SUSSEX HIP & KNEE REPLACEMENT CLINIC
Rationale for Spinal Anaesthesia Choices: For joint replacement surgery an anaesthetic is required. The choice is either a general anaesthetic or a spinal anaesthetic with full sedation. The decision as to which type of aaesthetic is always yours after weighing up the benefits and the risks of both options. Our rationale and recommendation for spinal anaesthetic is based on the following advantages:
General anaesthetic downsides; General anaesthetic is often associated with more confusion and feeling “groggy” immediately after the operation. There is is also a greater risk of nausea and vomiting afterwards as a side effect of morphine related agents used, these are not required with a spinal anaesthetic. There is some evidence of a greater potential to lose some cognitive function, with increasing seniority this becomes a greater issue. This is avoided with or significantly minimised with a spinal anaesthetic and sedation (we use propofol).
Spinal anaesthetic has benefits of comfort, lower overall risk and better initial well-being. The spinal anaesthetic blocks the feeling of the surgery from the operation site and therefore the body’s various stress systems are not triggered, or much less so. This means that the blood pressure is not raised, indeed blood pressure is typically lower as the blood vessels in the legs are relaxed.
CUSTOM KNEE REPLACEMENT • RAPID RECOVERY • HAMMER FREE KNEE REPLACEMENT • MUSCLE PRESERVING HIP REPLACEMENT
For hip replacement surgery: lower blood pressure means much less bleeding and therefore clearer visualisation of the details during the procedure, thus greater precision of the operation.
Furthermore lower blood pressure means less blood loss and thus a lower risk of blood transfusion. At the time of wake up you should have N O pain at all as you will still be comfortably numb. Finally there is a slight reduction in thrombosis risk with a spinal.
For knee replacement surgery the lower blood pressure following a spinal anaesthetic means the operation can be done without tourniquet (think the painful arm cuff when you have your blood pressure taken - but for an hour rather than 30 seconds or so. No tourniquet means the leg has blood flow and oxygen throughout the operation . The knee likes blood flow and oxygen, so No tourniquet means much less swelling, more comfort, a lower risk of wound problems, and an 80% reduction in thrombosis risk.
Furthermore MRI studies indicate that a knee replacement WITH tourniquet leads to a 20% reduction in muscle mass around the thigh muscles for at least 6 months from the muscles being compressed. Mad. These are the muscles you need after a knee replacement. The reduction in swelling, increased comfort, and maintenance of muscle bulk means a more rapid and comfortable recovery with a tourniquet-free knee replacement. The ability to carry out a knee re-placement without tourniquet is greatly facilitated by a spinal anaesthetic, as this blocks the body’s awareness of the surgery and thus the blood pressure response.
CUSTOM KNEE REPLACEMENT • RAPID RECOVERY • HAMMER FREE KNEE REPLACEMENT • MUSCLE PRESERVING HIP REPLACEMENT
Knee replacement comfort and thrombosis risk A spinal anaesthetic relaxes the arteries to the lower leg and increases the blood flow to the lower leg, leading to a small reduction in thrombosis risk. At the end of your operation, because the spinal anaesthetic is still working the expectation is of zero pain because one is still numb from the waist downwards; it is nice to wake up in absolute comfort and to be able to eat and drink straight away.
Spinal aneasthetic prevents spinal "wind-up" When the spinal anaesthetic wears off because of the manner of nerve signalling in the lower back one has a higher level of comfort for many months following the procedure than one would have had without a spinal anaesthetic.
Level of sedation During the procedure the anaesthetist will then run intravenous (into-theveins) deep (complete) sedation during the operation. This controlled deep sedation means there is an expectation (but not guarantee) that you will be asleep (completely out of it) and won’t hear anything during the operation that will cause distress. A very small number of patients report the sensation of movement under sedation; this is NOT pain which is fully blocked by the spinal anaesthetic. If this were to happen it will NOT be distressing.
