Unilateral Spinal Anaesthesia

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Unilateral Spinal Anaesthesia

1Borghi B, MD, 2Bacchilega I, MD

1Head of Coordination of Research in Anaesthesia 2Departmental Module Coordination of Research in
Anaesthesia, IRCCS Rizzoli Orthopaedic Institute Bologna Italy
Since 1909 (1) various techniques of localised spinal analgesia aimed at restricting the spread of
somatic and sympathetic block have been described. Unilateral spinal anaesthesia was first achieved in
1947 by subarachnoid injection of a hypobaric solution with the patient placed in the lateral position
(2).
Limiting the spread of the spinal block offers many clinical advantages. First and foremost the
haemodynamic impact of spinal anaesthesia is greatly reduced, as the increased venous capacity in
affected side is compensated by a reflex vasoconstriction in the non-blocked areas. In case of successful
unilateral spinal anaesthesia the difference in levels of sympathetic block between the two sides can be
easily detected by measuring a higher temperature in the affected side, caused by a greater
vasodilatation due to the sympathetic block. Moreover, it has been demonstrated by clinical trials
comparing unilateral spinal anaesthesia with conventional bilateral spinal block that cardiac index values
are much more stable during the former than during the latter, with a smaller reduction in arterial blood
pressure and heart rate (3), and a much lower incidence of clinically relevant hypotension (5% Vs 20%).
(4) These characteristics justify unilateral spinal anaesthesia in case of elderly patients with poor
cardiovascular homeostasis. In addition, other features present advantages for fitter patients, in
particular the increased patient autonomy after surgery due to lack of motor block in the non-operated
leg. This aids nursing management, as the patient can assist with the unblocked limb and maintain
spontaneous micturition, earlier ambulation after surgery as well as improved patient well being by
avoiding the unpleasant experience of sudden, though reversible, paraplegia. Unilateral spinal anaesthesia
is indicated for all procedures involving the lower limb both orthopaedic and vascular, some operations in
the perineal area, and some general surgical procedures such as inguinal or crural hernia repair,
especially in day case surgery. In attempting to restrict spinal block to the surgical side it is mandatory to
consider various factors:

1. Density of the local anaesthetic solution

2. Patient's position during induction of spinal anaesthesia
3. Design of spinal needle
4. Speed of intrathecal injection
5. Dose of local anaesthetic solution

A difference in density between local anaesthetic solution and CSF enables the nerve roots of the
treated side to be affected selectively with the patient turned in a lateral decubitus position. The
normal density of the CSF (37C) is between 1.0001 and 1.0005 g/ml in 95% of cases. Solutions with
density < 0.9998 g/ml at 37C are considered hypobaric; solutions with density >1.00088 at 37C are
considered hyperbaric; solutions with densities between these two values at 37C are considered
isobaric.
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Table 1

1% Lidocaine
2% Lidocaine
0.25% Bupivacaine
0.5% Bupivacaine
0.5% Bupivacaine (Gluc 8%)
1% Bupivacaine (Gluc 10%)

Density Room Temperature

(24C)
0.9980
1.0000
1.0033
1.0032
1.0244
1.0450

Density Body Temperature

(37C)
0.9941
0.9950
0.9996
0.9984
1.0230
1.0350

Hypobaric solutions (density at 37C < 0.9998 g/ml) being "lighter" than CSF tend to spread towards
the nondependent side. Hyperbaric solutions containing glucose in various percentages have a density
at 37C >1.0008 g/ml and tend to spread towards the dependent side. The few studies of hypobaric
solutions available in the literature show a more predictable unilateral distribution of nerve blockade
when using hyperbaric solutions. This could be explained by the much greater measured density
difference between hyperbaric solutions and CSF in comparison with hypobaric solutions and CSF.
Hypobaric solutions are, of course, low concentration and therefore should be used in large volumes. In
addition, their density at room temperature is often > 1.008 g/ml, dropping to hypobaric levels once
injected and reaching 37C. During the time it takes for this process to occur the density may be
isobaric or even hyperbaric.
Maintaining a lateral decubitus position allows surgical anaesthesia to be restricted to the operative
side only. Before performing the dural puncture, the position of the spine must be maintained as
horizontal as possible using pillows or tilting the operating table and the dural puncture must be
performed in the most appropriate vertebral interspace. In the 5 - 10 minutes after intrathecal
injection the progression of sensory and motor block must be carefully evaluated, tilting the operating
table in a cranial or caudal direction to extend the block to other dermatomes if it is inadequate.
With regard to hypobaric solutions, the position of the operated side in a nondependent side
theoretically allows the lateral decubitus position to be maintained during the entire surgical procedure.
When using hyperbaric solutions the patient must lie on the surgical side and this may require sedation
or analgesia when turning the patient in certain situations such as femoral fracture.
Another important aspect to consider whenever trying to perform unilateral spinal anaesthesiais the
direction of the local anaesthetic solution flowing out of the spinal needle. It has been demonstrated
that the use of directional pencil point needles together with a slow injection speed (about 3 ml min1)
minimises turbulence so that anaesthetic solution and CSFmix to produce a homogeneous mixture
with balanced baricity.
Directional pencil point needles available are the Whitacre and the Sprotte type. Both have an
atraumatic non-cutting tip and a side orifice. The Sprotte type has got a longer and wider side hole:
this theoretically may help to produce a laminar flow during injection, but also may limit the success
rate of spinal anaesthesia as a part of the local anaesthetic solution can escape into adjacent
compartments during injection. During dural puncture, after the free flow of CSF is observed, the
orifice must be turned toward the operative side before starting the injection of anaesthetic solution. As
regards the size of the spinal needle, a smaller size produces greater injection speed and turbulence
and increases the risk of PDPH. In our clinical practice we prefer to use 27 Gauge Whitacre spinal
needle for young people and 25 Gauge for elderly patients.

