Complications of Spinal Anesthesia

Navigating the Challenges: Complications in Spinal Anesthesia

While spinal anesthesia is generally safe, complications can occur. This comprehensive guide covers prevention strategies, early recognition, and evidence-based management approaches for common and rare complications.

Common Complications (Incidence >1%)

  1. Hypotension (Incidence: 10-30%)
    • Prevention:
      • Fluid preloading (500-1000 mL crystalloid)
      • Left uterine displacement in pregnancy
      • Incremental dosing of local anesthetic
    • Recognition:
      • Systolic BP <90 mmHg or >20% decrease from baseline
      • Associated nausea/bradycardia (Bezold-Jarisch reflex)
    • Management:
      • Fluid bolus (250-500 mL)
      • Ephedrine 5-10 mg IV (first line in obstetrics)
      • Phenylephrine 50-100 mcg IV (first line in cardiac patients)
  2. Post-Dural Puncture Headache (PDPH) (Incidence: 1-10%)
    • Prevention:
      • Use pencil-point needles (25G or smaller)
      • Parallel needle bevel orientation
      • Avoid multiple dural punctures
    • Recognition:
      • Postural headache (worse upright, relieved supine)
      • Associated nausea, photophobia, tinnitus
    • Management:
      • Conservative: Bed rest, hydration, caffeine (300-500 mg)
      • Pharmacological: Sumatriptan, ACTH
      • Interventional: Epidural blood patch (15-20 mL autologous blood)

Uncommon Complications (Incidence 0.1-1%)

  1. High Spinal/Total Spinal
    • Prevention:
      • Test dose aspiration before injection
      • Use baricity to control spread
    • Recognition:
      • Rapid ascending sensory level
      • Hypotension, bradycardia, respiratory depression
    • Management:
      • ABCs: Intubate if respiratory compromise
      • Aggressive hemodynamic support
      • Consider stopping surgery if severe
  2. Nerve Injury (Incidence: 0.01-0.1%)
    • Prevention:
      • Avoid paresthesia during needle placement
      • Stop injection if patient reports pain
    • Recognition:
      • New neurological deficit post-procedure
      • Pain, numbness, or weakness in dermatomes
    • Management:
      • Urgent neurological consultation
      • Consider MRI for structural lesions
      • Most resolve spontaneously within 6-12 months

Rare but Serious Complications (Incidence <0.01%)

  1. Infectious Complications
    • Meningitis (bacterial/viral)
    • Epidural abscess
    • Prevention: Strict aseptic technique
    • Management: Antibiotics, surgical drainage if abscess
  2. Hematoma
    • Risk factors: Coagulopathy, difficult insertion
    • Recognition: Severe back pain, neurological deficits
    • Management: Emergency decompression within 8 hours

Documentation Essentials

When complications occur, document:

  • Time of onset and symptoms
  • Interventions performed
  • Response to treatment
  • Consultations obtained
  • Patient communication

Prevention Checklist

  1. Verify coagulation status
  2. Use smallest gauge pencil-point needle
  3. Maintain strict asepsis
  4. Confirm CSF flow before injection
  5. Have emergency equipment available

Further Learning

Revisit the anatomical foundations in our Anatomy and Physiology guide. Perfect your technique with our Step-by-Step Guide.

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