Neuraxial anesthesia is not practiced uniformly across the globe. From the operating rooms of major academic medical centers to district hospitals in resource-limited settings, the techniques, protocols, and outcomes associated with spinal and epidural anesthesia vary considerably.
Looking at global neuraxial practices reveals three interconnected challenges: how geography and resources shape technique selection, why cultural and systemic factors create persistent variation, and where targeted innovation can narrow performance gaps that currently leave some patients at higher risk than others.
Regional variations in practice
Comparisons across health systems reveal striking differences in how neuraxial techniques are applied. In resource-limited countries — particularly in Sub-Saharan Africa and Southeast Asia — neuraxial anesthesia has emerged as a primary approach for procedures below the umbilicus.
A 2016 analysis by Médecins Sans Frontières examined 75,536 anesthetics delivered at humanitarian medical sites between 2008 and 2014, finding all-cause perioperative mortality of 0.25%. When stratified by technique, neuraxial anesthesia (spinal anesthesia) demonstrated a mortality rate of 0.04% compared to significantly higher rates for general anesthesia with intubation.
Another 2021 multicenter international study examining open appendectomy across 14 hospitals found that 353 of 655 patients received neuraxial anesthesia, with the countries operating under neuraxial approaches being Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Multivariable analysis showed neuraxial anesthesia was independently associated with fewer postoperative complications and shorter hospital length of stay compared to general anesthesia.
In well-resourced countries, patterns differ markedly. Geographic analysis of regional anesthesia utilization across U.S. hospital regions from 2016 to 2021 revealed considerable variation, with the Midwest demonstrating higher utilization rates for total knee arthroplasty (10.9%) and total shoulder arthroplasty (9.9%) compared to other regions, despite similar patient populations and surgical indications.
Equipment and infrastructure shape practice patterns profoundly. Resource-limited settings often lack reliable electricity, compressed gases, and sophisticated monitoring equipment, making neuraxial techniques safer and more practical than general anesthesia. Conversely, well-equipped facilities may have greater flexibility in technique selection. Yet this advantage does not always translate to optimal utilization of neuraxial approaches where they would benefit patients most.
Cultural and systemic factors
Cultural anesthesia variations influence practice patterns in ways that extend beyond simple resource availability. Training infrastructure varies dramatically between regions, with many providers in low-resource settings receiving limited formal instruction and minimal access to ongoing supervision or professional development.
Cultural health beliefs affect patient acceptance as well. Survey data indicates that ethnic and cultural background influences both patient expectations about anesthesia and their willingness to accept unfamiliar techniques like neuraxial blocks. A multinational cross-sectional study across 13 high-income countries found that among nulliparous women, epidural anesthesia use varied from 19.4% in England to 83.4% in Finland, illustrating how cultural practices and regional norms shape utilization patterns.
Healthcare system structures create additional variation. Institutional practices, payment models, and protocol standardization all influence which techniques providers choose and patients receive. For example, the presence of fellowship-trained regional anesthesiologists at a facility significantly affects neuraxial anesthesia utilization rates. Global neuraxial practices also reflect different regulatory environments and professional society guidelines, which can promote or constrain technique adoption based on local consensus and historical precedent.
A 2014 study examining aseptic technique compliance for neuraxial labor analgesia in Israel surveyed anesthesiologists before and after publication of international guidelines. While overall compliance improved from 2006 to 2009, marked inter-hospital variation persisted, suggesting that while national and international guidelines may influence practice broadly, local implementation determines actual clinical change. Cultural anesthesia variations thus operate at multiple levels, from individual provider preferences to institutional protocols to national healthcare policies
Patient outcome impacts
The consequences of practice variation are measurable and considerable. A 2016 systematic review and meta-analysis on anesthesia-related maternal mortality in low- and middle-income countries found that general anesthesia compared to neuraxial anesthesia tripled the odds of maternal death and doubled the odds of perinatal death. Among anesthetic-attributed deaths where the underlying cause was reported, 45% were due to airway complications and 31% from pulmonary aspiration — complications largely avoided with neuraxial techniques.
Regional anesthesia comparisons within well-resourced countries reveal different but equally concerning patterns. A 2023 retrospective cohort study using the National Surgical Quality Improvement Program examined racial and ethnic differences in regional anesthesia for total knee arthroplasty from 2017 to 2019. On multivariable analysis, Black patients had lower odds of receiving regional anesthesia (adjusted odds ratio 0.93, 99% confidence interval 0.89-0.98) than White patients, while Hispanic patients had lower odds (adjusted odds ratio 0.88, 99% confidence interval 0.83-0.94) than non-Hispanic patients.
A 2021 study examining cesarean delivery outcomes using the American College of Surgeons NSQIP database found that Black parturients were 29% less likely to receive neuraxial anesthesia compared to White parturients after adjusting for potential confounders. American Indian or Alaska Native parturients were 78% less likely to receive neuraxial anesthesia compared to White parturients.
Standardization efforts show promise in reducing outcome disparities. Implementation of Enhanced Recovery After Surgery (ERAS) pathways, which often include neuraxial techniques as core components, has demonstrated success in minimizing care variation and improving results across diverse patient populations. Where protocols are implemented consistently, outcome gaps may narrow.
Innovation bridging the gap
While the disparities in access and outcomes present significant challenges, collaboration and emerging technologies are helping to narrow performance gaps across global neuraxial practices. Where they take root, they’re creating pathways to more equitable neuraxial care.
International guideline development through organizations like the American Society of Regional Anesthesia and the European Society of Regional Anaesthesia has created evidence-based frameworks that transcend national boundaries. The ASRA-ESRA Delphi Consensus studies have standardized nomenclature and anatomical descriptions, establishing a common language across institutions and training programs worldwide.
Digital education platforms are expanding access to training. The growth of Free Open Access Medical Education allows providers in remote areas to access procedural videos, technique demonstrations, and expert guidance. Mobile applications providing regional anesthesia learning modules show high engagement from users in low- and middle-income countries, suggesting strong demand for accessible educational resources.
The result is accessible innovation. For example, ultrasound guidance, once available only in well-equipped facilities, continues to become more affordable, portable, and durable. Devices such as the Accuro® 3S ultrasound system from RIVANNA® can make real-time imaging accessible to providers in resource-limited settings, where automated anatomical guidance can compensate for limited training and challenging patient anatomy.
Moving from variation to alignment
The convergence of affordable technology, shared evidence, and collaborative guidelines is bringing global neuraxial practices toward greater consistency. As innovation reaches more providers worldwide, standardized training frameworks and accessible ultrasound technology can create opportunities for evidence-based care across diverse healthcare settings. Alignment is achievable, but only when clinical expertise and technological advancement work together to elevate standards globally.