FT07 The extra kick of continuous spinals

The extra kick of continuous spinals Danny Feike Hoogma, MD, PhD University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium University Hospitals Leuven Department of Anesthesiology Herestraat 49 3000, Leuven Belgium Danny.hoogma@uzleuven.be   Abstract Continuous spinal anesthesia (CSA) offers a hybrid approach by combining the precision of single-shot spinal anesthesia with the flexibility of catheter-based delivery. Compared to general or single shot spinal anesthesia, CSA offers improved hemodynamic control, reduced vasopressor use, and adaptability for prolonged procedures. Particularly beneficial in elderly and comorbid patients, CSA supports a patient-centered approach and should be considered a valuable option in the high-risk population offering the ‘extra kick’ in tailored anesthetic care. Keywords: continuous spinal anesthesia, neuraxial block, hemodynamic stability, elderly, high-risk surgery   Introduction Neuraxial anesthesia techniques are an integral part of the anesthesiologist’s armamentarium and can be used to provide primary anesthesia for abdominal, obstetric, vascular and lower limb surgery. Within this domain, two primary techniques are distinguished: spinal and epidural anesthesia. Spinal anesthesia is characterized by a definitive endpoint, rapid onset, and the use of lower doses of local anesthetics to achieve a dense and reliable block. In contrast, epidural anesthesia typically requires higher doses, has a slower onset, and is associated with a higher percentage of failure and side effects (table). To combine the benefits of both, combined spinal epidural (CSE) techniques is often employed, allowing for rapid onset via spinal injection and prolonged anesthesia or analgesia through an epidural catheter. However, CSE still carries the disadvantages of epidural anesthesia, including dosing variability, side-effects and failure rates. 1 2Continuous spinal anesthesia (CSA), first described by Henry Perce Dean in 1906, remains underutilized despite being around for over a century with excellent results. CSA merges the benefits of single shot spinal anesthesia (SSSA) with the flexibility of catheter-based dosing, allowing for prolonged and titratable anesthesia. This technique has been successfully applied across various surgical populations, including the frail cardiovascular or respiratory compromised patient. Despite its track record, certain patient with significant cardiovascular or pulmonary comorbidities, prolonged surgical needs, or frailty, are frequently defaulted to general anesthesia (GA). In such cases, CSA offers a tailored and underused solution.3 This narrative review aims to compare CSA with other techniques, highlighting its unique advantages and advocating its broader adoption, particularly in elderly, high-risk patients considered to tricky for SSSA or general anesthesia (GA).3 Why CSA now? In contemporary era, the aging patient population is presenting with increasing rates of comorbidities and frailty, particularly for interventions such as hip fracture surgery.4–6 These patients have a disproportionate impact on healthcare resources, a challenge compounded by ongoing shortages of healthcare personnel. Strategies to optimize perioperative outcomes and reduce healthcare system burden while maintaining quality of recovery are required. CSA offers distinct advantages in this context. In elderly, frail patients undergoing hip fracture surgery, CSA has demonstrated superior hemodynamic stability compared to SSSA, CSE and potentially GA.7 8 The ability to incrementally titrate local anesthetics doses significantly reduces the incidence and severity of hypotension as demonstrated by multiple randomized controlled trials.7 9 10 Moreover, regional anesthesia techniques, including CSA, are associated with a lower risk of respiratory complications and improved cognitive outcomes.10 This may translate into fewer perioperative complications, reduces hospital stays and lower resource utilization. While CSE allows rapid onset and extended duration of anesthesia via titration of the epidural catheter, it carries a notable risk of technical failure and occurrence of side effects (i.e., urinary retention, unilateral block or hypotension). These complications can delay recovery and increase resource demands.11 12 CSA may offer a more reliable alternative, particularly