Segmental Thoracic Spinal Anesthesia Rasha S Bondok M.D. Assisstant Professor Ain-Shams University

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’ which produced perfect and deep analgesia for the body segment including the neck and upper limbs Jonnesco T. General spinal analgesia. Br Med J 1909;2:1396-1401

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. In 2006, the new era of studies on spinal blocks in the thoracic region, looking for complete safety, started Van Zundert et al published a case-report in which a patient with severely abnormal respiratory function (chronic obstructive pulmonary disease with severe emphysema attributed to homozygote α-1-antitrypsine deficiency), requiring continuous oxygen therapy, had frequent respiratory infections and severe functional impairment.12 Even with minimal activity the patient developed hypoxaemia. Using the thoracic CSE technique, with a minute dose of local anaesthetic, cholecystectomy could be performed successfully, with no problems preoperatively. The patient was discharged from the hospital on Day 4 with no further deterioration of his pulmonary function. 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;96:464-466.

ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY A year later 2007 the same group performed a feasibility study in 20 patients asa 1 /2 using the CSE technique in the lower thoracic region, and concluded that segmental spinal anaesthesia can be used successfully and effectively in abdominal surgery

Major Concern The major concern is that dural puncture at the thoracic region may lead to needle damage to the spinal cord

What makes it accepted?!!!! PROs Neurologists and radiologists perform subarachnoid myelographic injections at mainly cervical (occasionally thoracic) levels. What supports this technique primary positive aspects that they relied upon subarachnoid myelography, done by neurologists and neuroradiologists, they usually used thoracic and cervical Punctures to inject the dye 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;30:1360-1363

What makes it accepted?!!!! PROs…Anatomical Explanation Imbelloni L E & Gouveia 2010 T2 5.2 mm T5 7.75 mm T10 5.88 mm Imbelloni et al 2008 T2 3.6 (0.79)mm T5 4.32 (1.1)mm T10 3.3 (0.78)mm 5.2mm 3.6mm 7.6mm 4.3mm 3.3mm -Recently, the anatomy of the thoracic spinal canal was investigated with MR imaging -The space between the posterior dura mater and spinal cord in the thoracic region was measured withMRimaging -As we see from the mri images --- the cord and the cauda equina are touching the dura mater posteriorly in the lumber region whereas the cord lies more anteriorly in the thoracic region -The widest distance between the dura mater and the spinal cord was at the mid thoracic segment -These studies were done while the patients were in the supine position However Neuroaxial block are performed with the patient in the lateral / sitting position 5.9mm Imbelloni L E et al. Magnetic resonance imaging of the spinal column Br. J. Anaesth. 2008;101:433-434 Imbelloni L E , Gouveia Low Incidence of Neurologic Complications during Thoracic Epidurals: Anatomic Explanation AJNR Am J Neuroradiol.2010; 31: E84

What makes it accepted?!!!! PROs…Anatomical Explanation Supine T1 2.7 (0.85)mm T6 3.75 (1.5)mm T9 2.45 (0.6)mm Lateral T1 4.27(1.8)mm T6 4.45 (1.1)mm T9 2.4(0.78)mm -Lee and his colleagues investigated the anatomy of the spinal cord and surrounding structures in different postures -They concluded that in all postures the greatest width between the sp cord and the post dura was the greatest at the midthoracic level - And that the cord sits even further anterior with the patient in the sitting or lateral recumbent position Sitting T1 4.6 (1.3)mm T6 5.95 (1.9)mm T9 4.0 (0.48)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):364-369

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 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

Technique Patients are placed in the left lateral/sitting position The patient is placed in either the left lateral recumbent position or the sitting position. Clear markings are made on the patient’s back to define the exact thoracic interspace 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 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

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 et al, have chosen the 10th interspace as lying in the ‘centre’ of the surgical field -although more studies are necessary to identify the most optimal interspace. -No saline is used as the seeker solution, as you have to be absolutely sure that any fluid that comes back is indeed the CSF van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

