Pediatric Anesthesia ISSN 1155-5645

REVIEW ARTICLE

Spinal blocks
Hannu Kokki
Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland

Keywords
adolescent; child; infant; complications;
spinal anesthesia; adverse effects; blood
patch; epidural
Correspondence
Hannu Kokki,
Department of Anaesthesiology and
Intensive Care, Kuopio University Hospital,
University of Eastern Finland, FI-70800
Kuopio, Finland
Email: hannu.kokki@kuh.fi
Accepted 9 August 2011
Section Editor: Per-Arne Lonnqvist
doi:10.1111/j.1460-9592.2011.03693.x
Summary
Every anesthetist should have the expertise to perform lumbar puncture
that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy
and effective technique: small amount of local anesthetic injected in the
lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia,
and sympathetic and motor block in the lower part of the body. The main
limitation of spinal anesthesia is a variable and relatively short duration of
the block with a single-injection of local anesthetic. With appropriate use
of adjuvant or combining spinal anesthesia with epidural anesthesia, the
analgesic action can be controlled in case of early recovery of initial block
or in patients with prolonged procedures. Contraindications are rare.
Bleeding disorders and any major dysfunction in coagulation system are
rare in children, but spinal anesthesia should not be used in children with
local infection or increased intracranial pressure. Children with spinal anes-
thesia may develop the same adverse effects as has been reported in adults,
but in contrast to adults, cardiovascular deterioration is uncommon in chil-
dren even with high blocks. Most children having surgery with spinal anes-
thesia need sedation, and in these cases, close monitoring of sufficient
respiratory function and protective airway reflexes is necessary. Postdural
puncture headache and transient neurological symptoms have been
reported also in pediatric patients, and thus, guardians should be provided
instructions for follow-up and contact information if symptoms appear or
persist after discharge. Epidural blood patch is effective treatment for pro-
longed, severe headache, and nonopioid analgesic is often sufficient for
transient neurological symptoms.

in animals indicate that exposure of the developing

Introduction
Spinal anesthesia was an innovative and popular tech-
nique in pediatric anesthesia in the first half of the
1900, but then its use decreased significantly, for exam-
ple, after the Woolley and Roe case in 1947 and develop-
ments in general anesthesia (1). The new interest for
the use of spinal anesthesia rose three decades ago
when awake spinal anesthesia was introduced for her-
niotomies in preterm neonates with high risk of apnea
associated with general anesthesia (2). However, spinal
anesthesia is a feasible technique not only in neonates
but also in older children and adolescents (3).
There is a public concern on the safety of general
anesthesia in pediatric patients as experimental studies
brain to anesthetic agents can lead to neuronal apopto-
sis and neurodegeneration, and neurobehavioral and
functional deficits (4). Whether spinal anesthesia may
pose similar or other risk that may cause long-lasting
harms to growing body has been neither indicated
nor formally evaluated, but some concerns have
been raised with the use of excessive doses of local
anesthetics in neonates (5). However, there is a recent
interest to used spinal anesthesia, and several centers
have described their experiences with spinal anesthesia
(6–9).
In Kuopio, we have used spinal anesthesia in pediat-
ric patients for the last two decades, and as we do
400–500 cases annually, we have an experience on

56 Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd

H. Kokki
around 10 000 pediatric spinal anesthesias. We do not
use spinal anesthesia in newborns, as the technique in
small infants was found to be challenging to perform
and excessive dose of local anesthetics was needed for
sufficient blocks. Our method for infants <5 kg of
body weight is a segmental epidural anesthesia with an
indwelling catheter technique, a technique that allows
a titration of the block and using the catheter for post-
operative pain relief.
The use of spinal anesthesia in pediatric patients has
been recently reviewed by several authors (10–14), and
here, I will discuss some of the topics that may be
interesting for the pediatric anesthetists.
