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 block (or plexus anesthesia)
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 seven days.

Frequently Asked Questions About Regional Anesthesia

What is epidural anesthesia?

Epidural anesthesia is an RA technique that 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, abdominal, or joint replacement surgery.

What is spinal anesthesia?

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

What are peripheral nerve blocks (or plexus anesthesia)?

Peripheral nerve blockade (or plexus anesthesia) is an RA technique that involves injecting medication directly around nerves to render a specific region or area insensate. Recent 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.

Most upper- and lower-extremity operations can be performed under this type of anesthesia, and frequently, peripheral nerve blocks are the preferred technique. Additionally, a catheter can sometimes be introduced during placement of the initial anesthetic, allowing for continuous infusion of medications for prolonged periods to provide many days of pain management.

What is local anesthesia?

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 small, superficial procedures can be accomplished this way, including some eye surgeries, hernia repairs, breast surgeries, and many plastic surgery and dermatologic procedures. Even knee arthroscopy is commonly performed this way.

Can these RAs be combined, or can pain management be prolonged?

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

Some 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, often under ultrasound guidance, right next to the nerves we wish to block. The catheter is then secured to the skin, and a small 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 (except for epidurals or spinals, which do require hospital stays). 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 continuous block is made by you, your anesthesiologist, and your surgeon. Historically, we know which patients and which type of surgeries benefit the most from this technique, and we will recommend it when appropriate.

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. Why anesthetize the whole body for surgery on your hand or foot?

The second most dramatic advantage is superior pain control after the surgery. The mainstay of postoperative pain control has always been opiate medications (morphine, Demerol, Vicodin, Percocet, etc.). Opiates, however, are not always completely effective and have a long list of side effects and risks associated with them. A common example is that many people experience nausea and vomiting when taking opiates.

With RA, we can often minimize or eliminate the need for opiates, allowing these patients 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.

Finally, there are numerous other advantages to RA for certain operations, such as less chance of chronic pain, less operative bleeding, and fewer blood clots in the postoperative period. 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 is usually dictated by the anesthetic technique, type of surgery, and other medical problems you may have (including obesity, smoking, and drug use).

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, provide you the best postoperative pain control, and minimize your risk.

The risks that apply to all regional anesthetic techniques are local anesthetic toxicity (seizures, unconsciousness, and 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. Specific complications and side-effect risks are best discussed with your anesthesiologist.

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. The reported frequency of this complication, depending on how it is defined, ranges from essentially zero to as high as 10 percent.

The good news is that nearly all of the "nerve injuries" are either very short-lived (days) or simply go away (heal) on their own, leaving no residual difficulty. While mild nerve dysfunction is a relatively common issue after all types of anesthetics, it is incredibly rare for a patient to have a permanent nerve injury after any kind of anesthetic.

Does it hurt?

With a few exceptions, regional anesthetics are usually administered with the patient awake but moderately sedated. Local anesthetic is used to numb the injection site, and the injection 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 common question. 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 sometimes because your risk under 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 full general anesthesia in addition to the regional anesthetic. There are very few patients who recall any aspect of being in the operating room as uncomfortable, and many do not remember it at all.

My friend got "numbed up" for her 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?

There are many different variables that come into play. We do place peripheral nerve catheters in some patients with the plan that they can go home the day of surgery. A small pump filled with anesthetic medication is then attached to the catheter and delivers medication for several days. After about 2–3 days, most people tolerate the surgical pain easily with oral medication, and the catheter can be removed.

I've heard of people being paralyzed 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! However, nerve injuries do rarely happen. It is best to discuss this issue directly with your anesthesiologist.

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