CUSTOM KNEE REPLACEMENT • RAPID RECOVERY • HAMMER FREE KNEE REPLACEMENT • MUSCLE PRESERVING HIP REPLACEMENT
Return of feeling. Typically the feeling in the legs will return 3 hours later, as the local anaesthetic wears off-just as it does at the dentist after a dental filling or similar. As the feeling returns you may get pins and needles. The above forms the basis for our recommendation for spinal anaesthetic however the final decision is always yours. If you would like to discuss the difference in anaesthetics please can this be done ahead of time rather than on the day of surgery. This timing relates to the legal frame work of having a cool-off period of approximately 10 days to weigh up new information. Just before surgery/anaesthesia there simply isn't 10 days. Thus it is better ( we have to) unless you waive your legal right to the cool-off) to postpone your surgery and discuss this and indeed any other details that would affect your consent to treatment.
Our goal is you are fully prepared for your surgery with no last minute questions-UK case law just doesn't permit it. Just ring Deborah for an appointment. Occasionally a spinal anaesthetic is not technically possible on the day, and thus the anaesthetist would revert to a general anaesthetic as a plan “B”. I hope this is helpful and I very much look forward to seeing you for your operation. James Lewis, Specialist Joint Replacement Consultant, GMC 3276523 Custom Knee replacement, Tourniquet free and hammer-free Knee replacement. Muscle preserving, geometric reconstruction, uncemented Hip Replacement Reviewed with Dr Allan, Dr Spring and Dr Nicholson 7th August 2019, updated 23 Jan 2021
CUSTOM KNEE REPLACEMENT • RAPID RECOVERY • HAMMER FREE KNEE REPLACEMENT • MUSCLE PRESERVING HIP REPLACEMENT
Video Showing Spinal Anaesthesia and recovery after hip Replacement
CUSTOM KNEE REPLACEMENT • RAPID RECOVERY • HAMMER FREE KNEE REPLACEMENT • MUSCLE PRESERVING HIP REPLACEMENT
Anaesthetic choices for hip or knee replacement This leaflet explains what to expect from your anaesthetic when you have an operation to replace your hip or knee. It has been written by anaesthetists, patient representatives and patients, working together. Introduction When you are going to have a hip or knee replacement there are two main different types of anaesthetic you can have: ■
a spinal anaesthetic (sometimes also with sedation to relax you)
■
a general anaesthetic.
There are other procedures that you can have as well, which should reduce your pain and make the whole experience more comfortable. These are: ■
a nerve block
■
local anaesthetic infiltration (injections) around the joint and the wound
■
occasionally an epidural.
Before your operation
The preoperative assessment clinic Most hospitals will invite you to attend a preoperative assessment clinic to look at your general health and activity levels. Please bring your tablets in the original packaging or a copy of your current prescription. You will be asked about your general health and activity and about previous illnesses, operations and anaesthetics. You will also be asked any allergies you may have.
rcoa.ac.uk/patientinfo | 1
Anaesthetic choices for hip or knee replacement Staff will assess your health for the operation and order all the tests that you need, such as blood tests or an ECG (heart tracing). Staff can also talk to you about types of anaesthetic for your operation. You may also meet an anaesthetist to discuss your health in more detail and your anaesthetic choices. They may strongly recommend one particular way of having your anaesthetic if you have medical concerns. In patients with complex medical problems or with severe limitations in activity not due to your joints, it is possible that your anaesthetist will think there are very high risks. You may want extra time to think about whether to go ahead with the operation at all and to discuss it with your family or others.
Enhanced recovery programme Many hospitals offer an enhanced recovery programme, which aims to shorten the time it takes to recover from your operation and speed up your return to a normal life. This means that the staff looking after you will follow an evidence-based programme of care, called a care pathway. This covers: ■
preparing you before surgery
■
setting out a typical plan for the anaesthetic and pain relief
■
organising the care that you need on the ward afterwards
■
encouraging early eating, drinking and walking, all of which shorten the time you need to spend in hospital.
The anaesthetic care for enhanced recovery will also keep pain and unpleasant after-effects to a minimum.
Hip and knee school Most enhanced recovery programmes offer information sessions that take place before your surgery. Members of the team who will be looking after you will explain each stage of your stay in hospital and your recovery afterwards. You can also ask any questions you might have about the procedure and the anaesthetic.
Questions you may like to ask your anaesthetist ■
What can I do to improve my health before the surgery?
■
Who will give my anaesthetic?
■
What type of anaesthetic do you recommend?