Indications for spinal anesthesia
Surgery on the lower part of the body is the main indi-
cation for spinal anesthesia in children. In neonates,
unsupplemented spinal anesthesia is used for inguinal
hernia repair (7). In older children and adolescents,
spinal anesthesia is commonly used for different types
of abdominal, inguinal, urological, and lower limb
procedure (10,11). In addition, spinal anesthesia has
been used for umbilical incisions, such as pyloromyot-
omy (15), and even for pediatric cardiac surgical
patients (16), because in young children, spinal anes-
thesia is the most effective method in suppressing the
cardiovascular and stress response to surgery.
Spinal anesthesia is particularly useful in children in
whom the anesthetist wishes to avoid general anesthe-
sia and airway manipulation with endotracheal tube or
laryngeal mask airway. During and within the first
2 weeks after an acute respiratory infection, endotra-
cheal anesthesia is associated with an increased risk of
respiratory complications (17). In these events, spinal
anesthesia allows the planned surgery to be performed
without unexpected cancellations (11). Spinal anesthe-
sia could be used also in children with a known diffi-
cult airway (10). However, in these cases, there should
be a plan how to provide an open airway if sedation is
needed.
Spinal anesthesia is also feasible technique in chil-
dren with the presence of a full stomach such as in
pediatric patients with lower limb trauma and testicu-
lar torsion (18). The risk of aspiration is low with
spinal anesthesia because protective airway reflexes are
ensured when no or only light sedation is provided.
Spinal anesthesia is associated with a relatively low
incidence of emetic episodes, and thus, it is a good
choice for children with increased risk of postoperative
nausea and vomiting (11,19).
Spinal anesthesia may be used in children with pul-
monary or neuromuscular disease in whom general
Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd
Spinal blocks
anesthesia is considered to worsen respiratory function
(20). Because amino-amide local anesthetics, in con-
trast to some case reports with amino-esters (21), may
not trigger malignant hyperthermia, spinal anesthesia
with amino-amide local anesthetics can be used in
malignant hyperthermia-susceptible patients (22).
The benefits of spinal anesthesia are most evident in
the pediatric day-case surgery where there is a close
co-operation between the surgical and anesthetic teams
and the amount of time needed to complete the opera-
tion is often <60–75 min, which is a typical duration
of a single-injection spinal anesthesia in children (19).
In outpatient setting, the high success rate and
straightforward recovery helps to plan the operative
lists. Spinal anesthesia could be used also in situations
where there is a limited access for resources. Most chil-
dren live in developing countries (23), and in a situa-
tion with limited resources, drugs, and equipment,
spinal anesthesia is a safe, simple, and relatively inex-
pensive alternative to general anesthesia. A rapid turn-
over in the operating room and uneventful recovery
should provide further cost savings (15,24).
Contraindications to spinal anesthesia
There are absolute and relative contraindications to
spinal anesthesia. It should be avoided in children with
infection at the puncture site, ongoing degenerative
axonal diseases, increased intracranial pressure, and
severe hypovolemia (9). In Kuopio, we do not consider
the presence of a ventricular shunt as a contraindica-
tion to spinal anesthesia if the child’s medical condi-
tion is stable. During the last decade, the risks of
spinal hematoma have been one of the main concerns
in adult patients with intraspinal anesthesia and anal-
gesia (25). However, coagulopathy and bleeding dis-
orders are relatively rare in children, and drugs
affecting coagulation function are less frequently used
in pediatric patients than in adults and elderly patients
(26). Although very rare cases of neuraxial hematomas
have been reported in children with diagnostic lumbar
puncture (27) and epidural anesthesia (28), spinal anes-
thesia should be safe if there is no positive family or
patient history for major dysfunction in coagulation
system (29). However, an alternative anesthetic tech-
nique should be considered when there are difficulties
to identify the subarachnoidal space. A bloody tap
may occur, but there is no need to postpone surgery, if
there is no history for bleeding disorder (30).
Major deformities of the spinal column are relative
contraindication to spinal anesthesia. However, in
some patients, spinal deformity may compromise the
respiratory function or cause other functional prob-
57
Spinal blocks
lems, and in these cases, spinal anesthesia can be con-
sidered as an alternative technique (20).
