesia for cesarean sections in patients with preeclampsia. Patients with preeclampsia are at an increased risk of experiencing severe hypotension following spinal anesthesia, which could have more profound and deleterious effects on both the fetus and the mother. However, bupivacaine, the most commonly used drug, can induce severe hypotension even at low doses. The purpose of this study is to minimize post-spinal hypotension in both the mother and the fetus.

 To determine and compare the reduction in hypotension following spinal anesthesia in patients with preeclampsia between the ropivacaine and bupivacaine groups.

 In a randomized clinical trial, a total of 90 parturients with preeclampsia undergoing spinal anesthesia were enrolled and randomly divided into 2 groups: One receiving ropivacaine and the other receiving bupivacaine. The dose of spinal ropivacaine was 15 mg of a 0.5% solution, and the dose of bupivacaine was also 15 mg of a 0.5 % solution. Hemodynamic parameters, including systolic and diastolic blood pressure and heart rate, were recorded following the administration of spinal anesthesia. Pain scores and the time until the return of motor movement were also documented.

 For statistical analysis, the t-test, Chi-square, and ANOVA tests were utilized to compare the groups. Demographic variables, including maternal age, gestational age, parity, and gravidity, were not significantly different between the 2 groups. The trend of mean systolic blood pressure (SBP) was significantly lower in the bupivacaine group compared to the ropivacaine group at all measured time points in the study (P < 0.05). The amount of ephedrine used after spinal anesthesia was significantly different at 2 and 4 minutes in the ropivacaine group compared to the bupivacaine group (P = 0.012, P = 0.025). Post-operative pain scores at 1 hour in recovery were not significantly different between the ropivacaine and bupivacaine groups (P = 0.015). The time to knee movement was also significantly shorter in the ropivacaine group compared to the bupivacaine group (P < 0.001).

 Ropivacaine reduces the incidence of hypotension in spinal anesthesia compared to bupivacaine for cesarean section in patients with preeclampsia. This is attributed to a lower occurrence of spinal-induced hypotension, improved hemodynamic control, reduced ephedrine usage, and faster patient ambulation. A future study could focus on investigating different dosages of both drugs with a larger number of participants.

Spinal anesthesia is one of the most common and safest methods of anesthesia. However, a challenge for patients who are candidates for spinal anesthesia is the pain caused by inserting the spinal needle. It seems possible to reduce needle pain with local pressure, based on the gate control theory in spinal anesthesia.

This clinical trial aims to evaluate the effect of applying local pressure on the intensity of pain caused by needles during spinal anesthesia.

In this study, 120 adult patients aged 18 - 50 who were scheduled for elective surgery under spinal anesthesia and had an American Society of Anesthesiologists (ASA) I-III were randomly assigned to the control and intervention groups. In the intervention group, just before inserting the spinal needle, a local pressure of about 5 kg using the thumb was applied to the skin at the needle insertion point for 15 seconds. The control group received routine anesthesia. The severity of needle pain was compared between the two groups using the verbal rating scale (VRS) tool.

The incidence of mild pain in the intervention and control groups was 78.7% and 60%, respectively. Also, the control group experienced higher levels of moderate and severe pain compared to the intervention group. In addition, patients in the control group had a higher chance (odds ratio (OR): 3.4, 95% confidence interval (CI): 1.5 - 7.8, P = 0.039) of experiencing moderate to severe pain compared to the intervention group. Pain intensity was significantly lower in patients with a spinal anesthesia history (P = 0.028).

Our findings showed that applying local pressure on the skin before inserting a spinal needle can effectively reduce pain during spinal anesthesia. However, further studies with a larger sample size are necessary to confirm the effects of applying local pressure to reduce needle pain during spinal anesthesia.

Post-dural puncture headache (PDPH) is a common side effect after spinal anesthesia.

This study aimed to compare the sedative dose of propofol and midazolam in reducing headaches after spinal anesthesia.

In order to conduct this study, 80 candidates for spinal anesthesia were divided into two groups, A and B. Both groups received spinal anesthesia with marcaine. In group A, propofol was infused slowly at a dose of 30 g per minute, and in group B, 1 mg midazolam was injected intravenously. In the two groups, the incidence and intensity of headaches were measured using the VAS pain scale. Data were analyzed using Mann-Whitney and t-tests at a significance level of 0.05.

In this study, 65% (52) were male and 35% (28) were female. There was no significant difference between the two groups in terms of demographic information (P > 0.05). In the propofol group, the incidence and severity of headaches were significantly lower than in the midazolam group (P < 0.01).

This study’s results indicated that administering low-dose propofol as a sedative during spinal anesthesia may be more effective in reducing PDPH than midazolam.

Spinal anesthesia is gaining popularity and more frequent use due to its efficacy, patient satisfaction, lower complication rates, and good durability. Nerve blocks reduce the complications and risks associated with general anesthesia and lessen the patient’s need for postoperative care compared to general anesthesia, leading to earlier patient discharge. One spinal procedure involves administering low doses for anesthesia induction. This review article explored this approach by incorporating studies reporting the administration of lower doses of the local anesthetic bupivacaine. Findings indicate that lower and conventional doses of bupivacaine have comparable sensory and motor block impacts and induction times. However, the recovery time at lower doses is faster, and patients are discharged sooner from the postanaesthetic care unit. Complications associated with spinal anesthesia are significantly decreased at lower doses of bupivacaine administration. Thus, lower doses can be used to induce spinal anesthesia successfully with minimal adverse effects.