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Type, dose and volume of local anaesthetic solutions influence the optimal duration of the lateral
decubitus position and the success of a selective block. The dose of local anaesthetic solutions injected
in the spinal canal is very important. In fact, to optimise the success rate of a unilateral spinal
anaesthetic the injected dose should be minimized and the dural puncture should be performed as near
as possible to the nerve roots involved in the surgical site. Using this technique the volume of
anaesthetic solution to be diluted with CSF is greatly reduced. Therefore, a low dose of anaesthetic is
sufficient to achieve surgical anaesthesia on operative side. Large doses cause migration of spinal block
which may occur if the patient is turned supine even1 hour after the injectionThus hypobaric solutions
require the use of large volumes. By contrast, hyperbaric solutions allow small doses to be used,
reducing the risk of "spill over" block even with a period of lateral decubitus of 10-15 min. When small
doses are used, a short duration of surgical anaesthesia should be expected and this could affect the
intraoperative success of spinal anaesthesia.
A study carried out in 2000 on 51 outpatients scheduled for knee arthroscopy compared 3 groups
using 4 mg, 6 mg or 8 mg of 0.5% hyperbaric bupivacaine. Results showed that the smaller dose (4
mg) was sufficient for good quality spinal anaesthesia lasting about 61 19 minutes and that the
criteria for discharge (in particular micturition) were met 60-90 minutes earlier than the other groups
(5). Moreover, from the analysis of the data collected, we did not find any correlation between patients'
weight and height, amount of bupivacaine received and duration of surgery . Low doses used to
perform unilateral spinal anaesthesia had a great impact on final outcome, in particular on
cardiovascular effects and on block resolution.
A study carried out in 1996 on 24 healthy volunteers with either 3.75 mg, 7.5 mg or 11.25 mg 0.75%
hyperbaric bupivacaine showed the following dose response characteristics (6)

Peak sensory level

S2 recovery (min)
Tolerance of thigh tourniquet (min)
Discharge (min)

Tolerance of thigh tourniquet

Recovery of quadriceps block
Discharge criteria

3.75 mg
T9
74 43
41 21
110 35

Duration/mg bupivacaine (min)

7 (2 - 11)
16 (14 - 19)
21 (17 - 25)

7.5 mg
T7
133 59
58 39
196 44

R
0.8
0.9
0.9

11.25 mg
T4
220 52
91 40
232 50

P
<0.0001
<0.0001
<0.0001

These dose response characteristics may be useful for outpatient procedures, as shown also by an
Italian multicenter study comparing unilateral versus conventional bilateral hyperbaric bupivacaine
spinal anaesthesia for outpatient knee arthroscopy (7).

In 100 outpatient knee arthroscopies 8 mg 0.5% hyperbaric bupivacaine was administered in 2

different ways: 50 pts needle orifice dependent, no barbotage, 15 min lateral decubitus (group USA) 50
pts needle orifice cranial, 3 barbotage, immediately supine (group Conventional)

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Surgical block

Max. sensory lev. operated side

Max. motor bl. operated side
Max. sensory lev. operated side
Max. sensory lev. operated side
2 segment regression (min)

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USA

Conventional

(n = 30)
15 5

(n = 30)
13 5

T8
(T12 - T2)
3
(2 - 3)
L2
(/ - T6)
0
(0 - 3)
96 32

T8
(T12 - T1)
3
(2 - 3)
T8
(L4 - T1)
2
(0 - 3)
89 26

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USA
(n = 30)
S2 Resolution (min)
Unassisted Ambulation (min)
Micturition (min)
Home Discharge (min)

Conventional
(n = 30)
137 49
190 58
244 91
253 86

160 41
179 59
263 98
275 103

Otherwise, in terms of mortality, morbidity and social recovery (job, hobbies,etc.) data in the literature
is not clear so far about the final outcome of unilateral spinal anaesthesia.

