Back pain after epidural anesthesia: what to do, treatment

Fast Facts About General Anesthesia

Here are some key points about general anesthesia. More detailed and supporting information can be found in the main article.

• The anesthesiologist usually administers a general anesthetic before surgery
• There are some risks associated with the use of general anesthetics, but they are relatively safe when used correctly
• Very rarely, a patient may experience unintentional awakening during surgery
• Side effects of general anesthesia may include dizziness and nausea
• The mechanisms by which anesthesia works are still only partially understood.

General anesthetics cause reversible loss of consciousness and analgesia necessary for surgery . The mechanism of action of anesthetics is not fully understood. There are several theories about this.

General anesthesia is essentially a medically induced coma, not sleep. Anesthetic drugs make the patient indifferent and turn off consciousness .

They are usually administered intravenously or by inhalation . Under anesthesia, the patient does not feel pain and may also experience amnesia.

The drugs will be administered by an anesthesiologist, who will also monitor the patient's vital signs during the procedure.

In this article, we'll look at a number of topics, including the possible side effects of general anesthesia, the risks involved, and some theories about how they work.

Effect of spinal anesthesia technique on the incidence of headaches and back pain

R.R. SAFIN, R.T. GILYALOV, O.G. ANISIMOV, V.A. KORYACHKIN

Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan

Safin Rustam Rafilievich

Candidate of Medical Sciences, anesthesiologist-resuscitator, ICU-4

420015, Kazan, st. Mushtari, 30, apt. 56, tel. 8-919-683-29-14, e-mail

Low back pain and headache (LP and headache) are complications of spinal anesthesia (SA). The causes of BE are painful and repeated manipulations during SA. The causes of headache depend on the design and caliber of the spinal needle. This study compared the incidence of post-puncture pain when using a utility model (RF Patent No. 121436) for inserting a thin spinal needle with existing SA methods. There was a decrease in the frequency of headache when compared with conventional SA of a larger caliber and a decrease in the frequency of BE when performing SA with thin spinal needles after insertion of a guide needle.

Key words:
spinal anesthesia, headaches, back pain.
R. _ R. _
SAFIN , R. _ T. _ GYLALOV , O. _ G. _ ANISIMOV , V. _ A. _ KORYACHKIN
Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan

Influence of spinal anesthesia technique on headache and backache frequency

Backache (BA) and headache (HA) are the accidents of spinal anesthesia (SA). BA is caused with painful and frequent manipulation in the course of SA. HA depends on design and gauge of spinal needle. In this research was compared BA and HA frequency when using useful model (RF patent No. 121436) for installation of a thin cerebro-spinal needle using common ways of SA. Was recorded the frequency drop of HA by comparison with the usual SA with a bigger gauge and the frequency drop of BA when making SA with thin cerebro-spinal needles after injection of a guide-needle.

Key words:
spinal anesthesia, headache, backache.
Headache and back pain after spinal anesthesia (SA) are unpleasant complications that worsen the quality of life of patients in the postoperative period. Some authors believe that the cause of back pain is transient radicular syndrome, caused by the neurotoxicity of the local anesthetic and the tension of the nerve sheaths and roots during prolonged flexion of the patient's back. Others consider this type of pain to be a manifestation of a small epidural hematoma. Still others see a cause-and-effect relationship between pain, the size of the needle gauge and the number of unsuccessful attempts. Regarding headaches, all authors are unanimous: the thicker the gauge of the needle, the more often this complication occurs. The use of thin pencil-point needles certainly reduces the risk of developing headaches, but requires the use of a thick introducer needle, which itself can cause the development of BE after SA [1-3].

Goal of the work -

development of spinal anesthesia techniques to reduce the incidence of post-puncture headaches and back pain.

Materials and methods

450 patients aged 18 to 57 years who underwent knee arthroscopy under SA conditions were examined. The patients were divided into three groups comparable in their characteristics: in the first group (n=150), SA was performed with a Quincke 25 G needle using an external non-invasive guide [4]; in the second (n=150) - with a Quincke 22 G needle without an introducer, in the third (n=150) - with a Quincke 25 G needle using an introducer. 5 days after the operation, patients were surveyed by telephone to determine the development of pain in the puncture area or headaches.

The obtained digital data were processed using a multi-row parametric ANOVA test.