The main limitation for the use of spinal anesthesia
in children is the limited duration of action. In chil-
dren, single-dose spinal anesthesia does not allow the
performance of operations lasting over 75–90 min (11).
If the surgery is likely to be prolonged use of spinal
adjuncts to local anesthetic, combined spinal-epidural
block or an alternative technique should be considered.
Thus, it is important to communicate with the surgeon
before a single-shot spinal anesthesia is provided.
Sedation
The aim of sedation is to provide analgesia, anxiolysis,
sedation, and motor control during lumbar puncture
and the procedure. Analgesia for puncture site is easily
achieved with transdermal local anesthetic such as
eutectic mixture of lidocaine and prilocaine applied
into the puncture site for 60 min. Motor control is
important to prevent harms to neural structures while
the needle tip is in subarachnoidal space, but also
because kicking and fussing may lead to an excessive
spread of block (31).
To provide safe care, children should be monitored
closely during sedation. Most important is to monitor
respiratory function; both oxygenation, with pulse
oximetry, and ventilation, with capnography, should
be monitored to detect early any respiratory compro-
mise. Bispectral index and entropia monitoring do not
provide accurate data on sedation level in infant, but
in children 2 years or older, both monitors are useful
tools to titrated appropriate level of sedation during
spinal anesthesia. In Kuopio, our target ranges for
bispectral index and state entropia during intraopera-
tive sedation are 60–70 (32).
Sedation is not always used. In neonates, awake regio-
nal anesthesia does not exacerbate ventilatory distur-
bance. Abajian et al. (2) described the technique of
unsupplemented spinal anesthesia in ex-preterm infants
scheduled for herniotomy in 1984, and since then, this
technique has been used in many neonatal units. How-
ever, it has not been established whether the episodes of
apnea as whole can be reduced with this technique. It
has been shown that the risk of apnea is less in neonates
who have spinal anesthesia alone, but if the block fails
or surgery outlasts the duration spinal block benefits of
awake regional anesthesia are lost if supplementation is
needed. Supplementation of spinal anesthesia with seda-
tives or general anesthetics is associated with a signifi-
cantly high incidence of apneas (33,34).
The choice of sedative may also affect the outcome,
and more prospectively collected data on different sed-
58
H. Kokki
atives are needed. Ketamine, benzodiazepines, and
older volatile anesthetics used in conjunction with
spinal anesthesia seems to be associated with a signifi-
cantly increased risk of apnea (34). But whether the
light sedation with barbiturates (35), as we do in Kuo-
pio, or the two newer inhalation agents, sevoflurane
and desflurane, are safer in this respect has not been
formally evaluated. However, before more data are
available, all high-risk babies should be monitored
appropriately whichever type of anesthesia is used.
Some co-operative children want to be awake during
the procedure, and occasionally, spinal anesthesia may
be used without concurrent sedation. In older children,
most important is to provide appropriate information
about what is to be done, and familiar and firm assis-
tance to maintain the position during the lumbar punc-
ture will minimize the need for sedation. Some
children like to listen to music or watch videos rather
than sleep during the surgery with spinal block. In
older children who wish to be sedated small incremen-
tal doses of midazolam, thiopental, or propofol are
useful to promote sleep, to ensure a calm state, and to
relieve anxiety and tension. After completion of block,
only minor doses are needed because spinal anesthesia
itself has a sedative action and it increases the sensitiv-
ity to sedatives (36).
Different types of sedatives may be used, but one of
the most interesting drugs at this time is dexmetedomi-
dine. Dexmedetomidine is a potent, specific, and selec-
tive a2-adrenoceptor agonist. It has several desirable
properties for an optimal sedation compound; it
induces sedation that mimics natural sleep, anxiolysis,
analgesia, and decreased activity of the sympathetic
nervous system. Because dexmedetomidine does not
depress respiratory function, it is a promising com-
pound for pediatric sedation (37). However, further
confirmatory studies are needed to establish the effi-
cacy and safety of dexmetedomidine in sedation during
pediatric regional anesthesia.
