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. 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 uid 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 anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufcient respiratory function and protective airway reexes 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 prolonged, severe headache, and nonopioid analgesic is often sufcient for transient neurological symptoms.

Introduction Spinal anesthesia was an innovative and popular technique in pediatric anesthesia in the rst half of the 1900, but then its use decreased signicantly, for example, after the Woolley and Roe case in 1947 and developments in general anesthesia (1). The new interest for the use of spinal anesthesia rose three decades ago when awake spinal anesthesia was introduced for herniotomies 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
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in animals indicate that exposure of the developing brain to anesthetic agents can lead to neuronal apoptosis and neurodegeneration, and neurobehavioral and functional decits (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 (69). In Kuopio, we have used spinal anesthesia in pediatric patients for the last two decades, and as we do 400500 cases annually, we have an experience on
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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 sufcient 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 postoperative pain relief. The use of spinal anesthesia in pediatric patients has been recently reviewed by several authors (1014), 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 indication 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 pyloromyotomy (15), and even for pediatric cardiac surgical patients (16), because in young children, spinal anesthesia 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 anesthesia and airway manipulation with endotracheal tube or laryngeal mask airway. During and within the rst 2 weeks after an acute respiratory infection, endotracheal 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 anesthesia could be used also in children with a known difcult 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 children with the presence of a full stomach such as in pediatric patients with lower limb trauma and testicular torsion (18). The risk of aspiration is low with spinal anesthesia because protective airway reexes 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 pulmonary or neuromuscular disease in whom general
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anesthesia is considered to worsen respiratory function (20). Because amino-amide local anesthetics, in contrast 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 benets 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 operation is often <6075 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 children live in developing countries (23), and in a situation with limited resources, drugs, and equipment, spinal anesthesia is a safe, simple, and relatively inexpensive alternative to general anesthesia. A rapid turnover 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 contraindication to spinal anesthesia if the childs medical condition 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 analgesia (25). However, coagulopathy and bleeding disorders 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 anesthesia should be safe if there is no positive family or patient history for major dysfunction in coagulation system (29). However, an alternative anesthetic technique should be considered when there are difculties 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 prob57

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lems, and in these cases, spinal anesthesia can be considered as an alternative technique (20). The main limitation for the use of spinal anesthesia in children is the limited duration of action. In children, single-dose spinal anesthesia does not allow the performance of operations lasting over 7590 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 compromise. 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 intraoperative sedation are 6070 (32). Sedation is not always used. In neonates, awake regional anesthesia does not exacerbate ventilatory disturbance. 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. However, 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 benets of awake regional anesthesia are lost if supplementation is needed. Supplementation of spinal anesthesia with sedatives or general anesthetics is associated with a signicantly high incidence of apneas (33,34). The choice of sedative may also affect the outcome, and more prospectively collected data on different sed58

