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Patient Guide > Regional Anesthesia

Regional anesthesia (RA) refers to the techniques used to make only certain "regions" of the body insensate or "numb" to the pain of surgery. The most common methods used today are epidural anesthesia, spinal anesthesia, peripheral nerve (or plexus) anesthesia, and local anesthesia. Regional anesthesia can be used alone or combined with sedation or general anesthesia to provide the surgical anesthetic. Additionally, regional anesthesia usually provides for a prolonged period of superior pain control (analgesia.) Depending on the method used, this pain control can sometimes be extended up to 7 days.

Epidural anesthesia is a RA technique which refers to placement of medications in the epidural space of the spinal column. A catheter is usually placed in the epidural space to deliver medication for several days. Most commonly, an "epidural" is used for relief of pain during labor and delivery. However, it is also frequently used for pain relief after major chest, major abdominal or joint replacement surgery.

Spinal anesthesia is a RA technique which refers to injection of medication into the spinal sac within the spinal column. "Spinals" are frequently used as the primary anesthetic for certain urologic and obstetric procedures (C-sections, transurethral resection of prostate, etc.) Additionally, it can be used for medium duration pain management (up to 24 hours).

Peripheral nerve blocks, or plexus anesthesia, is a RA technique which involves injecting medication directly around nerves to render a specific region or area insensate. Technique advancements now allow us to visualize many nerves in the body with a portable ultrasound device and place the medications around nerves under direct vision. Many upper and lower extremity operations can be performed under this type of anesthesia. Additionally, a catheter can usually be introduced during placement of the initial anesthetic, allowing for continuous infusion of medications for prolonged periods. Look here for more information on continuous regional anesthesia. Frequently, peripheral nerve blocks are the preferred technique for many orthopedic surgical procedures, in both inpatients and outpatients.

Finally local anesthesia refers to the technique of simply injecting numbing medications directly at the site of the surgical incision. Most commonly patients experience "locals" at the dentist's office. However, many other procedures can be accomplished this way including most eye surgery, hernia repairs, many plastic surgery or dermatologic procedures, etc. Even knee arthroscopy is commonly performed this way.

All the above techniques are frequently combined with sedation anesthesia, or general anesthesia (GA), in order to try and minimize side effects while providing you as comfortable a surgical experience as possible.

Frequently Asked Questions about Regional Anesthesia:

What are the benefits of regional anesthesia? Why should I choose this over general anesthesia?

What are the risks and side effects of regional anesthesia?

Does it hurt?

I don't want to be awake for surgery.....can you just "knock" me out?

My friend got "numbed up" for her ankle/foot/shoulder/hand surgery and went home that day. She said the surgery never hurt because there was some kind of pump that gave her medicine for a couple days......can I have that?

I've heard of people being paralysed after having a spinal. Is that possible?

What are the benefits of regional anesthesia? Why should I choose this over general anesthesia?
There are numerous advantages to using RA. The most obvious one is the ability to localize the anesthetic to only the operative site. As such, the risks and side effects of general anesthesia can be eliminated (or minimized in the case of combined RA/GA). Why anesthetize the whole body for surgery on your finger?

The second most dramatic advantage is superior pain control after the surgery. The mainstay of post operative pain control has always been opiate medications (morphine, demerol, vicodin, percocet, etc). Opiates are not always completely effective, and have a long list of side effects and risks associated with them. For example, many people have terrible nausea and vomiting after taking opiates. With RA, we can often minimize or eliminate the need for opiates allowing these people to not have to choose between feeling pain or feeling nauseated. Additionally, RA techniques can be tailored to provide analgesia (pain control) for several hours to several days after the surgery. Look here for information on continuous peripheral nerve blocks.

There are numerous other advantages to RA for certain operations such as less chance of chronic pain, less operative bleeding, fewer blood clots in the postoperative period, etc. These issues can be discussed in detail with your anesthesiologist.
What are the risks and side effects of regional anesthesia?
ALL anesthetics (regional, general, and even simple sedation) carry some degree of risk. The likelihood of a given complication in you is usually dictated by the anesthetic technique, type of surgery, and other medical problems you may have (including obesity, smoking, drug use, etc). With modern anesthetic techniques, however, the chance of a serious complication is exceedingly rare. Your anesthesiologist will recommend the type of anesthetic he/she feels is most appropriate for your surgery, will provide you the best postoperative pain control, AND minimizing your risk.

