Good evening everyone. I am very much thankful to ISACON Kerala for providing me this opportunity again to present my topic on segmented spinal. The new era of segmented spinal began when in 2006 A. van Zundert gave spinal at T10 for laparoscopic polycystectomy in a patient with severe COPD.
This is a changing scenario. Initially there was a lot of lots of criticism when I started doing this then there was little acceptance then appreciation. and now it has become a more standing regional anesthetic technique. Now what is different? In short giving spinal near the targeted nerve roots with a very low volume of local anesthetic drug is often necessitating dural puncture at high lumbar or thoracic levels lower the volume of the dose of the drug more likely to produce a true segmental block.
The factors making segmental spinal feasible there is natural thoracic kyphosis g765 amount of csa but thoracic levels is very less. Thoracic nerve roots are very slight and thin, favoring its efficient blockade. In thoracic segments, the spinal cord is positioned anteriorly, and there is no significant difference in the onset time for isovaric and hyperbolic drugs at thoracic levels.
Few important questions are asked whenever we talk about segmented spinal, neurological injury, ventilatory impairment, bradycardia, and hypotension. The major concern whenever we talk about segmented spinal is damage to the spinal cord. On MR imaging, the space between posterior dura and the spinal cord was measured. The spinal cord lies more anteriorly in the thoracic region, while the cord and cauda inguina touches the posterior dura at lumbar levels. The distance is widest at the mid-thoracic level in all positions.
This is midline MRI of the spinal column showing a significant space. Here you can see clearly the space between posterior dura and the spinal cord. This is the position of spinal cord at thoracic, thoracic lumbar and cauda inguina levels. M.Belloni and Guia did a study on low incidence of neurological complications during thoracic epidurals and they provided an anatomic explanation for this.
They measured the exact distance at various levels and they found the distance to be around 7.75 millimeters at T-U-I levels. Liara did study of anatomy of the spinal column in various positions and they found the distance to be more in all positions more so in the lateral and sitting positions. This is again midline MRI of the spinal column because of the angulation required. to perform a spinal at mid thoracic level, the distance between posterior and the spinal cord is further increased.
Here you can see it is almost 8 millimeter as compared to the 4.5 millimeters at T12 L1 levels. There are some additional points for in safety of segmental spinal. The incidence of neurological injuries after accidental dural puncture during thoracic epidural is very less. Many anesthesiologists unknowingly use high lumbar or thoracic spaces.
for giving spinal especially in obeys and parturians and the level at which the spinal cord terminates is also variable but the risk is rather real than theoretical with any spinal anesthesia. Ventilatory impairment the main inspiratory muscle of respiration is diaphragm which is usually unaffected. Expiration at rest is a passive process only possible expiration and cuffing may get affected but due to the low dose of the drugs used that preserves the cuffing ability due to minimal motor weakness. of the abdominal muscles. Heart rate may decrease, a block extends T1 to T4, but due to the lumbosacral sparing and less venodal tension in the lower limbs, the right at tail filling is maintained.
That usually sustains the outflow from intrinsic chronotropic receptors maintaining the heart rate. Less hypotension is due to the less sympathetic blockade and less volume of the drug used. Feasibility, technical feasibility, yes, technically it is very much feasible.
Economic, it's very, very economic. Legal still a question mark and about operational with experienced clinician it is very much feasible. Practically all the intra-octagonal surgeries, prone lateral position thoracolumbar spine and musculoskeletal surgeries, breast and superficial thoracic surgeries and even some awake thoracoscopic surgeries can be done under segmented spinal. There are three different modes either it can be used as a single short segmented spinal for short to mid duration surgeries or it can be combined with epidurals.
for longer duration surgeries or epidural can be used as a backup in very morbid cases when you are using very low dose intrathecally for segmented spinal. The epidural can be handy as a backup by epidural volume extension technique or for post-op analgesia. The third option is continuous segmented spinal anesthesia using SpinoCats.