in elderly, frail patients, though high-quality comparative data are lacking. Ultimately, the choice of anesthetic technique should be individualized, with a focus on minimizing complications and facilitating early recovery. This approach aligns with current recommendations from the American Society of Anesthesiologist, which emphasize patient-centered care and risk reduction in vulnerable populations.12 Complications and their management While CSA in generally safe and effective, certain complications are more relevant in elderly, frail patients undergoing procedures such as hip fracture surgery. The most notable among these are intraoperative hypotension, post-dural puncture headache (PDPH) and catheter-related issues such as dislodgement or malfunction. Intraoperative hypotension is a frequent complication associated with neuraxial anesthesia, particularly in elderly patients with limited cardiovascular reserves. The ability to titrate local anesthetics is one of CSA’s most compelling benefits in high-risk populations. Compared to SSSA, the incidence of severe hypotension is reduced from 51% to only 8% when CSA is used.7 Catheter-related complications, though infrequent, can be disruptive. Issues such as dislodgement of malfunction may necessitate conversion to GA, increasing perioperative risk.7 These challenges underscore the need for improved catheter design and insertion techniques to enhance reliability and reduce intraoperative interruptions. PDPH is another recognized complication of CSA, though its incidence in elderly, frail patients is significantly lower than in younger adults. This reduced risk is attributed to age-related changes in dura elasticity and decreased cerebrospinal fluid pressure.13 14 The use of small-gauge, non-cutting (atraumatic) spinal needles and catheters further minimized the likelihood of PDPH. Clinically, PDPH presents as a postural headache (worse when upright, relieved by lying down), often accompanied by neck stiffness, nausea, photophobia, auditory symptoms (tinnitus, hearing loss). Symptoms usually develop within the first few days of the procedure and resolve spontaneously within 2 weeks. The American Academy of Pain Medicine, in its 2024 guidelines, emphasizes that PDPH should be suspected in any patient with a new, postural headache following neuraxial procedures, especially if associated with these features.13 Conservative treatment including hydration and systemic non-opioid analgesics are generally considered sufficient. In rare instances, an epidural blood patch may be required.13 Despite these potential complications, the overall impact of CSA-related adverse events on recovery and resource utilization in elderly, frail patients is minimal. With appropriate techniques, equipment, and vigilance, CSA remains a safe and effective but underutilized option in this population. Barriers to adoption & gaps Several barriers contribute to this limited adoption, including equipment limitations, lack of familiarity, and institutional inertia. One of the primary challenges is the historical unreliability of spinal catheters, which has led to concerns about dislodgement, malfunction, and inconsistent drug delivery. These technical issues have discouraged widespread use, particularly in high-stakes surgical settings.15 To overcome this, industry innovation is essential, modern, atraumatic, and reliable catheter systems must be developed and made widely available to support safe and effective CSA implementation. Another significant barrier is the lack of standardized protocols and training. Many anesthesiologists are more familiar with single-shot spinal or epidural techniques, and CSA is often perceived as technically demanding or unfamiliar. This perception can be addressed through targeted education, simulation-based training, and the development of evidence-based guidelines that support CSA use in specific patient populations, such as the elderly or those with significant comorbidities. Institutional resistance to change also plays a role. New techniques are often adopted only when they are easy to implement and perceived as low-risk. For departments already proficient in neuraxial anesthesia, CSA could be integrated relatively smoothly, provided that appropriate equipment and support are available. In this context, regional anesthesia champions can play a pivotal role by leading