Incidence

A total spinal is unlikely, although not unheard of. It more commonly happens in these two scenarios:

• An epidural catheter has migrated intrathecally and an epidural dose of local anaesthetic is subsequently given
• Epidural anaesthesia has failed and spinal anaesthesia has been used. The dural hole, albeit small, can allow the large volume of epidural local anaesthetic to 'jet' in under pressure. This sequence of events is most likely to happen in obstetrics, where labour epidurals are commonly topped up for urgent caesarean sections

Providing a total spinal is recognized and treated in a timely manner, recovery is complete. If recognition or treatment is delayed, hypoxic brain injury can result.

Total spinal can occur in other regional blocks. For instance, it can follow inadvertent puncture of a dural sleeve during interscalene brachial plexus block or during psoas compartment block.

Treatment

Treatment is as per high spinal, but will usually require active management of the airway, including tracheal intubation if airway protection is required.

Supportive care continues until the block has regressed sufficiently; this usually only takes a matter of hours. Appropriate care is most easily provided in intensive care.

Patients who have suffered a total spinal report that consciousness may be lost late or may not be lost at all. Practitioners must bear this in mind and must consider the need for drugs to prevent patient awareness during airway management and during supportive care.