The results obtained and their discussion

Analysis of the data obtained (Table 1) showed that 5 days after SA, headache was noted in the first (main) group in 2.7%, in the second - in 5.3% (p <0.05), in the third - in 2 .0% (p>0.05) of patients. Back pain was registered in the main group in 2.0%, in the second group - in 6.0% (p<0.05), in the third - in 8.0 (p<0.05)% of patients. A comparison of the second and third groups showed that PPP was detected in 5.3 and 2.0% (

p<0.05), back pain - in 6.7 and 8.0% (p>0.05), respectively.

Table 1.

Incidence of post-puncture headaches and back pain

* — p<0.05 compared with the first group;

$ — p<0.05 compared to the second group

In the second group, an increase in headaches was noted, which, in our opinion, is associated with the use of large (22G) diameter needles and repeated attempts at puncture of the subarachnoid space. The increase in the frequency of headaches is associated with the needle gauge [5], since the use of Quincke 22G needles is accompanied by a loss of cerebrospinal fluid of 116 ml/5 hours [6]. In addition, in this group there was a high frequency of repeated punctures: if the tip of the Quincke needle gets into the bone tissue, it is possible to form burrs, which, when the needle is removed, damage the arachnoid membrane and thereby contribute to the leakage of cerebrospinal fluid.

Back pain after subarachnoid puncture (the so-called syndrome of transient neurological disorders) occurred significantly more often in the second and third groups compared to the main group. It has been shown that during knee arthroscopy, back pain develops in 18-22% [7]. From our point of view, the reduction in back pain is due to less traumatic puncture of the subarachnoid space.

Thus, the use of a Quincke 25 G needle with an external non-invasive guide for spinal anesthesia allows one to avoid additional tissue trauma during repeated attempts at subarachnoid punctures and reduce the frequency of post-puncture pain and back pain.

LITERATURE

1. Ovechkin A.M. Safety of neuraxial anesthesia from the point of view of evidence-based medicine / A.M. Ovechkin. — Selected lectures on regional anesthesia and treatment of postoperative pain. - Tver, 2011. - P.118-144.

2. Vandam LD Concerning neuroloic sequelae of spinal anesthesia / LD Vandam // Anesthesiology. - 2004. - V. 100. - P. 176-177.

3. Wilner D. Chronic back pain secondary to a calcified epidural blood putch / D. Wilner, C. Weissman, MY Shamir // Anesthesiology. - 2008. - V. 108. - P. 535-537.

4. Safin R.R. Guide for passing a thin spinal needle. RF Patent No. 121436 / R.R. Safin, I.O. Pankov, O.G. Anisimov // BIMP. - 2012. - No. 30. - P. 11.

5. Horlocker TT, Wedel DJ Neurologic complications of spinal and epidural anesthesia // Reg. Anesth. Pain Med. - 2000. - Vol. 25. - R. 83-98.

6. Holst D., Mollmann M., Ebel C. et al. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles // Anesth. Analg. - 1998. - Vol. 87. - R. 1331-1335.

7. Hodgson P., Liu S., Batra M., Gras T., Pollock J., Neal J. Procaine compared with lidocaine for incidence of transient neurologic symptoms // Reg. Anesth. Pain Med. - 2000. - 25. - R. 218-222.

Story

General anesthetics have been widely used in surgery since 1842, when Crawford Long prescribed diethyl ether to a patient and performed the first painless operation.

On October 16, 1846, American dentist and surgeon Thomas Morton first administered ether anesthesia to a patient to remove a submandibular tumor.

In Russia, the first operation under anesthesia was performed on February 7, 1847 by Pirogov’s friend at the professorial institute, Fyodor Inozemtsev.

Pirogov himself performed the operation using anesthesia a week later. Over the course of a year, 690 operations were performed under anesthesia in 13 cities of Russia, 300 of which were performed by Pirogov!

Soon he took part in military operations in the Caucasus. Here, for the first time in the history of medicine, he began to operate on the wounded with ether anesthesia. In total, the great surgeon performed about 10,000 operations under ether anesthesia.

Is it painful to do local infiltration anesthesia?

When performing anesthesia, a standard disposable syringe with a thin needle is used. Whether local anesthesia is painful depends on your general pain threshold. The patient feels the moment of the first puncture of the skin and a slight feeling of fullness when the drug is administered. After the medication begins to act, sensitivity disappears. The doctor checks how effective the injection is by tapping the skin. In response, there is a feeling that the injection site has become woody.