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 -Once the 16G Tuohy needle is in the epidural space, a long 27G pencil point spinal needle is introduced carefully -The needle illustrated (which was used in the study) has markings on the Tuohy needle that allow the user to know exactly how far the spinal needle protrudes beyond the tip of the Tuohy needle. -During the introduction of the spinal needle through the epidural needle, the dura mater can often be felt, -This manoeuvre should be done carefully, with controlled, slow, forward advancement of the spinal needle van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

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 Upon penetrating the dura, the spinal and the epidural needles are secured together by a locking device This ensures that the spinal needle does not move forward any further. Removing the stylet allows free aspiration of CSF – evidence of the dura mater perforation. van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

Technique Once flow of clear CSF has confirmed correct placement Inject 1 ml isobaric bupivacaine 5 mg/ml + 0.5 ml of sufentanil/fentanyl -Removing the stylet allows free aspiration of CSF – evidence of the dura mater perforation. -Then 1 ml of plain bupivacaine 5 mg/ml with 0.5 ml of sufentanil 5 μg/ml is injected intrathecally van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

Technique Only when the block is considered adequate An effective block extent includes the T4 to L2 dermatomes, evaluated by pinprick -Only when the block is considered adequate the surgery is allowed to start - minimum block extent includes the T4 to L2 dermatomes, evaluated by pinprick),

Sensory block: a) Upper sensory level: An effective sensory block median levels: upper T3 (range T2–T4); The extent of the sensory blockade should be evaluated before the surgeon starts the incision, including testing the trunk and the upper and lower extremities van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

Sensory block: Lower sensory level: L4 van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69 Sensory block: Lower sensory level: L4 effective sensory block [median levels: upper T3 (range T2–T4); lower L3 (range L1–L5)] developed within 15 min

Motor block: Modest amounts of lower limb motor block developed before the start of surgery in half the patients Firstly, one of the most obvious advantages is that there is no blockade of the lower extremities, i.e. little caudal spread. This means that a significantly larger portion of the body experiences no venal dilation, and may offer a compensatory buffer to adverse changes in blood pressure intraoperatively. Motor blockade of the lower extremities should be assessed every 5 minutes until the start of surgery. the patients have motor control over their legs during and after the surgery van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

What makes this technique segmental Segmental thoracic spinal anesthesia What makes this technique segmental It is a glass tube curved in the same way as the vertebral column and therefore the dural sac and subarachnoid space The first part of the demonstration shows the injection of a hyperbaric solution dyed pink with waxoline rhodamine in the lateral horizontal position and the glass spine then turned immediately supine. The demonstration shows how the injection in the mid-lumbar region would spread across and block the nerve roots of the cauda equina and then, after turning the patient into the supine position how the hyperbaric solution runs both caudad and cephalad in the subarachnoid space. The demonstration shows the dye cutting across the region of the cauda equina as usual and then when the horizontal position is assumed, the dye runs in both directions - caudad and cephalad in the subarachnoid space. As with injection of hyperbaric solution in the recumbent position, the local anaesthetic solution usually reaches the mid-thoracic region, but as an unpredictable amount of the solution is trapped in the caudal end of the dural sac, there is less available for spread cephalad. This may result in a shorter duration of action in the upper affected segments. The isobaric solution used for this part of the demonstration is dyed with methylene blue. Injection in the lateral, recumbent position shows the dye once again cutting across the region of the cauda equina. However, when the supine position is adopted, the dye makes no attempt to move upwards or downwards in the subarachnoid space, producing a more localised block than the hyperbaric solution Film: The spread of local anaesthetic solutions in the glass spine By Dr Len Carrie

Haemodynamic stability : The cardiovascular changes were minimal, two patients requiring ephedrine A limited block as described from T4 to L2 will consequently lead to minimal cardiovascular changes van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007. Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

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

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

Recommendations 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 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 The application of this technique should be restricted until much larger numbers of patients have been studied. Only a constantly vigilant, experienced anaesthesiologist, wellversed in the CSE technique, should consider using this method – after carefully weighing the pros and cons

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