The Difficult Neuraxial Block: When Should We Change Strategy? A Narrative Review of Recognition, Optimisation and Escalation

Background: Central neuraxial blockade is widely used for surgical anaesthesia and perioperative analgesia. However, anatomical variations, obesity, previous spinal surgery and operator-related factors can make neuraxial procedures technically challenging. Repeated needle insertions may increase patient discomfort and procedural difficulty, while delaying the establishment of an alternative anaesthetic plan. Objective: This narrative review examines the recognition and management of difficult neuraxial procedures, with particular emphasis on when to stop repeated attempts and change strategy. Methods: Relevant literature was reviewed using PubMed/MEDLINE and published reviews, systematic reviews, clinical studies and educational articles. Particular attention was given to the role of preprocedural ultrasound, alternative needle approaches, operator experience and the management of unsuccessful neuraxial procedures. Discussion: Difficult neuraxial access should prompt early reassessment of patient positioning, anatomical landmarks and needle trajectory. Changing the interspace, adopting a paramedian approach, using preprocedural ultrasound and seeking assistance from an experienced anaesthesiologist are potential strategies. Evidence suggests that ultrasound improves first-attempt success and reduces the number of needle attempts, particularly in patients with anticipated difficult anatomy. However, there is no universally established maximum number of attempts applicable to every patient or neuraxial technique. Conclusion: The decision to continue or abandon a difficult neuraxial procedure should be individualised. Repeated attempts without a meaningful change in strategy should be avoided. A structured escalation approach may improve procedural success, patient comfort and overall safety.