Spinal anesthesia or block is a one-time injection in the back whereas epidural anesthesia or block is injected either as a one-time injection or as a continuous infusion of local anesthetic medication. Let’s jump to find out more.
The patients receiving this can be classified into 3 major categories:
- Children – Boys and Girls
- Adult Males
- Adult Females
We have performed many spinal and epidural anesthesia in children. In this article, we will share our experiences with spinal anesthesia vs epidural anesthesia in children.
Authors
By Dr. Rajeev Iyer, MBBS, MD, FASA; Board Certified Anesthesiologist
Associate Professor of Anesthesiology,
The University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
Dr. Harshad Gurnaney, MBBS, MD is a Board Certified Pediatric Anesthesiologist & Pain Medicine Expert
What’s the difference between a spinal block and an epidural?
Spinal block or spinal anesthesia is provided as a single injection in the lower spine in the lumbar area. However, epidural can be either given as a one-time injection or as a continuous injection at any spine location. Epidural can be injected into a few different locations.
| Type of injection | Spine Level | Comments |
|---|---|---|
| Spinal Anesthesia | Lower lumbar spine | Commonly used in premature babies and sometimes in older children |
| Epidural Anesthesia | Cervical spine | I have used it in a few instances for anesthesia. This is however most commonly used for pain relief |
| Thoracic spine | Used during thoracic surgery & pain relief. Also used for certain spine injuries | |
| Lumbar spine | Used during abdominal & lower limb surgeries. Also used for certain spine injuries | |
| Sacral spine | Commonly used in children and is called caudal block |
Here is a live demo of how spinal anesthesia is actually done in children:
Epidural vs spinal which is safer?
Epidural and spinal have their own places where it is given to children. Both of them are safer. Like any procedures, they have some inherent risks. However, when done by qualified personnel with appropriate patient selection and precautions epidural and spinal anesthesia are extremely safe.
A study from India has shown that spinal anesthesia in children is safe, effective, and has a high success rate for lower abdominal and lower limb surgeries of less than 90 minutes duration. It can even be the method of choice for small children who go home the same day after surgery.
Regarding the safety of epidural anesthesia, a study looked at 70 children who received epidural blocks ranging from infants to older children. The study showed that epidural anesthesia is safe in children and any complications were minor.
Is epidural a type of spinal anesthesia?
I will start with anatomy here. The spinal cord where anesthesia works is an extension of the brain. This spinal cord is surrounded by a fluid space called cerebrospinal fluid or CSF. This is further cushioned by the following 3 layers from outside to inside:
- Dura
- Arachnoid
- Pia
| Type of Anesthesia | Where Injected |
|---|---|
| Spinal Anesthesia | Between dura and arachnoid matter where CSF is present |
| Epidural Anesthesia | Outside the dura or extradural space |
The below picutre shows where a spinal and epidural needles are placed in realation to the spine.
Is a spinal more painful than an epidural?
I am keeping a focus on children here.
Epidural anesthesia is given in children after general anesthesia. The passage of the epidural needle is not felt by children due to general anesthesia.
Sometimes epidural may be given awake in older children. Before putting in the epidural needle, lignocaine local anesthesia is infiltrated into the skin to make it numb so the passage of the epidural needle is not felt.
Spinal anesthesia can be done after sedation or in awake babies. A local anesthesia cream is placed 20 to 30 minutes prior to spinal anesthesia or local anesthesia is injected on the skin.
Bottom line, the pain of epidural and spinal are not significantly different if local anesthesia was not used on the skin. Since local anesthesia, sedation, or general anesthesia is used prior to these blocks, there is typically very little pain during the placement of spinal or epidural. There may be a sensation of the needle going on but this is more of a sensation than actual pain.
Which is better for children: epidural or spinal?
This depends on the type of surgery. Here is a table describing when both of these are used.
| Type of Anesthesia | Indication |
|---|---|
| Spinal Anesthesia | - Lower limb surgery - Lower abdominal surgery |
| Epidural Anesthesia (Used with general or spinal anesthesia) | - Thoracic surgery - Abdominal surgery - Hip surgery - Lower limb surgery - Chronic pain - Spine injury |
Which is better for C-section epidural or spinal?
A C-section is done under spinal anesthesia. Local anesthesia used in epidural is typically sufficient for pain relief but does not provide dense anesthesia to perform a surgery. Hence, surgeries are done with a spinal block and not epidural alone. If a pregnant woman is getting epidural anesthesia for labor pain and then requires a C-section, then either a large dose of the local anesthetic is given in teh epidural for the C-section or spinal anesthesia is administered. This is further detailed in this article from the American Society of Anesthesiologists.
If the C-section is emergent, then general anesthesia may be required.
Is a spinal needle the same as an epidural?
The spinal needle and epidural needle are different from each other. Both the needles have a stylet that prevents part of the skin from getting pushed into the spine if these needles were hollow.
An epidural needle is bigger in size than a spinal needle. The below figure describes these figures.