In conclusion,, it is very difficult to evaluate final place of unilateral spinal anaesthesia, as it has been
defined as a theoretical fiction with a clinical impact but we think it should be chosen as it allows

. No delay in readiness to surgery

. Better patient acceptance

. Better nurse acceptance

. Higher cardiovascular stability

. Rapid patient discharge

. Reduced urinary retention

Table 2

Dural Puncture (Level)

Saphenectomy

Knee- Leg Surgery

L1-L2
L2-L3

L3-L4
L4-L5

Inguinal Hernia
Repair
T12-L1
L1-L2

5-7,5

5-7,5

7,5-10

20-30

20-30

30-40

60-120

60-120

90-150

0,5% Hyperb. Bupivacaine (mg)

Injection time (sec)

Duration of Anaesthesia (min)

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References
1. Jonnesco T. Remarks on general spinal analgesia. Brit. Med. J. 2:1935, 1909
2. Lund P.C. Rumball A.C. Hypobaric pontocaine, new tecnic in spinal anesthesia. Anesthesiology;8:
270
3. Casati et al. Cardiac performance during unilateral lumbar spinal block after crystalloid preload. Can
J Anaesth 1997; 44: 623-8.
4. Casati A, Fanelli G, Aldegheri G, et al. Frequency of hypotension during conventional or asymmetric
hyperbaric spinal block. Reg Anesth Pain Med 1999; 24(3): 214-9
5. Lorenzini L, Stagni F, Borghi B et al. Prospective comparison, randomised among different doses of
0.5% hyperbaric bupivacaine in unilateral spinal anaesthesia for knee arthroscopy in day-surgery preliminary data. IMRAPT 2000; 21(3): 25
6. Dose-response characteristics of spinal bupivacaine in volunteers. Anesthesiology 1996;85:729-36
7. Fanelli G, Borghi B, Casati A, et al. Unilateral bupivacaine spinal anesthesia for outpatient knee
arthroscopy. Italian Study Group on Unilateral Spinal Anesthesia Can J Anaesth, Aug 2000, 47(8)
p746-51
Further reading
1. Vincenti E. Anestesia Spinale S.Marco Ed (Padova)1995
2. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT A low dose of plain or hyperbaric bupivacaine for
unilateral spinal anesthesia. Reg Anesth Pain Med, Nov 2000, 25(6) p605-610
3. Casati A, Fanelli G, Beccaria P, et al. Block distribution and cardiovascular effects on unilateral spinal
anaesthesia by 0,5% hyperbaric bupivacaine. A clinical comparison with bilateral spinal block. Min.
Anest. 1998;64:307-12
4. Fanelli G, Casati A, Beccaria P, et al. Bilateral versus unilateral selective subarachnoid anaesthesia:
cardiovascular homeostasis Br. J.Anaest. 1996;76:A242
5. Spinal anesthesia in outpatient knee surgery: 22-gauge versus 25-gauge sprotte needle. Anesth
analg 1995;81:73-9
6. Casati A, Fanelli G, Aldegheri G, et al. A transient neurological deficit following intrathecal injection
of 1% hyperbaric bupivacaine for unilateral spinal anaesthesia. Eur J Anaesthesiol, Jan 1998, 15(1)
p112-3
7. Meyer J, Enk D, Penner M Unilateral spinal anesthesia using low-flow injection through a 29-gauge
Quincke needle. Anesth Analg, Jun 1996, 82(6) p1188-91
8. Casati A, Coppelleri G, Fanelli G Unilateral spinal anesthesia: fact or fiction? Reg Anesth, Nov-Dec
1997, 22(6) p594-5
9. De Negri P, Borrelli F, Salvatore R, et al. Spinal anesthesia with clonidine and bupivacaine in young
humans: interactions and effects on the cardiovascular system. Minerva Anestesiol, Apr 1997, 63(4)
p119-25
10. Wemama JP, Delecroix M, Nyarwaya JB, et al. Permanent unilateral vestibulocochlear dysfunction
after spinal anesthesia. Anesth Analg, Feb 1996, 82(2) p406-8
11. Gentili ME, Mamelle JC, Le Foll G Combination of low-dose bupivacaine and clonidine for unilateral
spinal anesthesia in arthroscopic knee surgery Reg Anesth, Mar-Apr 1995, 20(2) p169-70
12. Cappelleri G, Casati A, Fanelli G, et al. Unilateral spinal anesthesia or combined sciatic-femoral
nerve block for day-case knee arthroscopy. A prospective, randomized comparison. Minerva Anestesiol,