After the end of anesthesia, sensitivity gradually increases, and a slight tingling sensation may appear. If anesthesia was performed for surgery, pain in the wound area begins to bother you, which can be reduced with the help of non-steroidal anti-inflammatory drugs.

Side effects

Nausea is a common side effect of general anesthesia.

There are a number of potential side effects of anesthesia.

Some people may experience none, others several. None of the side effects are particularly long-lasting and usually occur immediately after anesthesia.

Side effects of general anesthesia include:

• temporary confusion and memory loss, although this is more common in older people
• dizziness
• difficulty urinating
• bruising or soreness from the IV
• nausea and vomiting
• trembling and chills
• sore throat due to breathing tube

Medical errors

Back pain after epidural anesthesia may be the result of an anesthesiologist error. This happens rarely, but the statistics are still available. The doctor may have pierced the wrong place, which is facilitated by a lack of experience and knowledge. Getting into the epidural space is not easy. Due to the doctor’s inaccuracy, blood vessels, nerve formations, ligaments, and intervertebral hernias may be affected.

The anesthesiologist may touch a dense venous network, which happens very rarely. No special intervention is required, the pain will disappear on its own. However, the risk of injury is increased among individuals taking circulatory agents and in patients with coagulopathy. The doctor can also touch a hernia or damage the ligaments if there is a lack of experience in performing such manipulations. That is why anesthesia is usually performed only by experienced specialists with a “tactical hand”.

Pain may result from damage to the nerve roots. The range of side effects varies depending on the site of invasion, the depth of needle insertion, the nature of the injection and other factors. In this case, the patient experiences neurological disorders, paresthesia, pain, etc.

If you have pain, you should consult a doctor again

Risks

In general, general anesthesia is safe. Even very sick patients can be safely anesthetized. The surgical procedure itself involves much greater risk.

Modern general anesthesia is an incredibly safe procedure.

However, older adults and those undergoing lengthy procedures are most at risk for complications . These findings may include postoperative confusion , heart attack, pneumonia, and stroke.

Some specific conditions increase the risk for a patient undergoing general anesthesia, for example:

• obstructive sleep apnea, a condition in which people stop breathing while sleeping
• seizures
• existing heart, kidney or lung disease
• high blood pressure
• alcoholism
• smoking
• previous negative reactions to anesthesia
• medications that may increase bleeding - aspirin, warfarin , for example
• drug allergy
• diabetes
• obesity or overweight

What is spinal anesthesia

Spinal anesthesia refers to a regional anesthesia method that provides complete absence of sensation in the lower half of the body and serves as an excellent alternative to general anesthesia. During this procedure, an anesthetic is injected into the back to “switch off” the pain-conducting nerves.

The advantages of such anesthesia include:

• reducing the amount of blood lost during surgery;
• reducing the risk of complications such as pulmonary embolism and blood clots;
• reducing the negative impact on the lungs and heart;
• absence of vomiting, feeling of nausea, weakness;
• no pain at the end of the operation;
• the opportunity to communicate with the surgeon and anesthesiologist both during and after surgery;
• no strict restrictions on food and drink consumption in the postoperative period.

Operating principle

Spinal anesthesia involves the injection of a local anesthetic into the spinal space , which leads to a blockade of the area of ​​the spinal cord located nearby. In other words, the mechanism of action of such anesthesia is not the blockade of the terminal sections of the nerves (epidural anesthesia), but the spinal cord.

Pay attention to the difference between spinal and epidural anesthesia

As a rule, spinal anesthesia is carried out at the level of the lumbar region , which leads to the “switching off” of the spinal cord from the lower back - the section of the spinal cord formed by the nerves of the abdomen, perineum and lower extremities.

Video: “What is spinal anesthesia?”

Unintentional intraoperative awakening

This refers to rare cases where patients report remaining conscious during surgery, long after the anesthetic should have taken effect . Some patients are aware of the procedure itself, and some may even feel pain.

Unintentional intraoperative awakening is incredibly rare, affecting approximately 1 in every 19,000 patients under general anesthesia.

Because of the muscle relaxants used at the same time as anesthesia, patients are unable to let their surgeon or anesthesiologist know that they still know what is happening.

Unintentional intraoperative awakening is more likely during emergency surgery.

