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Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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Presentation on theme: "Rasha S Bondok M.D. Assisstant Professor Ain-Shams University."— Presentation transcript:

1 Rasha S Bondok M.D. Assisstant Professor Ain-Shams University

2 ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY In 1909, Thomas Jonnesco proposed the use of thoracic spinal block for surgeries of the neck, and thorax. He performed punctures between T1 and T2 vertebrae ‘ I have a total of 1,015 thoracic spinal analgesia all without death and without any serious complication’ Jonnesco T. General spinal analgesia. Br Med J 1909 ;2:

3 ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY In 2006, Andre Van Zundert et al. proposed segmental spinal block, for lap cholecystectomy in a patient with severe obstructive lung disease, using a low thoracic puncture (T10) for CSE block. van Zundert AJ, Stultiens G, Jakimowicz J et al. Segmental spinal anaesthesia for cholecystectomy in a patient with severe lung disease. Br J Anaesth, 2006;96:

4 ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY

5 Major Concern

6 What makes it accepted?!!!! PROs Neurologists and radiologists perform subarachnoid myelographic injections at mainly cervical (occasionally thoracic) levels. Robertson HJ, Smith RD. Cervical myelography: survey of modesof practice and major complications. Radiology. 1990;174:79Y83 Yousem D.M., Gujar S.K. Are C1–2 Punctures for Routine Cervical Myelography below the Standard of Care? A JNR 2009;30:

7 What makes it accepted?!!!! PROs…Anatomical Explanation Imbelloni L E et al. Magnetic resonance imaging of the spinal column Br. J. Anaesth. 2008;101: Imbelloni L E, Gouveia Low Incidence of Neurologic Complications during Thoracic Epidurals: Anatomic Explanation AJNR Am J Neuroradiol.2010; 31: E84 Imbelloni et al 2008T2 3.6 (0.79)mmT (1.1)mmT (0.78)mm Imbelloni L E & Gouveia 2010 T2 5.2 mmT mmT mm 3.6mm 4.3mm 3.3mm 5.2mm 7.6mm 5.9mm

8 What makes it accepted?!!!! PROs…Anatomical Explanation SittingT1 4.6 (1.3)mmT (1.9)mmT9 4.0 (0.48)mmLateralT1 4.27(1.8)mmT (1.1)mmT9 2.4(0.78)mm SupineT1 2.7 (0.85)mmT (1.5)mmT (0.6)mm Lee R.A., et al The anatomy of the thoracic spinal canal in different positions: a magnetic resonance imaging investigation. Reg Anesth Pain Med.2010;35(4):

9 How To Perform A Thoracic Spinal Technique van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

10 Technique Patients are placed in the left lateral/sitting position van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1):

11 Technique A CSE technique….at the T10 interspace using a 16 g Tuohy needle and a mid-line approach. The epidural space is identified using the ‘loss of resistance’ to air method. van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

12 Technique The distance from skin to epidural space being calculated from the length of needle protruding from the skin. A 27 G pencil point spinal needle is advanced through the first needle until the resistance of the dura mater is felt van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

13 Technique The dura is then pierced The two needles secured together by a locking device …..ensures that the spinal needle does not move any further forward van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

14 Technique Once flow of clear CSF has confirmed correct placement Inject 1 ml isobaric bupivacaine 5 mg/ml ml of sufentanil/fentanyl van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

15 Technique Only when the block is considered adequate An effective block extent includes the T4 to L2 dermatomes, evaluated by pinprick

16 Sensory block: a) Upper sensory level: Sensory block: a) Upper sensory level: van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

17 van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): Sensory block: Lower sensory level: Sensory block: Lower sensory level: L4

18 Motor block: van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

19 Segmental thoracic spinal anesthesia Film: The spread of local anaesthetic solutions in the glass spine By Dr Len Carrie

20 Haemodynamic stability : van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

21 Although…….. Accidental dural puncture during needle insertion occurrs in 0.4%–1.2% of thoracic epidural blocks None of these patients developed subsequent neurologic sequelae Scherer R, Schmutzler M, Giebler R, et al Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients. Acta Anaesthesiol Scand 1993;37:370–74 Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization. Anesthesiology 1997;86:55–63

22 Cons!!!!! Spinal cord damage is a potentially disastrous complication of spinal anaesthesia or indeed dural puncture for any reason although rare but the risk of neurological complication subsequent to spinal anaesthesia is rather real than theoretical with permanent neurological deficit occurring in 1 in 10000

23 Recommendations Patient safety Patient safety takes precedence over unnecessary risks to be taken for the success of the procedure. It is not a method that could be easily and safely applied by the majority of anesthetists experienced clinicians evaluation programesnot yet be used in routine clinical practice This technique is reserved for experienced clinicians working in defined and approved evaluation programes, and that it must not yet be used in routine clinical practice

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