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

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

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

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

Segmental ThoracicSpinal Anesthesia

Rasha S Bondok M.D.Assisstant ProfessorAin-Shams University

Page 2: 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’

Jonnesco T. General spinal analgesia. Br Med J 1909;2:1396-1401

Page 3: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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.

Page 4: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY

Page 5: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

Major Concern

Page 6: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 7: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 8: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 9: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 10: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 11: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 12: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 13: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 14: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 15: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

TechniqueOnly when the block is considered adequate An effective block extent includes the T4 to L2

dermatomes, evaluated by pinprick

Page 16: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 17: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 18: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 19: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

Segmental thoracic spinal anesthesia

What makes this technique segmental

Film: The spread of local anaesthetic solutions in the glass spine By Dr Len Carrie

Page 20: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 21: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 22: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 23: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

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

Page 24: Rasha S Bondok M.D. Assisstant Professor Ain-Shams University.

THANK YOU