■
Have you often used this type of anaesthetic?
■
What are the risks of this type of anaesthetic?
■
Do I have any special risks?
■
How will I feel afterwards?
rcoa.ac.uk/patientinfo | 2
Anaesthetic choices for hip or knee replacement Our Fitter Better Sooner resources will provide you with the information you need to become fitter and better prepared for your operation. Please see our website for more information: rcoa.ac.uk/fitterbettersooner
Preparing for the operation There is much you can do to prepare yourself for your surgery and the recovery period if you are having planned surgery. ■
If you smoke, giving up for several weeks before the operation will reduce the risk of breathing problems during your anaesthetic and after your surgery.
■
If you are overweight, reducing your weight will reduce many risks from having an anaesthetic and will improve your recovery.
■
If you have loose teeth or crowns, treatment from your dentist may reduce the risk of damage to your teeth during the anaesthetic.
■
If you have a long-standing medical problem such as diabetes, asthma or bronchitis, thyroid problems, heart problems or high blood pressure, you should check with your GP surgery that these are controlled as well as possible ahead of your surgery.
■
Increasing your activity in the weeks before surgery can improve your heart function and fitness levels. Studies have shown this can make a big difference to your recovery from surgery. If your joints are painful you may find swimming helpful.
■
Make sure you have enough medicines to last you during your hospital stay, as well as hearing aid batteries. Pack some magazines, puzzles or music with headphones to help you relax before and after your surgery.
■
It is best to plan early for your recovery at home afterwards and let your friends and family know how they can best help you. Think about what you will eat, whether you need any extra equipment or can make any changes at home to make your recovery easier.
Anaesthetic options Anaesthesia for your hip or knee replacement may be carried out with a combination of a spinal anaesthetic, a general anaesthetic, a nerve block and sedation. Your anaesthetist will discuss with you which is the best option for you.
Spinal anaesthetic Spinal injections are commonly used to give anaesthesia for both hip and knee replacements. A spinal is an injection of local anaesthetic. For an epidural, the anaesthetist places a fine plastic tube (epidural catheter) into the back. This allows extra local anaesthetic to be given if needed. The effects of an epidural can last a lot longer than a spinal anaesthetic and may keep you in bed for longer.
rcoa.ac.uk/patientinfo | 3
Anaesthetic choices for hip or knee replacement Please see our leaflet Your spinal anaesthetic which is available from our website: rcoa.ac.uk/patientinfo/leaflets-video-resources There are two situations when the anaesthetist may suggest an epidural instead of a spinal anaesthetic: ■
if there is a particular need for longer-lasting pain relief afterwards
■
if your operation is expected to last longer than two to three hours.
However, an epidural may keep you in bed for longer. Your anaesthetist will discuss with you if they think an epidural will be helpful for you. Please see our leaflet Epidural pain relief after surgery which is available from our website: rcoa.ac.uk/patientinfo/leaflets-video-resources
A general anaesthetic A general anaesthetic produces a state of controlled unconsciousness during which you feel nothing. You will receive: ■
anaesthetic drugs (an injection and/or a gas to breathe)
■
oxygen to breathe
■
sometimes, also a drug to relax your muscles.
You will need a breathing tube in your throat while you are anaesthetised, to make sure that oxygen and anaesthetic gases are able to reach your lungs. If you have been given drugs that relax your muscles, you will not be able to breathe for yourself and a breathing machine (ventilator) will be used. You will be unconscious during all of this. When your operation ends, the anaesthetic is stopped and you regain consciousness. Disadvantages A general anaesthetic alone does not provide pain relief after the operation. Strong pain killers may be needed, which make some people feel sick, drowsy or have itching. If used over a few days they can lead to constipation. To manage pain after the operation, a nerve block (where local anaesthetic drugs are injected around a nerve), wound infiltration (where local anaesthetic drugs are injected around the wound) or, more rarely, a spinal anaesthetic may be offered with a general anaesthetic. You can read more detail about your anaesthetic in our leaflet Anaesthesia explained which is available from our website: rcoa.ac.uk/patientinfo/anaesthesia-explained
A nerve block This is an injection of local anaesthetic near to the nerves that go to your leg. There are different types of nerve blocks – your anaesthetist may find the right nerve using an ultrasound machine. Part of your leg should be numb and pain-free for some hours afterwards. Depending on the type of nerve block, you may not be able to move your leg properly during this time. The operation cannot be done with a nerve block alone. You will need to have a spinal or a general anaesthetic as well.