Some advantages surgery is thought to be out of domain of spinal anesthesia or possibly segmented spinal like upper abdominal thoracic and breast surgeries. Higher levels of the blocks can be achieved with just half the dose that is required at the lower levels. Many will limit anorexia fluctuations, early recovery and voiding.
The special advantages of general anesthesia in patients with respiratory comorbidities can avoid post-op pulmonary complications and ventilatory support. There is also low incidence of post-op nausea and vomiting, either isobaric or hyperbaric, or even a combination of these two drugs can be used for some abdominal pelvic surgeries. In general, isobaric drugs are preferred for laparoscopic.
thoracoscopic breast and superficial surgeries in morbidly frail patients and hyperbaric drugs can be a choice in some muscular patients. Some advantages of isobaric drugs, they are less sensitive to position issues. In low doses, they are propensity to block sensory nerves in reference to motor ones. This is sometimes labeled as selective anesthesia.
The onset is usually gradual, you want an instability even with higher levels of the block. Motor block time is shorter, leading to early ambulation and voiding. The spinal can be given directly in the operative positions and the spinal can be given before epidural and at a space higher than epidural with isobaric drugs. Some disadvantages of isobaric drugs, levels of block cannot be modified by any change of positions, drugs need to be placed at the precise dermatomes.
Like in epidural sacral sparing is common when low doses at higher spaces are used. They usually take some time at lumbar levels for onset and slightly less muscle relaxation. so may need higher doses and they are sensitive to temperature variations and at time can have unpredictable results when there are wide variations in temperatures amongst the isobaric drugs chlorpropane 1%, BOPV can 0.5, RuPV can 0.5 and 0.75% or hyperbaric drug BOPV can 0.5% can be used chlorpropane 1% being 1% the volume required is more and is really useful for short duration surgeries up to 40 to 60 minutes. Leovpvacaine 0.5 and ropivacaine 0.75% are comparable. Ropivacaine being less lipid soluble is nearly half as potent as leovpvacaine intrathecally and there is stronger differentiation between sensory and motor blocks with ropivacaine.
Additional small doses of additives like fentanyl, dexameth, ketamine or clonidine can intensify the sensory blocks. Dexameth usually provides a longer duration than others in a dose dependent manner like 10 micrograms can provide a duration in excess of three hours. A ketamine though potentiating sensory block is known to shorten the motor block time.
VPUA can heavy can be used in the same dose range as asvaric drugs. The thoracic segmental anesthesia can be produced with just half the dose that is used at a number of levels. Gravity dependence spread has to be kept in mind and can be a better choice in some muscular patients. And this is important how to decide about the site of injection and doses.
For abdominal surgeries, depends on the type of surgery, site of surgery, average duration of surgery and comorbidities of the patient and whether you have combined it with epidurals or not. Dose of local anesthetic and site of injection along the near axis can be varied. In general, 1 ml of the isomeric drug spreads 2 to 3 segments above and below the site of injection. And accordingly, you can calculate your doses and site of injection you want to block the dermatomes for that particular surgery.
What that means is. 2 to 2.5 ml of the drug is sufficient to block segments from T2 to L5 S1 if spinal is given at T10. 10 thoracic space lying in the center of the surgical field for upper abdominal surgeries. With adequate dose, space above T10 is hardly required.
The space between T10 L1 and a dose of 2 to 2.5 ml with some additive works nicely for 90 to 120 minutes. and regression of effect from lumbosacral route starts varying up to 70 to 80 minutes and for surgeries like TLH involving pelvic manipulations going beyond this time you can use a combination of hyperbaric and asparic drugs. For breast and superficial thoracic surgeries spinal at mid thoracic levels with 1.2 to 1.5 ml with some additives.
With this much dose it can provide duration of 60 to 90 minutes or little more if dexmed is used as additive or prolonged procedures which is usually better to combine with epidurals or some locks rather than increasing the intrathecal dose to avoid adverse respiratory and cardiac events. These are the levels required for different types of breast surgeries like MRM requiring C5 to T7, mastectomy with transverse septum is flap may require C5 to L1 level. Partial mastectomy needs only T1 to T7 and epidural scoring scale for arm movement can be used to test the levels achieved for breast surgeries using segmented spinal.