Lumbar puncture
Dural puncture is performed in the lumbar area, and
because the spinal cord ends at L3 in infants and even
lower in some neonates (38), needle placement should
be at L4/5 or L5/S1 interspace. The intercristal line
can be used for the identification of safe puncture lev-
els for patients of all ages. The shape of the infants’
and children’s pelvis is more circular, and the position
of the iliaca crest is lower than that is in adults. Thus,
the line joining the most superior part of iliac crests,
Tuffier’s line, can be used for orientation also in pedi-
atric patients. The iliac crest is at the level of the fifth
Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd
H. Kokki Spinal blocks

lumbar vertebra in young children, and the position is limbs should not be raised, and Trendelenburg posi-
even lower in neonates (39), and a puncture at the in- tion should not be used to avoid unintentional exten-
tercristal level will be below the spinal cord. sion of the spinal block as the respiratory function
The flexibility of a child’s spine and the ready access may be compromised (44,46,47). Five years ago, in
to the intervertebral space make a dural puncture easy Kuopio, a technical assistant raised the legs of an 5-kg
to perform in children; firstly, the skin-spinal space dis- infant having spinal block for inguinal surgery to
tance is short (40), and secondly, the lumbar spinal install a grounding pad for electrocautery into the
canal is fairly wide even in small children, and the lower back, and as a result, spinal block spread into
interpedicular diameter of the spinal canal at lumbar the cervical segments, and the infant needed assisted
level at birth is 70% of the adult size (41). Owing to ventilation for an hour. Thereafter, his recovery was
relatively large spinal canal, the volume of cerebrospi- uneventful.
nal fluid per body weight is twice than that in adults, 4
vs. 2 mlÆkg)1, respectively. This, a larger amount of
Local anesthetics used for spinal blocks
lumbar cerebrospinal fluid, may be one of the reasons
why small children need higher body weight-based In children, spinal anesthesia is commonly used for
doses of local anesthetics, and the duration of the procedures with duration of 60–75 min or less, and in
spinal block is shorter than that in adults. Other sup- most children, (levo)bupivacaine, ropivacaine, and tet-
posed factors for shorter duration of action and higher racaine provide this long-lasting anesthesia (Table 1).
dose requirements are high cardiac index and regional Tetracaine, an amino-ester, and (levo)bupivacaine
blood flow both in the spinal cord and in the epidural and ropivacaine, amino-amide local anesthetics, are
space, and a relatively large surface area of the neural the agents most commonly used in children. The ester
tissues exposed, all of which promote the uptake of and amide compounds differ in regard to the manner
local anesthetic away form the injection site. The ana- in which they are metabolized, their stability in solu-
tomical configuration of the spinal column is flat in tion, and their potential for causing allergic reactions.
young children, and consequently, drugs injected into The amino-esters are hydrolyzed in plasma by pseudo-
the subarachnoid space spread rather evenly and com- cholinesterase, are somewhat unstable in solution and
monly result in a mid-thoracic block (42). a metabolite, aminobenzoic acid, can cause allergic
For spinal anesthesia, the patient is usually posi- reactions. With the amino-amides, allergic reactions
tioned on his side with the back flexed and neck are extremely rare, and the amide compounds undergo
extended. In newborns and small infants, the sitting enzymatic degradation by the liver and are extremely
position is also used. To ensure an open airway, the stable even after prolonged storage.
child’s neck should be extended (43). For spinal anesthesia, the dose of local anesthetic
Before injecting local anesthetic into the subarach- should de calculated on the basis of body weight.
noid space, it is important to ensure a free flow of However, nowadays obesity is common even in youn-
cerebrospinal fluid. To avoid an unintended subdural
injection, the needle should be advanced 1 mm beyond Table 1 Choice of local anesthetic dosages in pediatric spinal
the depth at which cerebrospinal fluid is first seen to anesthesia
flow out of the needle. When necessary, rotating the
needle for 90 will ensure a free flow of cerebrospinal Anticipated
Body duration of
fluid. The injection should be performed slowly,
weight Dose anesthesia
>20 s, to avoid extensive spread of the block (44). Drugs (kg) (mgÆkg)1) (min) References
After the injection, a free flow of cerebrospinal fluid is
determined to ensure continued correct placement of (Levo)bupivacaine –5 0.3–1 65–90 52,56–58,61
6–10 0.4–0.5 75 11,58
the needle (11).