rcoa.ac.uk/patientinfo | 4
Anaesthetic choices for hip or knee replacement Advantages A nerve block should give pain relief for some hours and will reduce the need for strong pain relief medicines. This will help with enhanced recovery and a quicker return to eating and drinking. Disadvantages Although your pain relief is better, the nerve block may prevent full movement of your leg and can lengthen the time before you walk.
Wound infiltration This is an injection of local anaesthetic, and sometimes other pain relief medicine, around the joint being operated on. It is given by the surgeon during the operation. It can be given as well as a spinal or general anaesthetic to make you more comfortable after the operation. Sometimes a small plastic tube is left in the joint to top up the injection.
Advantages It improves the pain relief, without affecting the muscle strength of the leg. The pain relief is variable, but you may be able to get up sooner than if you have a nerve block.
Sedation Sedation is often used with a spinal anaesthetic to make you relaxed and sleepy during the operation. ■
Sedation can often be tailored to your preference (such as minimal, moderate or deep sedation).
■
People who have sedation often have some memories of being awake in theatre.
Please discuss the use of sedation with your anaesthetist so that they know what you would like. You can read more about sedation in our leaflet Sedation explained which can be found on our website: rcoa.ac.uk/patientinfo/sedation
On the day of your operation
The hospital should give you clear instructions about stopping eating and drinking. These instructions are important. If there is food or liquid in your stomach during your anaesthetic, it could come up into your throat and lungs. This may endanger your life. If you have diabetes please check with your hospital about when to eat and drink and what diabetic medication to take on the day of your operation. If you are a smoker you should not smoke on the day of your operation. You should also not vape.
rcoa.ac.uk/patientinfo | 5
Anaesthetic choices for hip or knee replacement If you are taking medicines, you will need specific instructions from the pre-assessment team about which tablets you should take that day. You can take a sip of water to take any tablets as needed. If you take any ‘blood thinning’ drugs such as warfarin, clopidogrel or rivaroxaban, you will need to discuss with your consultant when you should stop taking them. However, there can be risks if you stop taking these medications and you may be prescribed an alternative instead. If you feel unwell when you are due to come into hospital, please telephone the ward for advice.
Meeting your anaesthetist Your anaesthetist will meet you before your operation. If you have not met them before they will discuss with you what anaesthetic choices are suitable for you. You may also meet Anaesthesia Associates who are highly trained healthcare professionals. You can read more about their role and the anaesthesia team on our website: rcoa.ac.uk/patientinfo/anaesthesia-team
Having a ‘pre-med’ (premedication) This is the name for drugs that can be given before an anaesthetic. There may be a drug to prevent sickness, to reduce acid in the stomach, to start off the pain relief or to help you relax.
When you are called for your operation ■
A member of staff will go with you to the theatre.
■
You can usually wear your glasses, hearing aids and dentures until you are in the room where your anaesthetic will be given. You may be able to keep them on if you are not having a general anaesthetic.
■
If you are having a local or regional anaesthetic, you may be able to take your own electronic device, with headphones to listen to music (check with your nurse beforehand).
■
You may walk to theatre, accompanied by a member of staff, or you may go in a wheelchair or on a bed or trolley. If you are walking, you can usually wear your own dressing gown and slippers.
Routine checks will be done as you arrive in the operating department, before the anaesthetic starts. You will be asked your name, your date of birth, the operation you are having, whether left or right side (if applicable), when you last ate or drank and any allergies. These checks are normal in all hospitals.
Starting the anaesthetic Your anaesthetic may start in the anaesthetic room or in the operating theatre. Your anaesthetist will be working with a trained assistant. The anaesthetist or the assistant will connect you to machines that measure your heart rate, blood pressure and oxygen levels (and sometimes some extra ones too).
rcoa.ac.uk/patientinfo | 6
Anaesthetic choices for hip or knee replacement A needle is used to put a thin soft plastic tube (a cannula) into a vein in the back of your hand or arm.