The different needles used for spinal and epidural anesthesia are in the below table.
| Type of Anesthesia | Needle Type | Comments |
|---|---|---|
| Spinal Needle (22-27G) | Quincke | Sharp tip and cutting edge (this is the one i use) |
| Whitacre | Pencil point and non cutting | |
| Sprotte | Pencil point and non cutting | |
| Atraucan | Makes a small linear cut in the dura. Quincke makes a V shaped cut. | |
| Epidural Needle (17-22G) | Tuohy needle | This is the most commonly used. I use this needle to place epidural |
| Hustead Needle | Looks similar to Tuohy. Tuohy has a curved tip but Hustead does not. | |
| Crawford | ||
| Weiss | ||
| Sprotte Spezial |
An epidural catheter is placed with an epidural needle. Here is an excellent article on epidural catheters from the journal Anesthesiology. This article discusses the history, innovations, and clinical implications of epidural catheters.
Which anesthesia is given in normal delivery?
I have done an entire article dedicated to this question. Check this out in this link to find more about this. Also, watch this in a video format on YouTube.
What is better spinal or general anesthesia for children?
In my experience, more than 99% of children get general anesthesia. This is because of three reasons:
- Surgery type
- Surgery duration
- Hospital’s culture
- Patient characteristics
Where indicated in premature babies and feasible surgeries, spinal anesthesia may be more favorable than general anesthesia if it can be avoided. According to two studies referenced on the American Society of Anesthesiologists website, infants having certain types of surgery have better recovery with spinal anesthesia than general anesthesia.
What is the disadvantage of spinal anesthesia?
There are two big ones I can think of
- Limited Duration of action. Spinal anesthesia in children typically works for approximately 60 minutes. On the other hand, it works for approximately 2 to 3 hours in adults.
- Children may not lie still to have a block in the back, unlike adults, and hence will need sedation or local anesthesia or both to do this block.
I have used the following medications along with local anesthesia to prolong the duration of spinal anesthesia. These are published scientific research studies and here is the information:
- Fentanyl – A pain medicine that is commonly used intravenously
- Clonidine – A medicine commonly used to reduce anxiety, provide sedation, and treat high blood pressure
- Neostigmine – Another commonly used anesthesia medicine to reverse muscle relaxants.
What are the risks of spinal anesthesia?
Spinal anesthesia is a safe procedure. Major complications are rare, however, there are few that are reported. The following are not specific to children but generally reported for spinal anesthesia and epidural anesthesia in adults and children.
| Complications | Incidence and Comments in Children | Incidence and Comments in Adults |
|---|---|---|
| Overall | Incidence of complications is between 1/1000 and 1/1,000,000 | |
| Urinary retention | Children will have urinary catheter placed | High incidence between 5-70%. Patients will have urinary catheter placed |
| Transient Neurologic Symptoms | 3-4% | Severe radicular pain. More in patients who receive lidocaine (i have not seen this being used), obese patients, lithotomy position for surgery and same day discharge. |
| Total spinal anesthesia | 0.6% | This may need conversion to general anesthesia |
| Spinal or Epidural hematoma | Epidural - 1:150,000 Spinal - 1: 220,000 | |
| Post dural puncture headache | 0.5 to 5% | Up to 7% |
| Failed spinal anesthesia | Yes this is possible due to various reasons | 85% recover within 3 months |
| Epidural abscess | 0.015% to 0.7% | |
| Drug toxicity | Local anesthesia gets absorbed into blood stream | |
| Backache | 5-10% | Can be common. There may be other factors contributing to the back pain. Self limited but may last several weeks. |
Can spinal anesthesia cause paralysis?
I analyzed the literature and found some anecdotal cases of paralysis after spinal anesthesia. These cases are extremely rare and these patients have other underlying risk factors. With increased recognition of risk factors, this complication should not deter anyone from having spinal anesthesia if indicated.
Spinal and epidural anesthesia should be performed by a qualified anesthesia doctor or qualified personnel under their supervision.
Can spinal anesthesia cause death?
There are rare reports of cardiac arrest reported in patients having spinal anesthesia and they have been successfully resuscitated. Assuming spinal anesthesia is done by qualified personnel, patients who have cardiac arrest can be resuscitated.
I did not find any report directly attributing spinal anesthesia to causing death. If you come across any reports of death with spinal anesthesia, comment below or use the contact me page to let me know. What are the long-term side effects of spinal anesthesia?
Bottom line: Spinal Anesthesia vs. Epidural Anesthesia
| Features | Spinal Anesthesia in Children | Epidural Anesthesia |
|---|---|---|
| Injection Site | Lower lumbar area (L4-5 and L5-S1) in neonates | Any indicated location of the spine |
| Local Anesthesia Dose | Younger children require higher doses | Younger age groups get less dose |
| Duration of action | Shorter duration of action compared to adults | Can be used as a continuous infusion to obtain desired effect to as long as possible |
| Cardiac effects | Unlikely in younger children due to immature sympathetic nervous system | Unlikely since it is doses gradually |
| Respiratory effects | Rare instances of total spinal anesthesia | Unlikely since dosed gradually |
| Drug Used | - Hyperbaric Bupivacine - Normobaric Bupivacaine - Mepivacine | - 0.125% or less concentration of Bupivacine - 0.1% Ropivacine |
| Adjuvants Used | Uncommon | Commonly used e.g. Clonidine |
| Needle Used | Smaller size pointed | Bigger size blunt |
| Use | Intraoperative | Intraoperative and Postoperative |
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