The risks that apply to all regional anesthetic techniques are local anesthetic toxicity (seizures, unconsciousness, cardiac rhythm abnormality with cardiac collapse), soreness at the injection site, bleeding/hematoma/bruising at the injection site, nerve damage, and an incomplete or failed block. Again, the risk of any of these complications occurring is very low, but never zero. For the specific complications associated with any given technique, see here. Specific complications and side effect risks are best discussed with your anesthesiologist.

A few comments about the topic of "nerve damage" after RA is in order. The vast majority of patients undergo regional anesthesia with few if any side effects. However, the notion of nerve damage, regardless of how unlikely, frightens many people. Nerve injuries have been reported after all types of anesthetics, both regional and general, and the reported frequency of this complication, depending on how it is defined, ranges from essentially zero, all the way to as high as 10% (one in every ten patients). The good news, is that nearly all of the "nerve injuries" are either are very short lived (days) or eventually simply go away (heal) on their own, leaving no residual difficulty. It is incredibly rare for a patient to have a permanent nerve injury after any kind of anesthetic.
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Does it hurt?
With a few exceptions, regional anesthetics are usually placed with the patient awake, but moderately sedated. Local anesthetic is used to numb the injection site and is usually noted as a minor sting. None of the procedures should be overtly painful. Most patients report little or no discomfort during placement of their regional anesthetic.
I don't want to be awake for surgery.....can you just "knock" me out?
This is a relatively common response. However, it is important to recognize that your anesthesiologist is recommending RA for good reasons. Usually, it is to improve your comfort level after surgery, but it is also frequently because your risk for general anesthesia may be higher than normal. Keep in mind that even if your primary anesthetic is to be a regional anesthetic, most patients are at least moderately sedated during surgery, or may also get general anesthesia. There are very few patients who recall any aspect of being in the operating room as uncomfortable.
My friend got "numbed up" for her ankle/foot/shoulder/hand surgery and went home that day. She said the surgery never hurt because there was some kind of pump that gave her medicine for a couple days......can I have that?
Maybe. There are multiple different variables that come into play. We do place peripheral nerve catheters in orthopedic patients with the plan that they can go home the same day as surgery. An electronic or mechanical pump, filled with anesthetic medication, is then attached to the catheter and delivers medication for several days. After several days, most people tolerate the surgical pain easily with oral medication and the catheter is pulled out. If a regional anesthetic is planned, you should discuss this possibility with your anesthesiologist. Also see the section below on CPNB.
I've heard of people being paralysed after having a spinal. Is that possible?
While almost anything is possible, the likelihood of such a catastrophic complication is extraordinarily low. You are statistically more likely to be struck by lightning on the way to the hospital! Nerve injuries do rarely happen, but the vast majority of those resolve on their own with no treatment.

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Issues associated with specific regional anesthesia techniques

Epidural anesthesia:
Epidurals are placed anywhere from the high back, all the way down to the tail bone, depending on the type of surgery. Side effects include inadequate or incomplete anesthesia/analgesia, technical difficulty during placement, pain during placement, transient low back pain, "spinal" headache, urinary retention, nausea/vomiting, pruritis (itching). VERY rare complications include nerve/spinal cord damage, epidural hematoma (bleeding), local anesthetic toxicity, and epidural infection/abscess.

Spinal Anesthesia:
"Spinal" side effects include inadequate or incomplete anesthesia/analgesia, technical difficulty during placement, pain during placement, transient low back pain, "spinal" headache, urinary retention, nausea/vomiting, pruritis (itching). VERY rare complications include nerve/spinal cord damage, epidural hematoma, local anesthetic toxicity, and meningitis.