atives are needed. Ketamine, benzodiazepines, and older volatile anesthetics used in conjunction with spinal anesthesia seems to be associated with a signicantly increased risk of apnea (34). But whether the light sedation with barbiturates (35), as we do in Kuopio, or the two newer inhalation agents, sevourane and desurane, 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 rm assistance to maintain the position during the lumbar puncture 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 incremental 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 sensitivity to sedatives (36). Different types of sedatives may be used, but one of the most interesting drugs at this time is dexmetedomidine. Dexmedetomidine is a potent, specic, and selective 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 compound for pediatric sedation (37). However, further conrmatory studies are needed to establish the efcacy 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 identication of safe puncture levels for patients of all ages. The shape of the infants and childrens 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, Tufers line, can be used for orientation also in pediatric patients. The iliac crest is at the level of the fth
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lumbar vertebra in young children, and the position is even lower in neonates (39), and a puncture at the intercristal level will be below the spinal cord. The exibility of a childs spine and the ready access to the intervertebral space make a dural puncture easy to perform in children; rstly, the skin-spinal space distance is short (40), and secondly, the lumbar spinal canal is fairly wide even in small children, and the interpedicular diameter of the spinal canal at lumbar level at birth is 70% of the adult size (41). Owing to relatively large spinal canal, the volume of cerebrospinal uid per body weight is twice than that in adults, 4 vs. 2 mlkg)1, respectively. This, a larger amount of lumbar cerebrospinal uid, may be one of the reasons why small children need higher body weight-based doses of local anesthetics, and the duration of the spinal block is shorter than that in adults. Other supposed factors for shorter duration of action and higher dose requirements are high cardiac index and regional blood ow both in the spinal cord and in the epidural space, and a relatively large surface area of the neural tissues exposed, all of which promote the uptake of local anesthetic away form the injection site. The anatomical conguration of the spinal column is at in young children, and consequently, drugs injected into the subarachnoid space spread rather evenly and commonly result in a mid-thoracic block (42). For spinal anesthesia, the patient is usually positioned on his side with the back exed and neck extended. In newborns and small infants, the sitting position is also used. To ensure an open airway, the childs neck should be extended (43). Before injecting local anesthetic into the subarachnoid space, it is important to ensure a free ow of cerebrospinal uid. To avoid an unintended subdural injection, the needle should be advanced 1 mm beyond the depth at which cerebrospinal uid is rst seen to ow out of the needle. When necessary, rotating the needle for 90 will ensure a free ow of cerebrospinal uid. The injection should be performed slowly, >20 s, to avoid extensive spread of the block (44). After the injection, a free ow of cerebrospinal uid is determined to ensure continued correct placement of the needle (11). After the local anesthetic has been injected, the stylet should be reinserted, and the needle may be left in the position for a few seconds to prevent the drug from tracking back into the tissues and site of skin puncture. This is especially suggested in small children because a relatively big hole in dura promotes the tracking of local anesthetic from the puncture site (45). The operative installation after intrathecal injection of local anesthetic is also important, and the lower
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limbs should not be raised, and Trendelenburg position should not be used to avoid unintentional extension of the spinal block as the respiratory function may be compromised (44,46,47). Five years ago, in Kuopio, a technical assistant raised the legs of an 5-kg infant having spinal block for inguinal surgery to install a grounding pad for electrocautery into the lower back, and as a result, spinal block spread into the cervical segments, and the infant needed assisted ventilation for an hour. Thereafter, his recovery was uneventful. Local anesthetics used for spinal blocks In children, spinal anesthesia is commonly used for procedures with duration of 6075 min or less, and in most children, (levo)bupivacaine, ropivacaine, and tetracaine provide this long-lasting anesthesia (Table 1). Tetracaine, an amino-ester, and (levo)bupivacaine and ropivacaine, amino-amide local anesthetics, are the agents most commonly used in children. The ester and amide compounds differ in regard to the manner in which they are metabolized, their stability in solution, and their potential for causing allergic reactions. The amino-esters are hydrolyzed in plasma by pseudocholinesterase, are somewhat unstable in solution and a metabolite, aminobenzoic acid, can cause allergic reactions. With the amino-amides, allergic reactions are extremely rare, and the amide compounds undergo enzymatic degradation by the liver and are extremely stable even after prolonged storage. For spinal anesthesia, the dose of local anesthetic should de calculated on the basis of body weight. However, nowadays obesity is common even in younTable 1 Choice of local anesthetic dosages in pediatric spinal anesthesia Anticipated duration of anesthesia (min) 6590 75 80 85 4580 90 90 105 85105 75 80 85

Drugs (Levo)bupivacaine

Body weight (kg) 5 610 1120 >20 5 610 1120 >20 5 610 1120 >20

Dose (mgkg)1) 0.31 0.40.5 0.30.4 0.250.3 0.51 0.5 0.5 0.5 0.20.6 0.40.5 0.30.4 0.20.3