11–20 0.3–0.4 80 11,59
After the local anesthetic has been injected, the sty-
>20 0.25–0.3 85– 11,62
let should be reinserted, and the needle may be left in Ropivacaine –5 0.5–1 45–80 51,52
the position for a few seconds to prevent the drug 6–10 0.5 90 51
from tracking back into the tissues and site of skin 11–20 0.5 90 51
puncture. This is especially suggested in small children >20 0.5 105 51
because a relatively big hole in dura promotes the Tetracaine –5 0.2–0.6 85–105 7
6–10 0.4–0.5 75 35,48
tracking of local anesthetic from the puncture site (45).
11–20 0.3–0.4 80 48
The operative installation after intrathecal injection
>20 0.2–0.3 85– 48
of local anesthetic is also important, and the lower

Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd 59

Spinal blocks H. Kokki

ger children, and in notably overweight children, doses

Adjuncts to local anesthetics
should be based on ideal body weight to avoid exces-
sive dosages. One of the major limitations of single-injection spinal
The use of isobaric and hyperbaric solutions has anesthesia is the relatively short and highly interindi-
been compared also in pediatric spinal anesthesia, and vidually variable duration on anesthetic, analgesic, and
similar block characteristics were found with both motor block action (48–51). Thus, different classes of
solutions indicating that the baricity may not be that adjuvant are combined with spinal anesthetics to mod-
important for the selection of local anesthetic in young ify the onset, intensity, and duration of spinal block
children as it is in adults (48). (Table 2). Because subarachnoidally injected drugs are
Tetracaine at a dose of 0.4 mgÆkg)1 of body weight in close contact with neural tissue, potential neurotox-
in children 1- to 2-year-old and in preschool children icity should always be considered before injecting any
at a dose of 0.3 mgÆkg)1 provides a sensory block to compounds into the cerebrospinal fluid. Adjuncts
T3–T5 with duration of 80–90 min, but in adoles- should not contain antioxidants and preservatives that
cents, the duration is significantly longer, up to 3 h have a potential for neurotoxicity (55).
(35,49).
In Kuopio, we use isobaric (levo)bupivacaine at a Table 2 Effects of additives to local anesthetics in pediatric spinal
dose of 0.5 mgÆkg)1 of body weight for children 5–10 anesthesia
kg, 0.4 mgÆkg)1 for children 11–19 kg, and 0.3 mgÆkg)1
Compounds Effect on spinal anesthesia References
for those 20 kg or over. These doses produce a sensory
block to the T3–T5 level with duration of 75–85 min Adrenaline Bupivacaine 0.3 mgÆkg)1 + adrenaline 52
(11,48,50). For ropivacaine, the appropriate dose seems 3 lgÆkg)1 (neonates)
to be 0.5 mgÆkg)1 of body weight (51). Recently, much Plain: 50 min
With adrenaline: 95 min
higher doses of (levo)bupivacaine and ropivacaine, up
Bupivacaine 0.8 mgÆkg)1 + adrenaline 56
to 1.2 mgÆkg)1 of body weight, have been suggested
4 lgÆkg)1 (neonates)
for neonates (52), but the safety of these higher doses Plain: 70 min
injected intrathecally has not been established. How- With adrenaline: 80 min
ever, in the dose-finding study where these proposals Tetracaine 0.2–0.3 mgÆkg)1 + adrenaline 2
are based a relatively thick needle, 25 Gauge, was used 2 lgÆkg)1 (neonates)
for lumbar puncture, and the needle was withdrawn Plain: 85 min
With adrenaline: 110 min
immediately after the injection of local anesthetic (52).