Patients who experience unintentional intraoperative awakening may suffer from long-term psychological problems. Most often, awareness is short-lived and only sounds, and occurs before or at the very end of the procedure.

According to a recent large-scale study of this phenomenon, patients experienced involuntary twitching , stabbing pain, pain, paralysis and suffocation, among other sensations.

Because unintentional intraoperative awakening is rare, it is unclear exactly why it occurs.

Why does postoperative pain occur?

Postoperative pain according to ICD-10 (International Classification of Diseases) refers to unspecified types of pain and does not carry any signaling information for either the patient or the doctor, since the causes and mechanisms of its occurrence are clear. Therefore, modern principles of patient management after surgery provide for maximum relief from unpleasant pain. Moreover, pain has a negative impact not only on healing, but also on vital processes in the body: the functioning of the cardiovascular, respiratory, digestive, central nervous systems, as well as blood clotting4.

The formation of painful sensations is ensured by a multi-level reaction that connects the immediate area of ​​damage (wound surface) and the central nervous system. It begins with mechanical stimuli in the area of ​​the incision and the release of biologically active substances (prostaglandins, bradykinins and others)4, and ends with information processing in the cerebral cortex and the connection of emotional and psychological components.

Pain syndrome develops as a result of the emergence of areas of increased pain sensitivity (hyperalgesia). Primary hyperalgesia is associated directly with damage and forms near the wound. The area of ​​secondary hyperalgesia covers a larger area and occurs later, over the next 12-18 hours4, as it is associated with stimulation of other types of receptors. It is she who is responsible for the preservation and intensification of pain on the second or third day after surgery, and subsequently for the development of chronic pain syndrome7.

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Types

There are three main types of anesthesia . General anesthesia is just one of them.

Local anesthesia is another option. It is done before minor surgeries such as toenail removal. This reduces pain in small, focused areas of the body, but the person receiving treatment remains conscious.

Regional anesthesia is another type. It numbs the entire part of the body - the lower half, for example, during childbirth. There are two main forms of regional anesthesia: spinal anesthesia and epidural anesthesia.

Spinal anesthesia is used for operations on the lower extremities and abdomen. The anesthetic is injected through a special very thin needle into the intervertebral space of the lumbar region . Epidural anesthesia is used for long-term pain relief. Can be used for operations on the chest, abdomen, and lower extremities. During an epidural, a thin plastic catheter is inserted through which a local anesthetic is injected. Pain relief can last as long as needed.

Features of the procedure

Spinal anesthesia is most often used to relieve pain during childbirth, during caesarean section, and during various gynecological operations. However, this type of anesthesia has found application not only in obstetric and gynecological practice, but also in urological surgery, thoracic, plastic, etc.

Epidural anesthesia is performed using various medications. The procedure is performed by an anesthesiologist. The puncture site is treated with an antiseptic, then an anesthetic drug is injected into the epidural space using a special needle. The anesthetic effect is to reduce the sensitivity of pain receptors in a certain area of ​​the body.

Punctures are made in different parts of the spine: from the cervical to the lumbar region. Localization depends on where you want to achieve a decrease in sensitivity. So, in order to relieve pain during labor, an injection is given in the lumbar region. Women quite often complain that their back hurts after epidural anesthesia. Doctors say that this phenomenon is temporary. When performing anesthesia, there is a risk of damage to the hard shell of the spinal cord by the needle, so the manipulation is performed only by certified anesthesiologists.

When providing obstetric and gynecological care, epidural anesthesia is prescribed in the following cases:

• C-section;
• early birth;
• arterial hypertension;
• prolonged labor;
• proteinuria;
• excessive labor;
• low pain threshold.

Epidural anesthesia is often used to aid labor and caesarean sections.

Women have back pain for the first time after spinal anesthesia; anesthesia itself does not affect the fetus in any way. The peculiarity of this anesthesia is that the patient does not lose the ability to move. Anesthesia may also be required for patients with musculoskeletal disorders (sciatica, intervertebral hernia, etc.). The manipulation must be carried out very carefully, since a bacterial infection can join local inflammation.

To avoid adverse consequences, the patient is examined for contraindications.

Local vs General

There are a number of reasons why general anesthesia may be chosen over local anesthesia.

This choice depends on age, health and personal preference.