References 52,5658,61 11,58 11,59 11,62 51,52 51 51 51 7 35,48 48 48

Ropivacaine

Tetracaine

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H. Kokki

ger children, and in notably overweight children, doses should be based on ideal body weight to avoid excessive dosages. The use of isobaric and hyperbaric solutions has been compared also in pediatric spinal anesthesia, and similar block characteristics were found with both solutions indicating that the baricity may not be that important for the selection of local anesthetic in young children as it is in adults (48). Tetracaine at a dose of 0.4 mgkg)1 of body weight in children 1- to 2-year-old and in preschool children at a dose of 0.3 mgkg)1 provides a sensory block to T3T5 with duration of 8090 min, but in adolescents, the duration is signicantly longer, up to 3 h (35,49). In Kuopio, we use isobaric (levo)bupivacaine at a dose of 0.5 mgkg)1 of body weight for children 510 kg, 0.4 mgkg)1 for children 1119 kg, and 0.3 mgkg)1 for those 20 kg or over. These doses produce a sensory block to the T3T5 level with duration of 7585 min (11,48,50). For ropivacaine, the appropriate dose seems to be 0.5 mgkg)1 of body weight (51). Recently, much higher doses of (levo)bupivacaine and ropivacaine, up to 1.2 mgkg)1 of body weight, have been suggested for neonates (52), but the safety of these higher doses injected intrathecally has not been established. However, in the dose-nding study where these proposals are based a relatively thick needle, 25 Gauge, was used for lumbar puncture, and the needle was withdrawn immediately after the injection of local anesthetic (52). Thus, it is likely that local anesthetic should have been escaped from the intrathecal space owing to the large hole in the dura. Moreover, with the same amount of local anesthetic injected segmentally into the epidural space in most neonates a sufcient anesthesia is achieved. The safety of these higher doses injected intrathecally has not been established. There could be a risk of neurological damage (5), and cases of high blocks are reported (7). More data are needed before these higher doses could be recommended for routine clinical use. Local anesthetics are highly protein bound compounds, and because protein concentration in cerebrospinal uid is low, most of the intrathecally injected local anesthetic should be protein-free (53). However, after spinal injection, plasma concentrations are very low, and thus, the risk of systemic toxicity is unlikely. In Beavoirs study, a single blood sample was obtained at 10 min after intrathecal bupivacaine 1 mgkg)1 of body weight, and a total plasma concentrations of bupivacaine were 0.25 0.30 lgml)1 and free bupivacaine concentrations only 0.050.06 lgml)1 (54).
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Adjuncts to local anesthetics One of the major limitations of single-injection spinal anesthesia is the relatively short and highly interindividually variable duration on anesthetic, analgesic, and motor block action (4851). Thus, different classes of adjuvant are combined with spinal anesthetics to modify the onset, intensity, and duration of spinal block (Table 2). Because subarachnoidally injected drugs are in close contact with neural tissue, potential neurotoxicity should always be considered before injecting any compounds into the cerebrospinal uid. Adjuncts should not contain antioxidants and preservatives that have a potential for neurotoxicity (55).
Table 2 Effects of additives to local anesthetics in pediatric spinal anesthesia Compounds Effect on spinal anesthesia Adrenaline Bupivacaine 0.3 mgkg)1 + adrenaline 3 lgkg)1 (neonates) Plain: 50 min With adrenaline: 95 min Bupivacaine 0.8 mgkg)1 + adrenaline 4 lgkg)1 (neonates) Plain: 70 min With adrenaline: 80 min Tetracaine 0.20.3 mgkg)1 + adrenaline 2 lgkg)1 (neonates) Plain: 85 min With adrenaline: 110 min Tetracaine 0.3 mgkg)1 + adrenaline (infants) Plain: 85 min With adrenaline: 130 min Bupivacaine 1 mgkg)1 + clonidine 1 lgkg)1 in neonates Plain: 70 min With clonidine: 110 min Bupivacaine 0.20.4 mgkg)1 + clonidine 1 lgkg)1 (adolescents) Plain: 110 min With clonidine: 135 min *Analgesia: from 330 to 460 min Bupivacaine 0.4 mgkg)1 + fentanyl 0.2 lgkg)1 (children) Plain: 80 min With fentanyl: 75 min *Analgesia: from 170 to 220 min Bupivacaine 0.40.5 mgkg)1 + fentanyl 0.251 lgkg)1 (infants) Plain: 50 min With fentanyl 0.25 lgkg)1: 55 min With fentanyl 0.5 lgkg)1: 55 min With fentanyl 1 lgkg)1: 55 min *Analgesia: 70, 95, 95 to >240 min, respectively References 52

