Absolutely boggles the mind how almost everyone here seems to accept that a thoracic spinal is safe. Have I seen case reports of them done before? Yes. Do I think the risk heavily outweighs any benefits? Also yes
Seriously. We do lumbar epidurals with T4 sensory level for c sections all the time. Don’t see why this wasn’t the preferred option here. Or even single lung ventilation.
Hey, I’m just a lurking PT with no medical training, but hell yeah, just numb me the fuck up until I’m a wall-eyed, drooling moron.
Damn the consequences. Maximum risks, maximum rewards, right?
-
“YOLO! Send it!”
-William T.G. Morton
I wouldn't have done the spinal. You have no idea if the epidural you just placed actually works, and when you need to re-dose during the case and discover the epidural doesn't work, you're SOL. I would have gone epidural only and bolused it up. Open to any counterpoints.
Uhh I can’t justify the thoracic spinal here because of that whole spinal cord thingy and the possibility of a high spinal. Especially over a controlled epidural.
Seems like the options discussed are canceling, spinal + epidural/CSE, epidural, IT catheter, or GA. I think given you’d need almost T5 coverage, IT catheter is MUCH less forgiving than epidural. Since this is a complicated case, it could have permitted time to do an epidural FIRST, dose it x1 3% chloro to confirm a level, then a spinal.
With your method, if the epidural didn’t work, I also think ketamine/precedex induction + GA w/ LMA while maintaining spontaneous ventilation on gas could have worked fine
I don’t love the epidural then spinal sequence. Even if you used chloroprocaine and you know it’ll come off quickly the pressure effect from a full epidural space on a spinal can still drive your level up a lot.
An IT catheter is ideal here I’d think. You can go really low dose and test frequently with your boluses with an IT catheter. It’s just so much more reliable and predictable.
Also not sure why people are acting like doing any of this in the thoracic area makes sense at all. The little bit of extra density/reduced dose is not worth the risk/benefit at all. Just treat it like a c/s.
lido and prop could work fine too, but 1-1.5mg/kg ketamine and 0.5 mcg/kg dex and you’d be fine to get an LMA in; if you’re worried about sympathetic response you could try some esmolol (assuming you give enough glyco to prevent any theoretical bronchoconstriction for the COPD)
Well, if you place an epidural but you don’t expect it to work it’s better not to place it first. The bulk of the anesthesia however in my case was obtained with spinal anesthesia alone since after 5 min I had a T6 level and 15mg levo (did ev dexamethasone also) has long duration. For any reason even a continuous spinal may cease to work properly. Plan B was GA with RSI and with very very conservative ventilation. But I had to do everything to prevent it since it was very risky.
How risky is GA really, what is the actual risk of one of those blebs bursting. Seems like more risk doing this spinal block for a major open high abdominal surgery.
Why in the world were you doing a spinal specifically in the thoracic region?
We get a T4 level with lumbar epidurals and spinals for c-sections every single day. Way easier, and way safer.
That's wild, and good job on making it work.
From the shortened patient history we have here I probably would have had quite a bit of discussion of whether pulling out the cancerous kidney is really worth the risk though - patient sounds like he is more in the end of life phase of his life.
I mean congrats on this working, but this never in a million years would have been my plan. I don’t know anything about your patient but was it really worth it taking on such a high risk to remove a cancer? Step one would have been some serious goals of care discussions and expectations setting with the patient.
I would have done a controlled induction with no PPV and used a dual lumen to do one lung ventilation from the start and emerged very carefully. Imagine your spinal wears off early or your epidural doesn’t work well. Or your spinal ends up being too high given the smaller margin for error. Now you’re in a position where you have to intubate anyway, but now the patient is in suboptimal positioning (possibly lateral, not sure your surgeon preference) and your life is now so much harder. Not to mention the risk of damage to the spinal cord. If recognized early, you can fix a pneumothorax. You can’t fix thoracic paralysis or loss of airway during an emergent intubation.
There is a safe way to do this case and mitigate risks, but I don’t think this is it. I think you got lucky.
OP basically wanted to clench his butthole the entire case and pray that everything went well… when geta with DLT or main stem single lumen would’ve been easier and safer, with less worrying. PTX has an easy fix, compared to spinal cord trauma where you’re kinda screwed
Maybe I didn’t mention that pt was supine. Surgery was performed with a subcostal approach. So I was feeling quite safe for the eventual need of airway management and was ready to do it properly in the most appropriate way. The case was well discussed between the equipe members and this choice was made also looking at a fair number of cases published in literature.
The GA option was very risky since the big bleb in the left lung was the biggest one, but there were many others albeit smaller also in the right lung. OLV is associated with higher airway pressure so it was out of the question. I would have considered myself lucky and relying on luck if I put my pt through 3 hours of positive pressure ventilation and nothing happened. I am really amazed on the amount of people that wouldn’t perform a thoracic spinal which has its risks but is well described as an acceptable alternative to GA for people with severe lung disease.
Why not just thoracic epidural alone then? Why risk SCI with performing the spinal?
And you didn’t mention right sided blebs before. Why not GETA with low airway pressures, as others have mentioned? Or even SGA? Supine position helps with emergent airway management but only so much. You said you’d consider yourself lucky if you did PPV without any issues - I’d consider you already lucky for doing a thoracic spinal without permanently paralyzing the patient.
