Do you practice segmental spinal anesthesia?

[DrAmir0078]

Dear SDN Anesthesiologists,
I hope you are doing well. Recently in the last few years a new technique of spinal anesthesia called "segmental spinal anesthesia", a type of neuraxial anesthesia using plain isobaric local anesthetic like bupivacaine and injected it to high spinal levels - Thoracic levels.

Personality, I do not get it, why to risk giving LA at higher levels while physiologically can do it at lumbar region and like cesarean section the LA will travel up to T2 - T4.

Injecting isobaric or even hyperbaric and with temperature and spine lordosis and other factors will make the baricity a bit hypobaric and will ascend.
Why such technique evolved, all researchers came from India, Italy and Middle East and personally knew some over here doing it, and I am standing confused about it.
Is it valid?
I believe it is still on expert opinion level, or even their research types.
Do you practice it? Reject its principles?

Peace,
Amir

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[Volatile]

Nope, not worth the risk in the litigious culture of the US. Plus I’m not sure I’ve come across a patient where a GA wasn’t as safe as potentially damaging someone’s cord.

 

[coffeebythelake]

Nope, not worth the risk in the litigious culture of the US. Plus I’m not sure I’ve come across a patient where a GA wasn’t as safe as potentially damaging someone’s cord.

And You can get the same effect with an epidural, without puncturing dura and potentially paralyzing the patient

 

[DrAmir0078]

Nope, not worth the risk in the litigious culture of the US. Plus I’m not sure I’ve come across a patient where a GA wasn’t as safe as potentially damaging someone’s cord.

Great, so it is only muscle show business and has not to do with being safe Anesthesiologist.

By the way, blocking thoracic segment like T8, isn't tend to block T8 motor, 2 segments up sensory T6 and 2 segments up autonomic T4.
The only advantage is the density of the block, meanwhile using whether hyperbaric or isobaric at lumbar level tends to ascend up to T6 and in some resources up to T2, and that can give you at least 45 minutes surgical time. Hemodynamics are better in favoring isobaric than hyperbaric.

Exactly like @coffeebythelake mentioned, epidural can give the same result. A question here, I only do lumbar epidural L3-L4 or L2-L3 and never went up, do you go higher than that in practice?
Thanks

 

[coffeebythelake]

Great, so it is only muscle show business and has not to do with being safe Anesthesiologist.

By the way, blocking thoracic segment like T8, isn't tend to block T8 motor, 2 segments up sensory T6 and 2 segments up autonomic T4.
The only advantage is the density of the block, meanwhile using whether hyperbaric or isobaric at lumbar level tends to ascend up to T6 and in some resources up to T2, and that can give you at least 45 minutes surgical time. Hemodynamics are better in favoring isobaric than hyperbaric.

Exactly like @coffeebythelake mentioned, epidural can give the same result. A question here, I only do lumbar epidural L3-L4 or L2-L3 and never went up, do you go higher than that in practice?
Thanks

We place thoracic epidurals frequently for major surgeries mostly for postop pain control. But if one is so inclined they could place a thoracic epidural and dose it for surgical block.

 

[pgg]

I think you'd have a hard time finding an anesthesiologist here who wouldn't call it dangerous and well outside the standard of care - and therefore malpractice if an injury results. A deliberate dural puncture and intrathecal injection at a thoracic level is a bad idea.

 

[DrAmir0078]

I think you'd have a hard time finding an anesthesiologist here who wouldn't call it dangerous and well outside the standard of care - and therefore malpractice if an injury results. A deliberate dural puncture and intrathecal injection at a thoracic level is a bad idea.

I agree with you, I have had hard time finding an Anesthesiologist here dares to do it; please write about it in your journals in the US and reject the technique as it possibly harms if it is done by whatever experience Anesthesiologist have from care point of view. I had read an article, but never convincing and even the systemic reviews shows possibility of cord injury in some cases.
Thank you, you relieved me !

 

[DrAmir0078]

Let's read this article together published last month at BJA and the authors from South Africa (it is a critical review).
I am always against it, likewise with you all.

Defining the role of thoracic spinal anaesthesia in the 21st century: a narrative review

Since the performance of the first thoracic spinal anaesthetic in early 1908 many anaesthetists have gained interest in this unorthodox neuraxial anae…

www.sciencedirect.com

 

[pgg]

Let's read this article together published last month at BJA and the authors from South Africa (it is a critical review).
I am always against it, likewise with you all.

Defining the role of thoracic spinal anaesthesia in the 21st century: a narrative review

Since the performance of the first thoracic spinal anaesthetic in early 1908 many anaesthetists have gained interest in this unorthodox neuraxial anae…

www.sciencedirect.com

It is interesting that they cite two MRI studies (N=50 and N=19) showing approximately 8-9 mm of posterior subarachnoid space between the dura and the spinal cord at the T5-6 level. That's more room that I would have expected, so maybe this is safer than we've all believed. Almost a cm of free space is a lot.

I didn't read the individual articles they cited though. I wonder how much variability there is in individuals. If the average is 8 mm does that mean 90% fall within 2-15 mm, or 6-10 mm? How many people are outliers with 1 mm of space?

Also, neuraxial techniques at the mid-thoracic level are technically more difficult. If one uses a paramedian approach is that safer or less safe?

I don't really believe the benefits of the technique justify the risk of cord puncture. I wouldn't do it.