During the operation An anaesthetist (or qualified anaesthesia practitioner working under their supervision) will stay with you for the whole operation and will monitor your condition very closely, adjusting the anaesthetic as required. If you are awake or having sedation, the anaesthetist will be able to talk with you to reassure you and help you relax.
Blood transfusion During or after some operations, you can lose a significant amount of blood. If necessary, a blood transfusion can be used to replace the blood you have lost. Please ask your surgeon or anaesthetist if you would like to know more about blood transfusion and any alternatives which may be available. You can also find more information from the NHS website: nhs.uk/conditions/blood-transfusion
After the operation ■
You will be taken to the recovery room, which is near to the operating theatre.
■
You will receive one-to-one care from a healthcare professional in the recovery room. There will be other patients in the same room. Your heart rate, blood pressure and oxygen levels will be monitored carefully. You will usually be given oxygen through a light plastic face mask. You may have a drip (a bag of sterile fluid attached to your cannula, which keeps you well hydrated).
■
If you have pain or sickness, it will be treated promptly.
■
You may be offered something to drink.
■
When the recovery room staff are satisfied that you have recovered safely from your anaesthetic you will be taken back to the ward.
Pain relief The anaesthetic for a hip or knee replacement is usually focused on minimising pain after your operation, but pain is a normal part of the recovery process. The aim of pain relief after your operation is to make pain tolerable and to allow you to get up and start using your new joint. It is not possible to eliminate pain altogether and a certain level of pain should be expected.
rcoa.ac.uk/patientinfo | 7
Anaesthetic choices for hip or knee replacement Here are some ways of giving pain relief:
Pills, tablets or liquids to swallow This is the most frequently used method of pain relief after hip and knee replacement.
Suppositories These waxy pellets are placed in your back passage (rectum). They are used occasionally.
Nerve blocks and epidurals These can give effective pain relief for hours or days after the operation.
Wound infiltration This can make you comfortable for some hours after the operation.
Injections Injections into a vein have a very rapid effect. Injections into the leg or buttock muscle work more slowly. Strong pain-relieving drugs such as morphine, pethidine or codeine may be given. Occasionally, pain is a warning sign that all is not well, so you should always report it to your nurses and seek their advice and help.
Side-effects, common events and risks Serious problems are uncommon with modern anaesthetics. Risk cannot be removed completely, but modern equipment, training and drugs have made anaesthesia a much safer procedure in recent years. Please see the individual risk leaflets available on our website: rcoa.ac.uk/patientinfo/risks/risk-leaflets Very common events after an anaesthetic include sore throat, sickness, thirst, shivering and bruising. Temporary memory loss may occur; this is more common in those who are over 60 years of age. There are rare risks including damage to teeth and nerve damage. The risk of a severe allergic reaction to a drug is estimated at 1 in 10,000. There is a very rare risk (1 in 20,000) of being conscious during a period of your anaesthetic. The risk of death directly as a result of an anaesthetic is estimated to be 1 in 100,000 for those people who are otherwise healthy. Anaesthetists take a lot of care to reduce these events and risks. Your anaesthetist will be able to give you more information about any of these risks and the precautions taken to avoid them. You can find a summary of common events and risks in anaesthesia on our website: rcoa.ac.uk/patientinfo/risks/risk-at-a-glance-infographics With increasing age and health concerns there are increased risks of blood clots in your legs or lungs and increasing risks of heart disease and stroke and even death around the time of an operation. You should discuss these risks with your surgeon, anaesthetist or pre-assessment team.
rcoa.ac.uk/patientinfo  |  8
Anaesthetic choices for hip or knee replacement
Tell us what you think We welcome suggestions to improve this leaflet. If you have any comments that you would like to make, please email them to: patientinformation@rcoa.ac.uk Royal College of Anaesthetists Churchill House, 35 Red Lion Square, London WC1R 4SG 020 7092 1500
rcoa.ac.uk
Fifth Edition, February 2020 This leaflet will be reviewed within three years of the date of publication. © 2020 Royal College of Anaesthetists This leaflet may be copied for the purpose of producing patient information materials. Please quote this original source. If you wish to use part of this leaflet in another publication, suitable acknowledgement must be given and the logos, branding and images removed. For more information, please contact us.
rcoa.ac.uk/patientinfo | 9
Your spinal anaesthetic This leaflet explains what to expect when you have an operation with a spinal anaesthetic. It has been written by anaesthetists, patients and patient representatives, working together. Introduction This leaflet explains: ■
what a spinal anaesthetic is
■
how it works
■
why you could benefit from having one for your operation.