Using isobaric drugs, position of the patient, forgiving spinal does not matter, can use any position, plane DVP can be 0.5%, specific gravity of 9990. 0.9990 is slightly hyperbaric, given in sitting position and kept seated for some time can lead to high levels of block at times. Temperature of the drug has inverse relation with varicity and cooled at 24 degrees, density of 1.0032, it becomes slightly hyperbaric and warmed at 37 degrees. can become a little hyperbaric.
These usually are minor differences, it does not make many difference but if there are wide variations in the temperatures then it can have some unpredictable results. Using combination of hyperbaric and isobaric drugs, sitting position is mandatory for giving spinal. Either quinque or pencil point can be used for giving spinal combined with epidurals.
CSC kit is the easiest and safest option. These are the landmarks for identifying the interpretable spaces for the spinal. C7 has the prominent spinous process. Then root of the spine of the scapula corresponds with T3. Inferior angle of the scapula corresponds with T3.
And these are the various dermatomes you may require to block for different surgeries. Semianatomical hurdles for thoracic spinal. The thoracic spinous processes are sharply angled and point quarterly between T4 to T9. It may be little difficult in this area but beyond T10 it resembles those in the lower region.
The inter laminar spaces in thoracic spine are very narrow and more challenging to access with a midline approach so a pyramidine approach can be very handy in such cases. These are some tips to use the pyramidine approach for thoracic spine. Those who have the facilities of ultrasound they can have a pre-procedural scan at mid thoracic levels. for guiding thoracic spinal either a transverse jaxtamudian scan to locate the LFD complex or a transverse jaxtamudian scan can be done.
Coming to my segmented spinal profile now more than around 3000 surgeries till date initially used for only high risk cases but now occupies nearly 50 percent of my ICB profile till date very few partial failures but no mishaps complete pre-anesthetic evaluation of the patient is done venous access. minimum mandatory monitoring, no sedative pre-medications, lateral decubitus is what I use, 27 gauge quick needle, then depending on the patient's parameters, site and type of surgery, dose of local anesthetic and site of injection is selected. For short duration like 40 to 60 minutes, I use chlorpropane 2.5 to 3.5 ml with or without additives. For mid-duration surgeries, either leave BPO can 0.5 or BPO can 0.75 or BPO can have 0.5 percent. with fentanyl, ketamine or dexameth according to need.
This is, if this you can remember, you can do any abdominal surgery of mid duration in this dosage for average female patient, 2 ml plus additive and for average male, 2.5 ml plus additive and spinal at T10 to L1 interspace. And combined with epidural, the initial dose can be kept to minimum in patients who are having multiple comorbidities. I usually combine these segmented spinels with various blocks like transverse abdominis plane block, rectus shield block or erector spinae plane block for open surgery or local anesthesia at the port site in laparoscopic surgery.
For brace surgeries, I use Leobipio can 0.5 or Ropio can 0.75% in 1.5 to 2 ml maximum with additive like fentanyl, ketamine or dexmed at mid thoracic levels and combine with epidurals or some blocks like like PEC1, PEC2, seratosensory plane block or electrospiny plane block for analgesia. This is true drug technique. You can combine isobaric and hyperbaric drugs for procedures like TLH, PCNL, colorectal surgery. Spinal needs to be given sitting position with 0.5 to 1 ml of hyperbaric drug initially and then 1.5 to 2 ml of isobaric drug in different ranges. The patient usually turns supine immediately after spinal.
or can be kept in the lateral position with operative side up or lateral position surgeries. Sensory block tested by pinprick usually sets in 3 to 4 minutes and complete block in 8 to 10 minutes. Some hemodynamic fluctuations can occur but usually within 10 minutes and very minimum and gradual.
No respiratory embarrassment is usually seen even with high thoracic or cervical looping movements. Initial partial non-rotor pumbosacral roots can be seen which usually recovers by the end of surgery. No additional supplements are usually required except in few laparoscopic surgeries.