The main reasons for choosing general anesthesia are:

• The procedure will likely take a long time.
• There is a possibility of significant blood loss.
• This may affect breathing, for example during breast surgery.
• The procedure will make the patient feel uncomfortable.
• It is difficult for the patient to maintain a forced position during surgery.

The purpose of general anesthesia is to induce:

• pain relief or elimination of the natural response to pain
• amnesia or memory loss
• immobility or elimination of motor reflexes
• dream
• relaxation of skeletal muscles

However, the use of general anesthesia poses a higher risk of complications than local anesthesia. If the surgery is minor, then the patient is offered local anesthesia, especially if he has a condition such as sleep apnea or other risk factors.

Types of therapeutic and diagnostic blockades

Local

The injection is made into the affected area, under or around the lesion, into the area of ​​altered tissue reactions, into inflammation, etc. They are divided into periarticular (in the tissue near the joints) and perineural (into the nerve canals).

Segmental

Injections into various segments, these include paravertebral blockades, which are given in the projection of segments of the spine. Each spinal nerve and spinal segment corresponds to a dermatome (a section of the skin, connective tissue), a sclerotome (an area of ​​the skeletal system), and a myotome (part of the muscular system). By injecting the drug intradermally into any dermatome, it is possible to influence the corresponding part of the spine and/or internal organ. The most common indication is myotonic reactions of paravertebral muscles in osteochondrosis.

Vertebral

This therapeutic blockade combines several techniques in neurology. Used for back pain. The anesthetic can be injected intradermally, between the spinous processes of the vertebrae to a depth of 2-4 cm, into the area of ​​the vertebral body. In the latter case, they retreat 3-4 cm to the side from the line of the spinous processes. The needle is directed at an angle of 35° and inserted 8-10 cm in depth.

Spinal blocks

Severe pain in the spine is associated with pinched spinal nerves. The blockade acts in a targeted manner and normalizes well-being. This is not a simple procedure, so it is carried out only as a last resort.

During the blockade, the nerve conduction of certain fibers is temporarily switched off. To do this, local anesthetics are used, which block cellular conduction by inhibiting voltage-dependent sodium pathways.

The procedures are indicated for disc protrusion, osteochondrosis, neuralgia, intervertebral hernia, myositis, spondyloarthrosis. Spinal blocks are cervical, thoracic, thoracolumbar, sacrolumbar, coccygeal, paravertebral. The latter are divided into intradermal and subcutaneous (numb the skin near the spine), intramuscular (relieve muscle spasm and inflammation), perineural ("turn off" the affected nerve).

The effect occurs in a few minutes. At the same time, vascular spasm is reduced, tissue restoration is accelerated, metabolism is normalized, and swelling from inflammation goes away.

Heel spur blocks

Used to relieve inflammation of the heel fascia. The injection is made into the heel spike, in the very center. Hormone-based medications are used. The effect is instant. The difficulty lies in the bone-salt structure of the spine, which complicates the process. The doctor must be highly qualified and experienced. Steroids not only relieve inflammation, but also “accelerate” metabolism. Due to the latter, the bone growth is reabsorbed. Most often, one of three glucocorticosteroids is used: Hydrocortisone, Diprospan or Kenalog. The effectiveness of the method depends 90% on the correct injection. Therefore, the procedure is carried out under ultrasound control. It is extremely painful, so local anesthesia with Ultracaine, Novocaine or other similar medicine is first provided. After the injection, do not step on your heel for 30-60 minutes. Next, to reduce pressure on the heel fascia, special insoles are used.

Joint blocks

They are used for small and large joints when pain is a consequence of a degenerative process or inflammation. The anesthetic is injected into the joint capsule. After this, the pain is completely eliminated. If the case is advanced, then it is significantly reduced. The main indications are bursitis, osteoarthritis of the joints, periarthritis, arthritis of a non-infectious nature, tenosynovitis. The procedure does not require preparation and is performed under local anesthesia. Duration – 20 minutes. The effect occurs within a few minutes. Immediately after administration of the drug, you can move. The duration of the effect depends on the degree of damage to the joint. It averages 21 days. Then repeated blockades are made. Sometimes injections are made not into a joint, but into a muscle. This is necessary to reduce the spasm that causes pain. This group also includes paravertebral blockades. The following joints are treated using this technology: ankle, hip, wrist, knee, shoulder, elbow.