What is a ‘spinal’? For many operations it is usual for patients to have a general anaesthetic. However, for operations in the lower part of the body, sometimes it is often possible for you to have a spinal anaesthetic instead. This is when an anaesthetic is injected into your lower back (between the bones of your spine). This makes the lower part of the body numb so you do not feel the pain of the operation and can stay awake. Typically, a spinal lasts one to two hours. Other drugs may be injected at the same time to help with pain relief for many hours after the anaesthetic has worn off. During your spinal anaesthetic you may be: ■
fully awake
■
sedated – with drugs that make you relaxed, but not unconscious.
For some operations a spinal anaesthetic can also be given before a general anaesthetic to give additional pain relief afterwards. Your anaesthetist can help you decide which of these would be best for you.
rcoa.ac.uk/patientinfo | 1
Your spinal anaesthetic Many operations in the lower part of the body are suitable for a spinal anaesthetic with or without a general anaesthetic. Depending on your personal health, there may be benefits to you from having a spinal anaesthetic. Your anaesthetist is there to discuss this with you and to help you make a decision as to what suits you best. A spinal anaesthetic can often be used on its own or with a general anaesthetic for: ■
orthopaedic surgery on joints or bones of the leg
■
groin hernia repair, varicose veins, haemorrhoid surgery (piles)
■
vascular surgery: operations on the blood vessels in the leg
■
gynaecology: prolapse repairs, hysteroscopy and some kinds of hysterectomy
■
urology: prostate surgery, bladder operations, genital surgery.
How is the spinal performed? ■
You may have your spinal in the anaesthetic room or in the operating theatre. You will meet the anaesthetic assistant who is part of the team that will look after you.
■
Your anaesthetist will first use a needle to insert a thin plastic tube (a ‘cannula’) into a vein in your hand or arm. This allows your anaesthetist to give you fluids and any drugs you may need.
■
You will be helped into the correct position for the spinal. You will either sit on the side of the bed with your feet on a low stool or you will lie on your side, curled up with your knees tucked up towards your chest.
■
The anaesthetic team will explain what is happening, so that you are aware of what is taking place.
■
A local anaesthetic is injected first to numb the skin and so make the spinal injection more comfortable. This will sting for a few seconds. The anaesthetist will give the spinal injection and you will need to keep still for this to be done. A nurse or healthcare assistant will usually support and reassure you during the injection.
You may also meet Anaesthesia Associates who are highly trained healthcare professionals. You can read more about their role and the anaesthesia team on our website: rcoa.ac.uk/patientinfo/anaesthesia-team
What will I feel? A spinal injection is often no more painful than having a blood test or having a cannula inserted. It may take a few minutes to perform, but may take longer if you have had any problems with your back or have obesity. ■
During the injection you may feel pins and needles or a sharp pain in one of your legs – if you do, try to remain still, and tell your anaesthetist.
■
When the injection is finished, you will usually be asked to lie flat if you have been sitting up. The spinal usually begins to have an effect within a few minutes.
rcoa.ac.uk/patientinfo | 2
Your spinal anaesthetic ■
To start with, your skin will feel warm, then numb to the touch and then gradually you will feel your legs becoming heavier and more difficult to move.
■
When the injection is working fully, you will be unable to lift your legs up or feel any pain in the lower part of the body.
Testing if the spinal has worked Your anaesthetist will use a range of simple tests to see if the anaesthetic is working properly, which may include: ■
spraying a cold liquid and ask if you can feel it as cold
■
brushing a swab or a probe on your skin and asking what you can feel
■
asking you to lift your legs.
It is important to concentrate during these tests so that you and your anaesthetist can be reassured that the anaesthetic is working. The anaesthetist will only allow the surgery to begin when they are satisfied that the anaesthetic is working.