Patient can be mobilized in 4-6 hours. About litigation, enough evidence to prove its utility in many cases where it is most indicated. Most cases of litigation are against regional anesthesia, but still thoracic epidural is being performed day in and day out and even by the trainees. So proper explanation and consent is must.
Started to appear in some textbooks. Till that time, we can keep our fingers crossed. It's a very useful technique with many advantages, minimal risk, with due precautions. No need to panic even if the block level is found to be higher than desired.
Lab surgeries may need little sedation and needing sedation is should not be considered as a failure of the block. When facilities are available, UHG can be helpful and the technique is reserved for experienced clinicians with good learning curve. I'll just go quickly through some of my videos.
Here you can see how straightforward it is at the high lumbar or low thoracic levels, it is T12L1 for probably epigastric hernia, 27 gauge quincanidine. This was a morbid obese patient for a stereoscopic removal of polyp, spinal in sitting position T12L1, as we wanted some lumbosacral environment also. This is the same patient during operation after one and a half hours and after three and a half hours. This is MRM under a combined spinal epidural at mid thoracic level.
The level is being tested to see how comfortable the patient is even with such high levels of block. The patient had no sensation at C8 levels but still the grip strength was good indicating only sensory blocks. MRM being done. This is the surgeons can give PEC1, PEC2 blocks when you have you have not used any epidural or any blocks intraoperatively.
You can ask the surgeon to give under vision. This is laparoscopic ruptured ectopic. You can see the patient moving her legs during the operation and the same patient being shifted herself from table to stretcher. These are two patients being interviewed, one at the end of surgery and one during the surgery.
They are even without nasal oxygen supplementation. This was traumatic diaphragmatic hernia. You can see whole of the left hemothorax filled with intestine contents. Diaphragmatic major repair being done.
The same patient at the end of surgery. Next takes the same patient. This was ventral hernia along with polycystectomy.
She was having multiple comorbidities, a lot of adhesions. The same patient at the end of surgeries. This was obstructed umbilical hernia. You can see his respiration.
It was done under combined spinal and epidural. The big transfer incision over the holopeptamine this is usually i monitor atco2 in patients nowadays the newer machines are provided with some atco2 probe for monitoring under spontaneous ventilation this is appendicectomy laparoscopic patient shifting herself this is laparoscopic cholecystectomy ETC-O2 monitoring. This procedure went on for two hours.
I used X-MED as additive, 10 micrograms. So the huge ovarian cysts of the malignant compressing all the intra-abdominal structures done under two drug techniques, 0.5 ml of the hyperbaric and 2 ml of isobaric, T12L1 level. This is the patient during operation.
The cyst had to be ruptured. it was a very large cyst, cystectomy, omentectomy and hystectomy was done. This is PCNL patient under true drug technique. This was again ruptured ectopic, patient being interviewed during surgery. The whole of the abdomen was filled with blood.
Old morbid patient, known case of CA vocal cord. Upper GI scope is showed near total occlusion, the post-record region. His feeding gastrostomy was done in the segmental span. We can see the patient moving his legs. This is a patient of Atlanta axial dislocation with...
bacillary re-invagination for laparoscopic hysterectomy. She was given the option of general anesthesia but she happily accepted the segmented spinal. This is again two drug technique for laparoscopic hysterectomy. We see the patient moving her legs at the end of surgery.
Colorectal anastomosis was done for CA rectum some six days back. The patient developed bilateral pneumonia. and the decency of the anastomosis he was taken again for surgery you can see under segmental spinal his initial parameters he was in sepsis this was a ruptured liver abscess in a young lady hemoglobin was just 4.9 as the reactive proteins were raised the whole of the terminal was filled with pus done under single shot segmented spinal you can see the first lecture this was sigmad volvulus done under segmented spinal these are my publications and thank you very much for patient listening this is myself with evan zunder he's a pioneer in segmented spinal thank you