Enhancing safety in neuraxial anesthesia: Understanding pathologies and improving decision-making

The use of spinal anesthesia and analgesia techniques, including epidural and subarachnoid procedures, is integral to modern medical practice. However, these procedures are frequently performed without imaging guidance, which can lead to significant risks, particularly in patients with underlying neuraxial pathologies. A recent study by Avellanal et al. 2024 emphasizes the need for thorough preoperative assessments to mitigate potential complications, particularly in patients with predisposing spinal conditions.

Key pathologies impacting neuraxial anesthesia

1. Lumbar spinal stenosis (LSS):
   • Affects up to 19% of individuals over 60.
   • Characterized by reduced spinal canal space, leading to pain and potential anesthesia challenges.
   • Clinical implications:
     • Difficulty with anesthetic diffusion.
     • Risk of traumatic root injury or lateralized blocks.
   • Recommendations:
     • Conduct MRI or CT scans for high-risk patients.
     • Avoid neuraxial procedures at severely stenotic levels unless guided by imaging.
2. Cerebrospinal fluid fistula and pseudomeningocele:
   • Typically arise from dural tears, often post-surgical.
   • It may present as postural headaches or remain asymptomatic.
   • Clinical recommendations:
     • Screen with imaging for patients with a surgical history.
     • Avoid neuraxial techniques at affected levels to prevent re-opening dural tears.
3. Facet cysts:
   • Synovial cysts are commonly found at the L4-L5 level.
   • It can obstruct anesthetic flow or be inadvertently punctured.
   • Guidelines:
     • Identify cyst presence through imaging.
     • Ensure alternative approaches or adjust techniques accordingly.
4. Arachnoid cysts:
   • Rare but significant, often congenital or post-surgical.
   • Absolute contraindication for spinal anesthesia.
   • Action points:
     • Screen patients with a history of neurological symptoms or surgery.
     • Employ imaging to detect and assess cyst impact.
5. Muscle collections, seromas, and hematomas:
   • Common in post-surgical settings, seromas can persist undetected.
   • Management:
     • Preoperative imaging to detect collections.
     • Exercise caution during needle insertion to avoid puncturing seromas.
6. Disc extrusions:
   • Large herniations can distort spinal anatomy, complicating procedures.
   • Steps to mitigate risks:
     • MRI screening for recent or severe back pain cases.
     • Avoid neuraxial blocks in cases with significant dural displacement.

Recommendations for preoperative evaluation

1. Comprehensive assessments:
   • Include patient history, physical examination, and imaging (MRI or CT) for suspected cases.
   • Incorporate validated tools to screen for conditions like LSS.
2. Risk-to-benefit analysis:
   • Prioritize alternative techniques when neuraxial procedures pose significant risks.
   • Reduce anesthetic dose to minimize neurotoxicity and complications.
3. Imaging integration:
   • Use X-ray, ultrasound, or fluoroscopy for guided procedures, especially in challenging cases.

Conclusion

The complexities of spinal pathology necessitate a shift in clinical practices towards thorough evaluations before neuraxial procedures. By incorporating advanced imaging and adopting a cautious approach, healthcare professionals can enhance patient outcomes and reduce the risks of morbidity. This paradigm change not only safeguards patient safety but also optimizes the efficacy of regional anesthesia techniques.

For more detailed information, refer to the full article in Regional Anesthesia & Pain Medicine.

Avellanal M, Riquelme I, Ferreiro A, et al. Neuraxial pathology and regional anesthesia: an education guide to decision-making. Regional Anesthesia & Pain Medicine 2024;49:832-839.

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