Peripheral Nerve Block-Interscalene Brachial Plexus:
This block is performed at the side/base of the neck and is particularly good for shoulder surgery. A single injection of a long acting anesthetic can be expected to last for up to 36 hours though 8-16 hours is more typical. Expect the arm to be very weak as long as there is any numbness present. Specific complications possible during this block are Horner's syndrome (droopy eyelid, blurred vision on the side of the nerve block), pneumothorax (collapsed lung), and temporary diaphragmatic paralysis resulting in mild to moderate shortness of breath. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block-Supraclavicular Brachial Plexus:
This block is performed just above the clavicle (collarbone). It is used for elbow, forearm, wrist and hand surgery. A single injection of a long acting anesthetic can be expected to last for up to 36 hours though 8-16 hours is more typical. Expect the arm to be very weak as long as there is any numbness present. A specific ptential complication associated with this block is pneumothorax. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block-Infraclavicular Brachial Plexus:
This block is performed just below the clavicle (collarbone). It is used for surgical procedures of the elbow, forearm, wrist and hand. A single injection of a long acting anesthetic can be expected to last for up to 36 hours though 8-16 hours is more typical. Expect the arm to be very weak as long as there is any numbness present. A specific complication associated with this block is pneumothorax. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

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Peripheral Nerve Block-Axillary Brachial Plexus:
This block is performed in the armpit. It is used for surgical procedures of the elbow, forearm, wrist and hand. A single injection of a long acting anesthetic can be expected to last for up to 36 hours though 8-16 hours is more typical. Expect the arm to be very weak as long as there is any numbness present. The most common complication at this site is an axillary hematoma/bruising. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block-Femoral Nerve:
This block is performed in the groin. It is most commonly used for knee replacement, and knee ligament repair. A single injection here usually lasts 8-16 hours. Expect thigh muscle weakness as long as their is numbness present. The most common problem with this block is inadequate anesthesia/analgesia since the knee is innervated by several different nerves. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia or analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block-Sciatic Nerve:
This block can be performed at several sites on the posterior thigh, from the buttock down to the knee. It is usually used for ankle and foot surgery. It can be added to the femoral block for better coverage of the knee. A single injection of a long acting anesthetic can be expected to last for up to 36 hours though 8-16 hours is more typical. Weakness of the hamstrings, and all the muscles of the lower leg can be expected as long as there is numbness present. The most common problem with this block is technical difficulty placing the block. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block-Transversus abdominus plane block:
This block is performed at the flank and usually used for hernia surgery, though it is occasionally indicated for some other abdominal procedures. The most common complication with this block is inadequate anesthesia/analgesia. Weakness of the abdominal muscles is possible with this block, though most people do not notice it. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block- Thoracic Paravertebral:
This block is placed in the upper back and is usually used for breast surgery. Eight to 12 hours of analgesia can be expected from a single injection of long acting anesthetic. The most probable complications from this block are pneumothorax (collapsed lung), inadequate analgesia, and epidural spread resulting in numbness on the opposite side of the block. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

Peripheral Nerve Block- Lumbar Paravertebral:
This block is placed in the lower back and is usually used for hip surgery. Eight to 12 hours of analgesia can be expected from a single injection of long acting anesthetic. The most likely complications from this block are hematoma or bleeding, inadequate analgesia, and epidural spread resulting in numbness on the opposite side of the block. Common to all peripheral nerve blocks are the risks of technical difficulty during placement, inadequate anesthesia/analgesia, soreness/bruising at the injection site, nerve damage, and local anesthetic toxicity (seizures, cardiac rhythm disturbance leading to cardiac arrest, and unconsciousness).

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Continuous Peripheral Nerve Blocks (CPNB)

Many of the above anesthetic techniques can be modified to provide pain control for several days after your surgery. In order to do this, a catheter (tiny plastic tube about the diameter of a pencil point) is positioned, under ultrasound guidance, right next to the nerve bundle we wish to block. The catheter is then secured to the skin and either an electronic or mechanical pump filled with anesthetic medication is connected. The pump then delivers the medication at a predetermined rate until the reservoir is empty. Depending on the circumstances, we might run the pump for 1-5 days after your surgery. The catheter is then simply pulled out, which is absolutely painless.

Having this type of RA does not preclude you from going home immediately after surgery. On the contrary, many people who would otherwise be admitted to the hospital for pain management, can now go home knowing their pain will be well controlled.

The decision to place a CPNB is between you, your anesthesiologist, and your surgeon. Historically, we know which patients, and which type of surgeries benefit the most from a CPNB. Your surgeon may mention it to you well in advance of your surgery.

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