Several adjuvants, added to local anesthetics, were suggested to induce an ideal regional block with high-quality analgesia. The purpose of this study was to evaluate the particular blocking properties of low-dose bupivacaine in combination with meperidine and fentanyl in spinal anesthesia during Cesarean sections. A randomized, double-blind clinical trial was conducted at Hafez Hospital affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) from February 2015 to February 2016. A total of 120 pregnant women, who underwent spinal anesthesia during elective Cesarean section were enrolled in the study. Based on block-wise randomization, the patients were randomly assigned to three groups, namely “B” group received 2 mL bupivacaine 0.5% (10 mg), “BM” group received 8 mg bupivacaine and 10 mg meperidine, and “BF” group received 8 mg bupivacaine and 15 µg fentanyl intrathecally. The block onset, the duration of analgesia, and the time of discharge from the post-anesthesia care unit (PACU) were all assessed. Data were analyzed using SPSS software version 21, and P<0.05 were considered statistically significant. The mean duration of motor blocks in the B group (150 min) were significantly higher than the BM (102 min) and BF (105 min) groups (P<0.0001). In both the BM and BF groups, the duration of sensory and motor blocks was the same. The length of stay in the PACU was significantly longer in the B group (P<0.001) than the BM and BF groups. When meperidine or fentanyl was added to bupivacaine, the duration of the analgesia lengthened (P<0.001).  Intrathecal low-dose spinal anesthesia induced by bupivacaine (8 mg) in combination with meperidine and/or fentanyl for Cesarean section increased maternal hemodynamic stability, while ensuring effective anesthetic conditions, extending effective analgesia, and reducing the length of stay in PACU.Trial Registration Number: IRCT2015013119470N14.

 Unilateral spinal anesthesia is often accompanied by technical difficulties in implementation, multiple puncture attempts, unsuccessful punctures, and, as a result, insufficient anesthesia, along with various complications associated with a dural puncture.

 This work compares the efficacy and safety of conventional Unilateral Spinal Anesthesia (USpA) and unilateral spinal anesthesia with electrical nerve stimulation (USpA+ENS).

 A total of 134 patients with an upcoming vascular surgery on one lower extremity were randomly assigned to two groups. All the patients were positioned with the operated limb below and used 7.5 mg of Bupivacaine-Spinal®. In the UsPA group, anesthesia was performed according to the standard technique. In the USpA+ENS group, electrical nerve stimulation was additionally used. Primary outcomes were the presence or absence of post-dural puncture headache (PDPH), number of puncture attempts, lateralization, and anesthesia adequacy. Secondary outcomes were intraoperative pain scores, the presence or absence of nausea and vomiting, and the need for hemodynamics correction.

 The frequency of puncture complications was sufficiently lower in the USpA+ENS group than in the UsPA group. The local anesthetic solution distribution, pain score indicators, and secondary outcomes were comparable in both groups with a slight difference.

 We showed that USpA+ENS reduces the incidence of puncture complications and improves the quality of anesthesia and adherence of both patients and anesthesiologists to the unilateral spinal anesthesia technique.

Spinal anesthesia is traditionally performed using landmark technique to identify the level and point of needle insertion. However use of ultrasonography (USG) has emerged among anaesthesiologists to guide neuraxial blockade. The views that are of utmost importance are “transverse spinous view”, “transverse interspinous view” and “longitudinal parasagittal oblique view”. For in-plane technique and real time imaging longitudinal parasagittal oblique view is used while transverse views are used for visualizing spinous level, epidural and subarachnoid space, posterior complex (PC), anterior complex (AC) and depth of canal. In patients with deformed spine like kyphoscoliosis or morbid obesity obtaining optimum views is not possible. We discuss a morbidly obese patient with very poor ultrasonographic views of spine. We describe a novel technique to estimate depth of spinal canal using only bony shadows in a single transverse view.

Pain control methods after cesarean section may interfere with infant breast-feeding. The aim of this study was to evaluate the effect of pethidine on breast feeding of infants born via cesarean section with spinal anesthesia.

In this randomized double-blind clinical trial, we evaluated 116 infants born via cesarean section in Gerash Amiralmomenin hospital (Southern Iran) in 2017. The subjects were selected through purposive sampling and randomly by permuted block randomization and assigned to intervention and control groups. The test group received 100 mg of pethidine as intravenous infusion and the control group received only routine cares. Infants’ breast feeding behavior in both groups was recorded within 48 hours of hospitalization, using the standard tool for rapid assessment of infant feeding behavior, which consists of 4 main components of breastfeeding, including readiness to feed, rooting, latching, and sucking with a score range of 0 to 3 for each component evaluated at 1, 6, 12, 24, 36, and 48 hours postnatally. Data were analyzed using independent t tests and chi-square test.