56

Clonidine

61

62

Fentanyl

59

58

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The most commonly used adjuncts are adrenaline, opioids (fentanyl), and clonidine. Combined with tetracaine and bupivacaine, adrenaline 25 lgkg)1 of body weight extends the duration of analgesia by up to 50% (56,57). Low doses of fentanyl, 0.2 lgkg)1 of body weight, have been added to intrathecal bupivacaine. At these dose levels, fentanyl improves the quality and prolongs the duration of spinal block without compromising the safety of spinal anesthesia (58). Higher doses of intrathecal fentanyl, 1 lgkg)1 of body weight (59), and intrathecal morphine, 7 lgkg)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 lgkg)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 lgkg)1, clonidine may induce hypotension, respiratory depression, and sedation (6163). Alternatives to single-shot spinal anesthesia In small infants, spinal anesthesia is a challenging technique, and owing to signicant interindividual variation in the duration of the block, the anesthetist must always be ready to deal with inadequate anesthesia 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 vulnerable patient group. Continuous spinal anesthesia is not frequently used in children although it has some theoretical advantages. Continuous spinal anesthesia allows the use of a small initial dose of local anesthetic followed by titration to the desired level and duration of anesthesia, giving small additional doses as required. The technique has been described in some relatively small samples suggesting that it may have some benets (16) but also risks of its own, such as leakage of cerebrospinal uid alongside the catheter and risk of dura-cutaneous stula formation (65). Combining spinal anesthesia with continuous epidural blockade a rapid onset and a prolonged duration of anesthesia can be obtained. With an epidural catheter increments could be given to extend the height and duration of the initial block achieved with spinal injection, and epidural catheter could be used for the treatment for postoperative pain following major surgery. Combined spinal-epidural anesthesia and analgesia is
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feasible technique for major abdominal, genitourinary, and lower limb orthopedic surgery (66,67). This technique 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 complications 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 complaints, and clinicians may misinterpret physical and behavioral changes suggestive of postpuncture complications (11). The most well known complication of dural puncture is a position-dependent headache (69). Overall, headache 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 readily after resuming the recumbent position. Children may have nausea and vomiting and associated symptoms from different cranial nerves, such as vertigo, tinnitus, diminished hearing, and blurred vision, may occur (11,7072). To reduce the risk of postdural puncture headache, lumbar puncture should be performed with a small diameter atraumatic needle with a stylet, as thin atraumatic needles are associated with the lowest incidence and severity of puncture complications (45). In Kuopio, 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 sufciently 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 generally undergoes spontaneous resolution within 35 days, but in some children, it may last for several days. The rst line treatment for severe symptoms is bed
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Table 3 Management on postdural puncture headache (references: 68,71,72) 1. Use thin atraumatic needle for lumbar puncture Incidence with cutting-point needles With 25- or 27-gauge needles: 45% With 22-gauge needle: 1015% 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 hydrationi.v. uids if p.o. uids not tolerated Nonopioid analgesicsparacetamol with NSAID Caffeineup to 10 mgkg)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 35 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 0.20.3 mlkg)1 of body weight

whose symptoms do not t with those of classic postpuncture complaints (7072). Backache following lumbar puncture and spinal anesthesia is common, 510% 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 socalled transient neurological symptoms (73). The symptoms 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 harmful psychological and physiological sequelae for the child. Spinal anesthesia produces a dense intra-operative analgesia, and when combined with sedation or general anesthesia, it reduces the requirements for anesthetic agents, muscle relaxants, and opioids intraoperatively. 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 puncture headache and transient neurological symptoms may develop also in children with spinal anesthesia. If these symptoms persist for long term, they may surpass the benets of spinal anesthesia and should therefore be identied and treated appropriately. Because in young children, these symptoms may be difcult to perceive, parents should be informed and given contact information should complications arise after discharge. Acknowledgments This research was carried out without funding.
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rest, normal hydration, nonopioid analgesics, and caffeine. If the symptoms persist, an epidural blood patch should be considered as it is an effective treatment (Table 3; 7072). An epidural blood patch is rarely required, but when a lumbar puncture has been performed with a cuttingpoint 2527 Gauge needle position-dependent headache 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 vertebra interspace, or one below or one above, where the lumbar puncture had been performed. The appropriate volume seems to be 0.20.3 mlkg)1 of body weight. This amount of blood compresses the dural sac sufciently to reverse the decreased pressure in the subarachnoidal 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 epidural space. If the symptoms are not relieved, other diagnoses should be considered before repeating the procedure. This is especially important in patients
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Conict of interest No conicts of interest declared. References

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