Tetracaine 0.3 mgÆkg)1 + adrenaline
Thus, it is likely that local anesthetic should have been
(infants)
escaped from the intrathecal space owing to the large Plain: 85 min
hole in the dura. Moreover, with the same amount of With adrenaline: 130 min
local anesthetic injected segmentally into the epidural Clonidine Bupivacaine 1 mgÆkg)1 + clonidine 61
space in most neonates a sufficient anesthesia is 1 lgÆkg)1 in neonates
achieved. The safety of these higher doses injected Plain: 70 min
With clonidine: 110 min
intrathecally has not been established. There could be
Bupivacaine 0.2–0.4 mgÆkg)1 + clonidine 62
a risk of neurological damage (5), and cases of high
1 lgÆkg)1 (adolescents)
blocks are reported (7). More data are needed before Plain: 110 min
these higher doses could be recommended for routine With clonidine: 135 min
clinical use. *Analgesia: from 330 to 460 min
Local anesthetics are highly protein bound com- Fentanyl Bupivacaine 0.4 mgÆkg)1 + fentanyl 59
pounds, and because protein concentration in cere- 0.2 lgÆkg)1 (children)
Plain: 80 min
brospinal fluid is low, most of the intrathecally
With fentanyl: 75 min
injected local anesthetic should be protein-free (53).
*Analgesia: from 170 to 220 min
However, after spinal injection, plasma concentra- Bupivacaine 0.4–0.5 mgÆkg)1 + fentanyl 58
tions are very low, and thus, the risk of systemic 0.25–1 lgÆkg)1 (infants)
toxicity is unlikely. In Beavoirs’ study, a single blood Plain: 50 min
sample was obtained at 10 min after intrathecal bupi- With fentanyl 0.25 lgÆkg)1: 55 min
vacaine 1 mgÆkg)1 of body weight, and a total With fentanyl 0.5 lgÆkg)1: 55 min
With fentanyl 1 lgÆkg)1: 55 min
plasma concentrations of bupivacaine were 0.25–
*Analgesia: 70, 95, 95 to >240
0.30 lgÆml)1 and free bupivacaine concentrations only
min, respectively
0.05–0.06 lgÆml)1 (54).

60 Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd

H. Kokki
The most commonly used adjuncts are adrenaline,
opioids (fentanyl), and clonidine. Combined with tetra-
caine and bupivacaine, adrenaline 2–5 lgÆkg)1 of body
weight extends the duration of analgesia by up to 50%
(56,57). Low doses of fentanyl, 0.2 lgÆkg)1 of body
weight, have been added to intrathecal bupivacaine. At
these dose levels, fentanyl improves the quality and pro-
longs the duration of spinal block without compromis-
ing the safety of spinal anesthesia (58). Higher doses of
intrathecal fentanyl, 1 lgÆkg)1 of body weight (59), and
intrathecal morphine, 7 lgÆkg)1 (16,60), have also been
used, but caution is needed at least in day-case surgery
owing to the risk of delayed respiratory depression.
Preservative-free clonidine at a dose of 1 lgÆkg)1 of
body weight prolongs the duration of sensory
and motor blocks by 30 min and postoperative
analgesia by 120 min achieved with bupivacaine
without compromising the hemodynamic stability.
At higher doses, 2 lgÆkg)1, clonidine may induce hypo-
tension, respiratory depression, and sedation (61–63).
Alternatives to single-shot spinal anesthesia
In small infants, spinal anesthesia is a challenging
technique, and owing to significant interindividual
variation in the duration of the block, the anesthetist
must always be ready to deal with inadequate anesthe-
sia and complications (64). In Kuopio, we do not use
spinal anesthesia in children <5 kg of body weight. In
small infants, we used segmental epidural anesthesia
with an indwelling catheter technique that allows the
titration of the optimal dose, and the catheter can be
used for postoperative pain management in this vulner-
able patient group.