During the operation (spinal anaesthetic alone) ■
In the operating theatre, a full team of staff will look after you. If you are awake, they will introduce themselves and try to put you at ease.
■
You will be positioned for the operation. You should tell your anaesthetist if there is something that will make you more comfortable, such as an extra pillow or an armrest.
■
You may be given oxygen to breathe, through a lightweight, clear plastic mask, to improve oxygen levels in your blood.
■
You will be aware of the ‘hustle and bustle’ of the operating theatre, but you will be able to relax, with your anaesthetist looking after you.
■
You may be able to listen to music during the operation. If you are allowed, bring your own music, with headphones. Some units supply headphones or play music in the operating theatre.
■
You can talk with the anaesthetist and anaesthetic assistant during the operation.
If you have sedation during the operation, you will be relaxed and may be sleepy. You may snooze through the operation, or you may be awake during some or all of it. You may remember some, none or all of your time in theatre. For more information about sedation, please see our ‘Sedation explained’ leaflet, which can be found on our website: rcoa.ac.uk/patientinfo/sedation You may still need a general anaesthetic if: ■
your anaesthetist cannot perform the spinal
■
the spinal does not work well enough around the area of the surgery
■
the surgery is more complicated or takes longer than expected.
rcoa.ac.uk/patientinfo | 3
Your spinal anaesthetic
After the operation ■
It takes up to four hours for sensation (feeling) to fully return. You should tell the ward staff about any concerns or worries you may have.
■
As sensation returns, you will usually feel some tingling. You may also become aware of some pain from the operation and you can ask for any pain relief you need.
■
You may be unsteady on your feet when the spinal first wears off and may be a little lightheaded if your blood pressure is low. Please ask for help from the staff looking after you when you first get out of bed.
■
You can usually eat and drink much sooner after a spinal anaesthetic than after a general anaesthetic.
Why have a spinal? The advantages of spinal alone compared with having a general anaesthetic may be: ■
a lower risk of a chest infection after surgery
■
less effect on the lungs and the breathing
■
good pain relief immediately after surgery
■
less need for strong pain-relieving drugs that can have side effects
■
less sickness and vomiting
■
earlier return to drinking and eating after surgery.
Understanding risk People vary in how they interpret words and numbers. This scale is provided to help.
Very common 1 in 10 One person in your family
Common
Uncommon
1 in 100 One person in a street
1 in 1,000 One person in a village
Rare 1 in 10,000 One person in a small town
Very rare 1 in 100,000 One person in a large town
Serious problems are uncommon with modern anaesthetics. New equipment and techniques, training standards and more effective drugs have made it a much safer procedure. To understand the risk to you, you must know: ■
how likely it is to happen
■
how serious it could be
■
how it can be treated.
The anaesthetist can discuss risks with you and help you make a decision on what type of anaesthetic is best for you.
rcoa.ac.uk/patientinfo | 4
Your spinal anaesthetic
Side effects and complications As with all anaesthetic techniques, there is a possibility of unwanted side effects or complications with a spinal anaesthetic. More information about the side effects and complications from a spinal anaesthetic can be found on our website: rcoa.ac.uk/patientinfo/risks/risk-leaflets
Very common events and common side effects ■
Low blood pressure – as the spinal takes effect, it can lower your blood pressure. This can make you feel faint or sick. This will be controlled by your anaesthetist with the fluids given through your drip and by giving you drugs to raise your blood pressure.
■
Itching – this can commonly occur if morphine-like drugs have been used in the spinal anaesthetic. If you have severe itching, a drug can be given to help.
■
Difficulty passing urine (urinary retention) or loss of bladder control (incontinence) – you may find it difficult to empty your bladder normally while the spinal is working or, more rarely, you may have loss of bladder control. Your bladder function will return to normal after the spinal wears off. You may need to have a catheter placed in your bladder temporarily, while the spinal wears off and for a short time afterwards. Your bowel function is not affected by the spinal.
■
Pain during the injection – if you feel pain in places other than where the needle is – you should immediately tell your anaesthetist. This might be in your legs or bottom, and might be due to the needle touching a nerve. The needle will be repositioned.
