Spinal block experiences?

[WhoisitnowRalph]

I'm having a fairly small op at the back of my leg in a couple of weeks (gastrocnemius release). I'm not fond of anaesthetics due to fear of nausea/vomiting, and although I had a GA a couple of years ago and didn't vomit, I felt pretty hideous - although that may have been due to fentanyl (sp?).

It seems I could have a spinal block instead of a GA, with sedation (although I don't mind being awake at all).

I gather that a drop in blood pressure can make you feel faint and sick when the injection takes place - and as a chronic migraine sufferer, the potential post-spinal block headache doesn't sound much fun.

Has anyone had a spinal block for a small op, how was it? Any sickness or murderous headache?

I work in anaesthetics (not an anaesthetist but an odp).

Spinal/sedation is increasingly used for lower limb surgery nowadays. It’s a good option but nausea wise it does lower blood pressure which causes nausea and vomiting. It’s more common in an obstetric setting though than orthopaedics (nausea that is, it still drops blood pressure but doesn’t cause as much nausea as messing with a uterus causes nausea and vomiting - vagus nerve stimulation). You also have to think are you happy to hear what’s happening in theatre? Plus you won’t feel pain but you potentially will still have sensation to a degree and will be able to feel them moving your foot around. Plus there is the potential of it not working and needing a general anaesthetic anyway (very very small chance).

The other option which will greatly reduce your chances of post operative nausea and vomiting is to ask for total intravenous anaesthetic (tiva). Not all anaesthetists are able to do it though. It’s the gas that they use to keep you asleep that makes you feel sick but this way it’s a medication called propofol (that they send you to sleep with, plus will be used for sedation if you have a spinal) plus remifentinil which is a slightly stronger form of fentanyl but wears off quickly. There’s a much lower instance of post operative nausea and vomiting and it’s safer for a lot of patient groups. You don’t get the hangover feeling after a gas general anaesthetic either.

I’ve had 2 ga and both had tiva and it’s great. I felt amazing after, after my tonsillectomy I was waiting to go home and a guy opposite was feeling really awful, he clearly had a gas anaesthetic while I hadn’t. He asked how the hell was I so perky.

Personally I wouldn’t have a spinal but that’s because I have arthritis in my spine and where they put a spinal is the only ‘good’ part of my spine at the moment lol. If I didn’t I would. It’s a completely personal thing for which I’ve once been called an idiot by an anaesthetist. Err what happened to patient choice 😂.

@Greybeardy I’ve seen anaesthetists give spinals for hysteroscopys. A spinal and sedation is a common anaesthetic technique for orthopaedics.

And wth is floppy lateral? Sounds like bad practice. Even a small procedure should be properly laterally positioned.

I had a spinal block for my second c-section following a full on epidural for my first (I don't know the subtle differences - I think one just stayed attached, whereas the block was a one and done injection).

It was great - wore off fast with no after-effects (unlike the epidural which took an age to go, I shook like I was freezing throughout the op to the extent I didn't feel safe touching my baby, and my legs both swoll up like balloons which was great with a newborn!)

@Daveminion that is so interesting about tiva. I’ve had a few GA’s now and my last one the anaesthetist said he was going to give me oxy over morphine and I woke up feeling bloody amazing. I wonder if I had tiva there too.

What’s the restriction on it? I’m due more surgery this year and can’t stand the sickness and grogginess after a GA. infact when people fear going to sleep, I fear waking up! Haha!

Would love to trivia a tiva next time around (parathyroidectomy if it makes any difference - so throat)

I had a spinal block for stitches after I gave birth - it was by far my favourite part of the whole experience! My blood pressure dropped and also my temperature but that was put down to blood loss rather than the procedure itself. No after effects at all, I felt totally fine other than I couldn't move my legs for a while.

@DaveMinion I’m aware spinal with sedation is common for orthopaedic surgery (having done several thousand such anaesthetics!). Some surgeons might want a patient in the prone position for surgery on the back of the knee and managing someone sedated in the prone position can be challenging, as with your experience, I’m sure you’re aware. Am also aware hysteroscopies can be done with spinal (although am not quite sure why that’s relevant here). A ‘floppy’ lateral position isn’t that uncommon, isn’t unsupported and when done properly isn’t bad practice as it can allow surgical access without some of the risks of prone positioning. The volatile (not gas) vs TIVA debate is not quite as straightforward as suggested and while some people do get on better with TIVA I’ve certainly seen people puke after it too. If TIVA were ‘safer’ for a lot of patients we’d probably have entirely abandoned volatile by now. The balance of risk and benefit for any anaesthetic (indeed any procedure) will be different for every patient & that’s why I suggested that the OP should talk to the person actually involved in their care rather than take what’s written by a bunch of well-meaning strangers as gospel when making their decisions.