Nerve blocks

An anesthetic is injected into the area along which the peripheral nerve travels. This eliminates pain, vascular spasm, muscle tension, inflammation and swelling. Indications: neuritis, neuralgia, oncology, joint pathologies, muscular-tonic and tunnel syndromes. The procedure can be performed under ultrasound guidance. Duration – up to 10 minutes. The analgesic effect occurs within a few minutes and lasts up to 21 days. Repeated procedures can be performed, except in cases where the effect does not occur after 1-2 injections.

Preoperative assessment

Before undergoing general anesthesia, patients should undergo a preoperative assessment to determine the most appropriate medications, their amount and combination.

Some of the factors that should be examined in the preoperative assessment include:

• body mass index (BMI)
• disease history
• age
• medications taken
• time before anesthesia
• alcohol or drug use
• use of pharmaceuticals
• examination of the oral cavity, teeth and respiratory tract
• cervical spine mobility study

It is important that you answer these questions accurately. For example, if a history of alcohol or drug use is not mentioned, insufficient anesthesia may be given, which could lead to dangerously high blood pressure or unintentional intraoperative awakening.

Classification of anesthesia

Multicomponent anesthesia (anesthesia or general anesthesia) means a controlled, toxic, drug-induced coma. This condition is characterized by a temporary shutdown of reflexes, pain sensitivity, consciousness, as well as relaxation of skeletal muscles.

As for local anesthesia, it can be terminal, epidural, infiltration, spinal, conduction, caudal, plexus, intravenous under a tourniquet and intraosseous . Methods of plexus, spinal, intraoblique, conduction, epidural, intravenous under a tourniquet and caudal anesthesia are classified as methods of regional anesthesia.

Regional anesthesia is characterized by turning off conduction in a plexus of nerves or a specific nerve, achieving an analgesic effect while maintaining the patient’s breathing and consciousness. This type of anesthesia may be the only possible method of pain relief if the patient is elderly or has severe concomitant somatic pathologies.

Stages

The Gödel classification, developed by Arthur Ernest Gödel in 1937, describes four stages of anesthesia. Modern anesthetics and updated methods of drug have improved the speed of onset of anesthesia , overall safety and recovery, but the four stages remain essentially the same:

General anesthesia is similar to a comatose state and different from sleep.

Stage 1 or induction . This phase occurs between the administration of the drug and loss of consciousness. The patient moves from analgesia without amnesia to analgesia with amnesia.

Stage 2, or arousal stage . The period after loss of consciousness, characterized by agitated and delirious activity. Breathing and heart rate become erratic, and nausea, dilated pupils, and holding your breath may occur.

Due to irregular breathing and the risk of vomiting, there is a danger of suffocation. Modern fast-acting drugs are aimed at limiting the time spent on the 2nd stage of anesthesia.

Stage 3 or surgical anesthesia : muscles relax, vomiting stops, breathing is suppressed. Eye movements slow and then stop. The patient is ready for surgery

Stage 4, or overdose : if too much anesthetic has been administered, then depression of the brain stem occurs . This leads to respiratory and cardiovascular collapse.

The anesthesiologist's priority is to get the patient to stage 3 anesthesia as quickly as possible and keep him there throughout the operation.

Spinal and epidural anesthesia: advantages

Let us dwell in more detail on certain types of regional anesthesia - popular and in demand today.
You will come across some medical terms that you cannot do without. To begin with, we want to show you some drawings reflecting the structure of the human spine. Note the two sectors: the subarachnoid space and the epidural space, and their location in relation to the spinal cord:

Figure 1 and 2. The spinal cord and its membranes shown in a cross-section of the spine
The spinal canal has three connective tissue membranes that protect the spinal cord: the dura mater, the arachnoid mater, and the pia mater. The spinal cord and its roots are covered by a well-vascularized pia mater, and the subarachnoid space is delimited by two adjacent membranes - the arachnoid and dura mater.

Figure 3. The spinal cord and its membranes in another plane.

Figures 4 and 5. The spinal cord membranes in a three-dimensional image. In Figure 4, the epidural space extends down to the dura mater (gray cylinder), and the spinal cord lies within this cylinder.

Complications in the cervical spine

Surgeries on the cervical spine can be complicated by damage to nerves, blood vessels, muscles or cervical organs. In the postoperative period, some patients may experience displacement of installed metal structures.

Table 1. Complications with different approaches to the spine.