Continuous spinal anesthesia is not frequently used
in children although it has some theoretical advanta-
ges. Continuous spinal anesthesia allows the use of a
small initial dose of local anesthetic followed by titra-
tion to the desired level and duration of anesthesia,
giving small additional doses as required. The tech-
nique has been described in some relatively small sam-
ples suggesting that it may have some benefits (16) but
also risks of its own, such as leakage of cerebrospinal
fluid alongside the catheter and risk of dura-cutaneous
fistula formation (65).
Combining spinal anesthesia with continuous epidu-
ral blockade a rapid onset and a prolonged duration
of anesthesia can be obtained. With an epidural cathe-
ter increments could be given to extend the height and
duration of the initial block achieved with spinal injec-
tion, and epidural catheter could be used for the treat-
ment for postoperative pain following major surgery.
Combined spinal-epidural anesthesia and analgesia is
Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd
Spinal blocks
feasible technique for major abdominal, genitourinary,
and lower limb orthopedic surgery (66,67). This tech-
nique has been used also for inguinal surgery (68), but
it is too complicated for such a minor surgery, and the
total dose of local anesthetics should be calculated
carefully when different blocks are used in conjunction
to avoid risk of systemic toxicity.
Complications
Recent studies have established that following lumbar
puncture and spinal anesthesia, children may develop
the complaints similar to those developed in adults.
However, assessment of signs and symptoms of com-
plications in infants and young children is not as easy
and straightforward as it is among older children and
in adults. Infants are unable to verbalize their com-
plaints, and clinicians may misinterpret physical and
behavioral changes suggestive of postpuncture compli-
cations (11).
The most well known complication of dural puncture
is a position-dependent headache (69). Overall, head-
ache is a common symptom in children and in surgical
patients whatever type of anesthesia they have had.
However, the signs and symptoms of postdural puncture
headache are often easy to detect; it is often bilateral,
develops within the 24 h after lumbar puncture, the
symptoms occurs or worsens in minutes after assuming
the upright position and disappears or improves in read-
ily after resuming the recumbent position. Children may
have nausea and vomiting and associated symptoms from
different cranial nerves, such as vertigo, tinnitus, dimin-
ished hearing, and blurred vision, may occur (11,70–72).
To reduce the risk of postdural puncture headache,
lumbar puncture should be performed with a small
diameter atraumatic needle with a stylet, as thin atrau-
matic needles are associated with the lowest incidence
and severity of puncture complications (45). In Kuo-
pio, we use 27-gauge spinal needles with atraumatic tip
in children. A short needle allows good accuracy in
movement and ensures a minimal dead space; in
infants, 25- to 38-mm needles are sufficiently long, and
in small children, we use 50-mm needles. In school-age
children, a standard length adult spinal needle can be
used with a high success rate. The needle should have
a stylet, and it should be reinserted before needle is
withdrawn from the subarachnoidal space; this may
decrease the risk of postpuncture complications (45).
When postlumbar puncture headache develops, the
patient should be followed up carefully. Headache gen-
erally undergoes spontaneous resolution within 3–5
days, but in some children, it may last for several days.
The first line treatment for severe symptoms is bed
61
Spinal blocks
Table 3 Management on postdural puncture headache (refer-
ences: 68,71,72)
1. Use thin atraumatic needle for lumbar puncture
Incidence with cutting-point needles
With 25- or 27-gauge needles: 4–5%
With 22-gauge needle: 10–15%
2. Differential diagnosis necessary
Headache common complaint after surgery
PDPH should appear or worsen within 15 min after sitting or
standing and improve or disappear within 15 min after lying
Associated symptoms: neck stiffness, tinnitus, hypacusia,
photophobia, nausea
Develops within 24 h (5 days) after dural puncture
3. High spontaneous recovery rate and conservative treatment
often highly effective
Bed rest
Normal hydration—i.v. fluids if p.o. fluids not tolerated
Nonopioid analgesics—paracetamol with NSAID
Caffeine—up to 10 mgÆkg)1 per 24 h divided in 2 or 3 p.o. doses,
>25 kg: 100 mg · 3
4. Epidural blood patch highly effective for severe and persistent
symptoms
Indicated if severe symptoms do not resolve within 3–5 days or
symptoms persist over 7 days
Remove autologous blood aseptically
Inject blood into epidural space at the same intervertebral space
or one above/below as the lumbar puncture
Appropriate volume of autologous blood 0.2–0.3 mlÆkg)1 of
body weight
rest, normal hydration, nonopioid analgesics, and caf-
feine. If the symptoms persist, an epidural blood patch
should be considered as it is an effective treatment
(Table 3; 70–72).