implementation efforts, sharing clinical experiences, and promoting CSA through research and peer education. Finally, there is a lack of high-quality comparative data evaluating CSA against other techniques in specific populations. While existing studies suggest benefits in terms of hemodynamic stability and reduced complications, further randomized controlled trials are needed to solidify CSA’s role and guide best practices. Conclusion In the evolving field of regional anesthesia, CSA stands out as a precise, flexible, and patient-centered technique. Its capacity for titrated dosing, extended duration, and reduced hemodynamic disruption makes it particularly valuable in high-risk populations. As the anesthesia community continues to value patient-specific approaches, CSA deserves renewed attention and broader application. With appropriate training, equipment, and evidence-based protocols, this once-sidelined technique is poised to deliver its full potential, an extra kick, where it’s needed most. Table: Specifics of different neuraxial techniques Single-Shot Spinal (SSSA) Epidural Anesthesia Combined Spinal-Epidural (CSE) Continuous Spinal Anesthesia (CSA) Onset time Rapid Slow Rapid (spinal), then slow Moderate (titrated) Duration Fixed Adjustable Adjustable Adjustable Block density High Variable High (spinal component) High Hemodynamic control Poor Moderate Moderate Excellent Ability to extend duration No Yes Yes Yes Technical failure rate Low Moderate Low Low CSF confirmation Yes No Yes Yes Risk of PDPH Low Very Low Moderate Low to Moderate Suitability for frail patients Limited Variable Variable ExcellentReferences Coppens S, Dewinter G, Hoogma DF, Raudsepp M, Vogelaerts R, Brullot L, et al. Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents. European Journal of Anaesthesiology 2024.Roofthooft E, Rawal N, Van de Velde M. Current status of the combined spinal-epidural technique in obstetrics and surgery. Best Pract Res Clin Anaesthesiol. 2023;37(2):189–98.Kumar CM, Seet E. Continuous spinal technique in surgery and obstetrics. Best Pract Res Clin Anaesthesiol. 2023;37(2):139–56.Sandhu MRS, Tickoo M, Bardia A. Data science and geriatric anesthesia research: opportunity and challenges. Clin Geriatr Med. 2025;41(1):101–16.McIsaac DI, MacDonald DB, Aucoin SD. Frailty for perioperative clinicians: a narrative review. Anesth Analg. 2020;130(6):1450–60.Mazarello Paes V, Ting A, Masters J, Paes MVI, Graham SM, Costa ML, et al. A systematic review of the association between early comprehensive geriatric assessment and outcomes in hip fracture care for older people. Bone Joint J. 2025;107-B(6):595–603.Minville V, Fourcade O, Grousset D, Chassery C, Nguyen L, Asehnoune K, et al. Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients. Anesthesia & Analgesia 2006;102(5):1559–63.Koole C, Bleeser T, Hoogma DF, Coppens S, Teunkens A, Rex S. Haemodynamic effects of continuous spinal anaesthesia versus single-shot spinal anaesthesia or general anaesthesia for hip fracture surgery: a systematic review and meta-analysis. Br J Anaesth. 2024.Olsen F, Hard Af Segerstad M, Dalla K, Ricksten SE, Nellgard B. Fractional spinal anesthesia and systemic hemodynamics in frail elderly hip fracture patients. F1000Res. 2023;12:210.Li P, Li X, Peng G, Deng J, Li Q. Comparative analysis of general and regional anesthesia applications in geriatric hip fracture surgery. Medicine (Baltimore) 2025;104(2):e41125.Pass B, Knauf T, Knobe M, Rascher K, Bliemel C, Maslaris A, et al. Spinal anesthesia with better outcome in geriatric hip fracture surgery - an analysis of the registry for geriatric trauma (ATR-DGU). Injury 2023.Sieber F, McIsaac DI, Deiner S, Azefor T, Berger M, Hughes C, et al. 2025 American society of anesthesiologists practice advisory for perioperative care of older adults scheduled for inpatient surgery. Anesthesiology 2025;142(1):22–51.Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, et al. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med. 2024;49(7):471–501.Kim JE, Kim SH, Han RJW, Kang MH, Kim JH. Postdural puncture headache related to procedure: incidence and risk factors after neuraxial anesthesia and spinal procedures. Pain Med. 2021;22(6):1420–5.Benson JS. U.S. food and drug administration safety alert: cauda equina syndrome associated with use of small-bore catheters in continuous spinal anesthesia. AANA J. 1992;60(3):223.