Mar 2000, 66(3) p131-6; discussion 137
13. Spivak H, Nudelman I, Fuco V, et al. Laparoscopic extraperitoneal inguinal hernia repair with spinal
anesthesia and nitrous oxide insufflation. Surg Endosc, Oct 1999, 13(10) p1026-9
14. Kuusniemi KS, Pihlajamaki KK, Irjala JK, et al. Restricted spinal anaesthesia for ambulatory
surgery: a pilot study. Eur J Anaesthesiol , Jan 1999, 16(1) p2-6
15. Casati A, Fanelli G, Beccaria P, et al. Block distribution and cardiovascular effects of unilateral spinal
anaesthesia by 0.5% hyperbaric bupivacaine. A clinical comparison with bilateral spinal block. Minerva
Anestesiol, Jul-Aug 1998, 64(7-8) p307-12
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16. Corbey MP, Bach AB Transient radicular irritation (TRI) after spinal anaesthesia in day-care surgery
Acta Anaesthesiol Scand, Apr 1998, 42(4) p425-9
17. Fanelli G, Casati A, Aldegheri G, et al. Cardiovascular effects of two different regional anaesthetic
techniques for unilateral leg surgery. Acta Anaesthesiol Scand, Jan 1998, 42(1) p80-4
18. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT, et al. A low-dose hypobaric bupivacaine spinal
anesthesia for knee arthroscopies.Reg Anesth, Nov-Dec 1997, 22(6) p534-8
19. Pittoni G, Toffoletto F, Calcarella G, et al. Spinal anesthesia in outpatient knee surgery: 22-gauge
versus 25-gauge Sprotte needle. Anesth Analg, Jul 1995, 81(1) p73-9
20. Chabas E, Sala X, Nalda MA Unilateral spinal analgesia in a neonate Anaesthesia, Feb 1995, 50(2)
p182
21. Casati A, Fanelli G, Aldegheri G, et al. Frequency of hypotension during conventional or asymmetric
hyperbaric spinal block. Reg Anesth Pain Med, May-Jun 1999, 24(3) p214-9
22. Esmaoglu A, Boyaci A, Ersoy O, et al. Unilateral spinal anaesthesia with hyperbaric bupivacaine.
Acta Anaesthesiol Scand, Oct 1998, 42(9) p1083-7
23. Casati A, Fanelli G, Cappelleri G, et al. Low dose hyperbaric bupivacaine for unilateral spinal
anaesthesia. Can J Anaesth, Sep 1998,45(9) p850-4
24. Casati A, Fanelli G, Cappelleri G, et al. Does speed of intrathecal injection affect the distribution of
0.5% hyperbaric bupivacaine? Br J Anaesth, Sep 1998, 81(3) p355-7
25. Somri M, Gaitini L, Vaida S, et al. Postoperative outcome in high-risk infants undergoing
herniorrhaphy: comparison between spinal and general anaesthesia. Anaesthesia (England), Aug 1998,
53(8) p762-6
26. Liguori GA, Zayas VM, Chisholm MF Transient neurologic symptoms after spinal anesthesia with
mepivacaine and lidocaine Anesthesiology, Mar 1998, 88(3) p619-23
27. Casati A, Fanelli G, Berti M, et al. Cardiac performance during unilateral lumbar spinal block after
crystalloid preload. Can J Anaesth, Jun 1997, 44(6) p623-8
28. Iselin-Chaves IA, Van Gessel EF, Donald FA, et al. The effects of solution concentration and
epinephrine on lateral distribution of hyperbaric tetracaine spinal anesthesia. Anesth Analg, Oct 1996,
83(4) p755-9
29. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT, et al. Low-dose bupivacaine: a comparison of
hypobaric and near isobaric solutions for arthroscopic surgery of the knee. Anaesthesia (England), Jun
1999, 54(6) p540-5
30. Casati A, Fanelli G, Cappelleri G, et al. Effects of speed of intrathecal injection on unilateral spinal
block by 1% hyperbaric bupivacaine. A randomized, double-blind study. Minerva Anestesiol,1999,
65(1-2) p5-10
31. Casati A, Fanelli G, Cappelleri G, et al. Effects of spinal needle type on lateral distribution of 0.5%
hyperbaric bupivacaine. Anesth Analg, Aug 1998, 87(2) p355-9
32. Pollock JE, Neal JM, Stephenson CA, et al. Prospective study of the incidence of transient radicular
irritation in patients undergoing spinal anesthesia Anesthesiology, Jun 1996, 84(6) p1361-7

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