■
Post-dural puncture headache – there are many causes of headache after an operation, including being dehydrated, not eating and anxiety. Most headaches can be treated with simple pain relief. Uncommonly, after a spinal it is possible to develop a more severe, persistent headache called a post-dural puncture headache, for which there is specific treatment. This happens on average about 1 in 200 spinal injections. This headache is usually worse if you sit up and is better if you lie flat. The headache may be accompanied by loss of hearing or muffling or distortion of hearing.
For more information about post-dural puncture headaches, please read the leaflet Headache after a spinal or epidural injection which is available on our website: rcoa.ac.uk/patientinfo/risks/risk-leaflets
Rare complications Nerve damage – this is a rare complication of spinal anaesthesia. Temporary loss of sensation, pins and needles and sometimes muscle weakness may last for a few days or even weeks, but most disappear with time and a full recovery is made. Permanent nerve damage is rare (approximately 1 in 50,000 spinals). It has about the same chance of occurring as major complications of having a general anaesthetic. For more information on nerve damage please read the leaflet Nerve damage associated with a spinal: or epidural injection which is available on our website: rcoa.ac.uk/patientinfo/risks/risk-leaflets
rcoa.ac.uk/patientinfo | 5
Your spinal anaesthetic
Frequently asked questions Can I eat and drink before my spinal? You will be asked to follow the same rules as if you were going to have a general anaesthetic. This is because it is occasionally necessary to change from a spinal to a general anaesthetic. The hospital should give you clear instructions about when to stop eating and drinking before your surgery.
Do I have to stay fully conscious? Before the operation, you and your anaesthetist can decide together whether you remain fully awake during the operation or would prefer to be sedated so that you are not so aware of the whole process. The amount of sedation can usually be adjusted so that you are aware, but no longer anxious. It is also possible to combine a spinal with a general anaesthetic but this does mean there are risks of both a spinal and a general anaesthetic.
Will I see what is happening to me? A screen is placed across your body at chest level, so that you can’t see the surgery. Some operations use video cameras and telescopes for ‘keyhole’ surgery. Some hospitals give patients the option to see what is happening on the screen.
Do I have a choice of anaesthetic? Yes usually, depending on the actual surgery and any potential problems with you having a spinal. Your anaesthetist will discuss choices with you. There are uncommon reasons why you may not be able to have, or may be advised not to have, a spinal anaesthetic. These include having: ■
certain abnormalities of your spine or previous surgery on your back
■
‘blood thinning drugs’ that cannot be stopped or abnormalities of your blood clotting
■
infection in the skin of your back or a high temperature
■
certain heart conditions.
Can I refuse to have the spinal? Yes. If, following discussion with your anaesthetist, you decide you do not want one or are still unhappy about having a spinal anaesthetic, you can always say no.
Will I feel anything during the operation? You should not feel pain during the operation but for some procedures you may be aware of pressure as the surgical team carry out their work.
Should I tell the anaesthetist anything during the operation? Yes, your anaesthetist will want to know about any sensations or other feelings you experience during the operation; this is part of their monitoring of the anaesthetic.
rcoa.ac.uk/patientinfo | 6
Your spinal anaesthetic Is a spinal the same as an epidural? No. Although they both involve an injection of local anaesthetic between the bones of the spine, the injections work in a slightly different way. With an epidural a fine plastic tube remains in your back during the operation meaning that more anaesthetic can be used as necessary. More details can be found in our leaflet Epidural pain relief after surgery, which is available from our website: rcoa.ac.uk/patientinfo/leaflets-video-resources
Where can I learn more about having a spinal? You can speak to your anaesthetist or contact the pre-assessment clinic or anaesthetic department in your local hospital.
Tell us what you think We welcome suggestions to improve this leaflet. If you have any comments that you would like to make, please email them to: patientinformation@rcoa.ac.uk Royal College of Anaesthetists Churchill House, 35 Red Lion Square, London WC1R 4SG 020 7092 1500
rcoa.ac.uk
Fifth Edition, February 2020 This leaflet will be reviewed within three years of the date of publication. © 2020 Royal College of Anaesthetists This leaflet may be copied for the purpose of producing patient information materials. Please quote this original source. If you wish to use part of this leaflet in another publication, suitable acknowledgement must be given and the logos, branding and images removed. For more information, please contact us.
rcoa.ac.uk/patientinfo | 7