An epidural blood patch is rarely required, but when
a lumbar puncture has been performed with a cutting-
point 25–27 Gauge needle position-dependent head-
ache may persist despite conservative treatment in one
of 750 children (71). With atraumatic needles, the risk
should be lower. When indicated, an epidural blood
patch is an effective treatment for severe and persisting
symptoms. Autologous blood is removed aseptically
and injected into the epidural space into the same ver-
tebra interspace, or one below or one above, where the
lumbar puncture had been performed. The appropriate
volume seems to be 0.2–0.3 mlÆkg)1 of body weight.
This amount of blood compresses the dural sac suffi-
ciently to reverse the decreased pressure in the sub-
arachnoidal space. If effective, patients should
experience immediate relief of their symptoms, but a
bed rest and a follow-up for 3 h after the procedure is
recommended to allow a clot formation into the epidu-
ral space. If the symptoms are not relieved, other diag-
noses should be considered before repeating the
procedure. This is especially important in patients
62
H. Kokki
whose symptoms do not fit with those of classic post-
puncture complaints (70–72).
Backache following lumbar puncture and spinal anes-
thesia is common, 5–10% of children may have some
symptoms in lower back. Overall, backache is a frequent
postoperative complication, and studies indicate that
the type of anesthesia, regional or general anesthesia,
does not affect its incidence. Thus, it is not known
whether spinal anesthesia per se is associated with any
increased risk of backache (11). However, in some cases,
backache may be a sign of subclinical neurotoxicity of
the local anesthetic, and children also may develop so-
called transient neurological symptoms (73). The symp-
toms of transient neurological symptoms appear in a
few hours after a full recovery of spinal block. Transient
neurological symptoms consist of pain originating in the
gluteal region and radiating to lower extremities, and
children may describe tingling feelings in the feet (74–
76). The intensity of pain varies from light to severe,
and neurologic examination and imagination evaluation
and electropathological testing are often negative (77).
Children may develop transient neurological symptoms
as often as adults, with bupivacaine the incidence is 3–
4%, most often symptoms are mild (11).
Conclusions
The aim of anesthesia is to provide good operating
conditions for the surgeon while minimizing any harm-
ful psychological and physiological sequelae for the
child. Spinal anesthesia produces a dense intra-opera-
tive analgesia, and when combined with sedation or
general anesthesia, it reduces the requirements for
anesthetic agents, muscle relaxants, and opioids intra-
operatively. Spinal anesthesia allows a fast return to a
bright and alert status and an early return of normal
appetite. Because analgesia continues into the early
postoperative period and nausea and vomiting are
uncommon following spinal anesthesia, ambulation
and discharge are not delayed.
Severe complications are rare, but a postlumbar punc-
ture headache and transient neurological symptoms may
develop also in children with spinal anesthesia. If these
symptoms persist for long term, they may surpass the
benefits of spinal anesthesia and should therefore be
identified and treated appropriately. Because in young
children, these symptoms may be difficult to perceive,
parents should be informed and given contact informa-
tion should complications arise after discharge.
Acknowledgments
This research was carried out without funding.
Pediatric Anesthesia 22 (2012) 56–64 ª 2011 Blackwell Publishing Ltd
H. Kokki
Conflict of interest
No conflicts of interest declared.
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