The highest score of breast-feeding behavior pertained to sucking reflexes in the control group and the lowest score to breast feeding readiness in the pethidine group. Readiness for feeding in the control group (2.09±0.53) was significantly higher than the pethidine group (1.81±0.61) (95% CI: 0.0552, 0.5092 and P=0.015). Sucking reflex (95% CI: -0.1461, 0.2208 and P=0.687), latching (95% CI: -0.3012, 0.0345 and P=0.118) and rooting reflexes (95% CI: -0.1685, 0.2342 and P=0.747) were almost equal in the control group (2.54±0.49, 2.52±0.38, 2.5±0.48, respectively) and pethidine groups (2.51±0.43, 2.65±0.45, 2.46±0.53, respectively). The total score of feeding behavior in the control group (9.66±1.04) was higher than that of the pethidine group (9.44 ±.69) (95% CI: -0.2032, 0.6412 and P=0.306). There was no significant difference between the infants’ feeding frequency (95% CI: -0.269, 1.930 and P=0.137) and duration of feeding (95% CI: -3.2067, 0.4597 and P=0.14).

Evaluation of infants in the first 48 hours after birth showed that those babies whose mothers received pethidine were less willing to start breast-feeding. However, other components of breast-feeding behaviors were similar.

 Recently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.

 In this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.

 In our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle (PAJUNK GmbH) at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0/9% were injected by a 25-gauge pencil-point Quincke needle (Dr. Japan Co, Ltd) at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.

 The mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.

 Spinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.

Spinal muscular atrophy is a rare genetic neuromuscular disease characterized by loss of anterior horn cells of spinal cord and brain stem nuclei, resulting in progressive muscle weakness. Anesthesia for these patients is risky because of the risk of worsening of muscle weakness and consequent postoperative respiratory complications. We report anesthesia management in a nulliparous parturient with type 3 disease who underwent urgent cesarean delivery due to progressive decline of amniotic fluid index.

Studies have reported lower pain threshold, spinal anesthesia duration, and level of sensoryblock in addicts compared to non-addict patients undergoing spinal anesthesia for surgery. Moreover, bloodgas and cerebrospinal fluid (CSF) were likely to be affected as well. The aim in the present study is to evaluateCSF and spinal parameters in addict versus non-addict patients during lower limb surgery.

In this case-control study, 22 opium addicts and 22 sex- and age- matched non-addicts undergoinglower limb surgery under spinal anesthesia were included. The CSF parameters, venous blood gas (VBG), andsensory and motor block findings were compared between the groups.

The addict and non-addict patients were similar regarding CSF and blood gas parameters excepthigher pH in VBG (7.39 ± 0.06 vs. 7.33 ± 0.11, P = 0.030) and CSF (7.39 ± 0.06 vs. 7.33 ± 0.11, P = 0.030) foraddict patients. The addict patients had significantly later onset of sensory block (5.72 ± 1.57 vs. 3.16 ± 0.93minutes, P < 0.001) and shorter motor block duration (137.72 ± 11.51 vs. 149.09 ± 14.44 minutes, P = 0.006),with no significant difference in the sensory block duration and motor block onset.

Addict patients have delayed onset of sensory block with shorter duration of motor block and lowersensory block level. Among the blood gas and CSF markers, only pH was significantly higher in addict patients,needing further evaluations; however, it seems that addiction has no significant effect on these parameters.

Spinal anesthesia is the most preferred method for cesarean section. This meta-analysis was performed to determine the effect of minimum and maximum intrathecal doses of meperidine (pethidine) [5 to 40 mg] on the maternal and newborn outcomes after cesarean section. Evidence Acquisition: The data were collected through the systematic search in the ISI, PubMed, Scopus, Google Scholar, Barakat, MagIran, SID, Irandoc, and EMBASE medical databases. Eighteen clinical trial studies with 1,494 patients were included.

Patients who had received intrathecal meperidine had experienced lower shivering, relative risk [RR] = 0.34 (95% CI = 0.23, 0.48) and longer analgesia, [standard mean difference (SMD)] = 7.67 (95% CI = 1.85, 13.49) after the surgery. Moreover, RR of nausea = 1.37 (95% CI = 1.13, 1.66), vomiting RR = 2.02 (95% CI = 1.28, 3.20), and pruritus RR = 9.26 (95% CI = 4.17, 20.58) was higher in the pethidine group than in the control group. There was no statistically significant difference in the Apgar score at one-minute RR = 0.99 (95% CI = 0.9, 1.09), at five-minute RR = 0.93 (95% CI = 0.87, 1.08), maternal hypotension RR = 1.00 (95% CI = 0.87, 1.15), and maternal sensory and motor blockade durations, SMD = -1.72 (95% CI = -3.78.0.34) and SMD = -4.38 (95% CI = -9.19, 0.44), respectively in the two pethidine and control groups.

Intrathecal meperidine can reduce shivering and increase the duration of postoperative analgesia, though it increases the relative risk of nausea, vomiting, and pruritus. No significant difference was found both in the Apgar score, maternal hypotension, and duration of the motor and sensory block.