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Segmental ThoracicSpinal Anesthesia
Rasha S Bondok M.D.Assisstant ProfessorAin-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’
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.
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
Major Concern
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;30:1360-1363
What makes it accepted?!!!! PROs…Anatomical Explanation
Imbelloni L E et al. Magnetic resonance imaging of the spinal column Br. J. Anaesth. 2008;101:433-434Imbelloni 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)mmT5 4.32 (1.1)mmT10 3.3 (0.78)mm
Imbelloni L E & Gouveia 2010
T2 5.2 mm
T5 7.75 mm
T10 5.88 mm
3.6mm
4.3mm
3.3mm
5.2mm
7.6mm
5.9mm
What makes it accepted?!!!! PROs…Anatomical Explanation
Sitting
T1 4.6 (1.3)mmT6 5.95 (1.9)mmT9 4.0 (0.48)mm
Lateral
T1 4.27(1.8)mmT6 4.45 (1.1)mmT9 2.4(0.78)mm
Supine
T1 2.7 (0.85)mm
T6 3.75 (1.5)mm
T9 2.45 (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):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
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
TechniqueA 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 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69
TechniqueThe 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 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69
TechniqueThe dura is then piercedThe 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 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69
TechniqueOnce flow of clear CSF has confirmed correct
placement Inject 1 ml isobaric bupivacaine 5 mg/ml + 0.5 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 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69
TechniqueOnly when the block is considered adequate An effective block extent includes the T4 to L2
dermatomes, evaluated by pinprick
Sensory block: a) Upper sensory level:
Sensory block: a) Upper sensory level:
T4T2
T3
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
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:
Sensory block: Lower sensory level:
L3
L2 L1
L4
Motor block:Motor block:
125%
225%
0 50%
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
Segmental thoracic spinal anesthesia
What makes this technique segmental
Film: The spread of local anaesthetic solutions in the glass spine By Dr Len Carrie
Haemodynamic stability : Haemodynamic stability :
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;37:370–74Giebler 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
RecommendationsPatient 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
THANK YOU