@Greybeardy and @DaveMinion THANK YOU

I do so love to hear scientific detail from the professionals, but anecdotal/personal experience from MN is all I have in the absence of a trained anaesthetist before I actually get there.

Let's face it, I stressed and begged for my last op that I wanted all possible avoidance of sickness and the guy still gave me gas and fentanyl. But that was for a cholecystectomy and a giant stone that had to be broken up to remove it through the keyhole, so I'm not that surprised that I felt a bit dodgy when I woke up...

Yes I believe I will be face down for this op. I also have a BMI of 38, if that makes a difference, but no breathing issues. I ticked yes to back problems, but to be fair it's a sacroiliac problem rather than a lumbar one.

So I should ask for 100% intravenous anaesthetic - TIVA?

I’ve had one a few times now. Had one for an emergency forceps delivery with first baby, one after second baby when the placenta retained and had one for my c-section. Never had a headache or any nausea at all, felt fine tbh.

@WhoisitnowRalph A cholecystectomy is a completely different beast to minor peripheral ortho surgery and would have a predictably higher incidence of nausea whatever anaesthetic technique is used (because not all nausea related to what type of anaesthetic is used). FWIW even if I’m doing TIVA for a chole I also give fentanyl (with an anti-emetic) as it’s less emetogenic than morphine. Severe pain is also emetogenic and so there’s a risk/benefit balance to consider with using weaker/no analgesia vs strong opioids (+/- antiemetic). I would not initially ask for ‘100% anything’ and would discuss with the anaesthetist what they normally do for the procedure (they will have good reason for the recipe they usually use for this...and it may be GA/neuraxial (ie.spinal)/regional) and discuss your concerns - the last thing you want is someone doing a procedure that they’re not completely comfortable with. Hope that helps and it goes smoothly.

I'm also emetophobic and had a spinal for an elective csection. Not a hint of nausea! I did mention on the pre-op forms that I have a tendency to feel sick easily so they'd give me something, and I think it was ranitidine (was a small shot of liquid that tasted salty and sweet at the same time). I felt completely fine during the op. I did get weird shaking legs afterwards which I think is a side effect of the spinal wearing off.

If it's a planned operation then it's very unlikely for you to be sick because you need to fast for 8-12 hours beforehand. There is nothing in your stomach. I was actually starving by the end of it all and the first thing I did when out of recovery was eat.

I have had 2 for hip replacements with sedation, no problems.

That makes complete sense @Greybeardy, thank you. I feel reassured and better armed with some understanding so I can have a discussion with the anaesthetist - the last one seemed a bit weary of it all and I sensed his impatience. Thanks for the info, really helpful.

I had a spinal for c-section with no side effects - and I am prone to low blood pressure and was sick throughout my pregnancy. I have had a general before for teeth extraction- that made me ill with reduced blood pressure and needing an ambulance later that day - I would take a spinal every time.

Ok, op is on Monday and I've just read the other thread about GA and I'm shitting myself again.

I'm so confused now about what anaesthesia method they will use - I thought the surgeon mentioned "local" with sedation, so initially I thought they would simply numb the immediate area (I'm having a small incision in the calf muscle behind the knee). Then there was talk of a spinal block, but ultimately it may need to be a GA.

I've had some helpful and technical responses on this thread but now I'm worrying again! I wish you could speak to the anaesthetist in advance, not just on the day. What if they don't come to see me, what if they forget me and I just have to go along with everything and don't get a say? I'm going to be struck dumb with fear anyway. I don't care about pain or death, I just don't want to vomit!

By way of an update, in case anyone searches this topic in future years and reads through this thread - I didn't need a spinal at all. I had loads of local at the incision site, then what they called "heavy sedation" - no anaesthetic gases, no opiates apart from a 10th of the usual dose of a-fentanyl (sp? it wasn't fentanyl but a variety of it), standard anti emetic and propofol. That anaesthetist was hilariously called Mr Jackson, and he was brilliant - smiley, easy going, reassuring, patient with my questions.

I was out for just over an hour, and woke with NOT A HINT of nausea. Dead tired, but rather than the usual groggy, sicky disoriented sensation, I just felt like I'd had the best sleep ever.

Slightly giddy as I gradually woke up, with the ghost of a headache, but otherwise the experience was actually quite pleasant.

I now have to self inject blood thinners and wear a sexy stocking on the good leg, and the heparin has made my heart race a bit with the first jab tonight (117 according to my watch). Hopefully that's normal eh...