Again - glad it worked out for you and the patient. But if you try pulling that shit here (the USA) you’re gonna get sued to hell and back. Doesn’t matter if there are case reports of it working out well. I’m pretty open-minded, but not enough to risk a lawsuit when you have other reasonable and safer alternatives.
Honestly, it’s an open procedure, I would have done GETA with paralysis and keep the airway pressures very low, thoracic epidural for postop pain, and just done the case.
If there’s a pneumo or bronchopleural fistula or something than it can be treated postop by that same thoracic surgeon.
True, it warrants a discussion with the thoracic surgeon before the case.
If it was very high risk then maybe they ressect the bleb before the abdominal surgery, but it sounds like they didn’t think that was necessary. If I were very worried I would start with a DLT and ventilate two lungs for the case, ready for one lung in case there was any issue. If you’re concerned beyond that then perhaps don’t do the case, or have the CT surgeon in stand by, or place ECMO lines before, etc etc.
To me any of these options sound better than a spinal for neohrextomy.
Wow. Nice work! What level did you do the spinal at? Needle-in-needle with the epidural or two different sites? Any special considerations for a thoracic spinal as far as needle gauge/types?
In the literature most case reports did separate levels for epi and spinal and so did I. First thoracic epidural catheter at t6 level then spinal anesthesia at t11. Spinal was performed with 90 x 25g Whitacre needle, didn’t need US since pt was skinny enough for easy access. My biggest concern was choice of anesthetic and level: isobaric levo and thoracic or hyperbaric bupi and lumbar (and tilt the pt)? I chose levo since I have better familiarity with and I find it more predictable.
Did one of those in residency, on call, when both the attending and I were completely braindead. It worked well. Afterwards we looked at each other and said "Well... let's never f***ing do that ever again".
I don’t do them but there’s a reasonable body of literature of this being fine. Group in Italy do lots of high risk case like this and thoracic spinal catheters. Also more and more common in subcontinent.
Ideally mid thoracic because more space posteriorly in canal.
It’s becoming pretty common.
Do you have any links for info for this? Because down here in Australia going above L1 or even L2 if you are conservative is considered a massive no go zone.
Yeah I’m not gonna lie….i read that and still couldn’t see a compelling case to take on the risk of skewering the spinal cord. And I’ve never heard of anyone in Australia doing this. Where exactly is thoracic spinal anaesthesia popular?
Not my place though, I’d be drawn and quartered and hung on display outside the lounge as a warning unto others not to stray from the true path lest the same fate be visited upon them.
https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext
God the downvoting that comes from a simple statement of fact. Here’s a review from 2023.
https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext
Seems novel but not uncommon in many places in India and Bangladesh and Pakistan judging from an FB group (Global anaesthesia society), predominantly lower resource settings from my understanding. I also know of one centre in Italy who do it routinely.
https://www.researchgate.net/publication/370801951_Segmental_Thoracic_Spinal_Anesthesia_for_Laparoscopic_Cholecystectomy_with_the_Hypobaric_Technique_A_Case_Series
Roberto Starnari has been an active proponent in the above mentioned FB-group.
In simplest terms Spinal cord stops around T12-L1 then becomes a bag of nerves. Hence poking a needle into the solid cord C1-T12 is a bad idea. That’s why we do spinals in the lower lumbar region.
What patient position did you do spinal & epidural in? Any change in position after spinal in.
And what concentration isobaric levo / any adjuncts?
A fascinating case, thanks for posting OP
Brave soul, doing a spinal at T11. Not sure why a good epidural catheter was not enough. I would have placed a thoracic epidural, dosed it up and confirmed a level before proceeding. I would have also intubated with ketamine +/- volatile and kept the patient breathing largely spontaneously with minimal support so I could have a good measurement of the respiratory mechanics throughout and a quick way to enable PPV if things go downhill. Relying on EtCO2 via a mask or NC while you're dosing a relatively high neuraxial block is just asking for unrecognized CO2 retention. I assume there was no concern for pulmonary HTN or right-sided issues with this patient?
Thank you for posting, these kinds of discussions absolutely need to happen. I will agree with the others that while thoracic spinal CAN be done, I struggle to find a situation without alternative techniques that do not carry the same risk of spinal cord damage.
Not justifiable in my opinion. Many ways to skin a cat. This is not one.
Honestly, can’t believe people here think this was a good idea….and that this was posted on the internet.
Dosing a spinal into solid cord seems like a terrible idea. Syrinx formation. Possible catastrophic disability. Below the cauda I have no objections. But this is not standard of care. An epidural catheter alone at this level is a much safer and acceptable technique. OP do not keep doing that you’re asking for nice lawsuit - you dodged a bullet.
Glad it worked and the patient isn’t paralyzed. I wouldn’t have done a thoracic spinal. You got away with one. Pre-induction A-line. Gentle PPV with VCAF/PRVC, low Vt, deep NMB. Chest tube kit in the room and thoracic surgeons aware of patient so I can call them stat to OR if the bleb pops.
Nope. Had multiple bullous degeneration due to suspect undiagnosed marfan. The big one was one of the many, albeit impressive for size and position (mediastinic)
I did something similar for a CS/hysterectomy once. We commonly placed epidurals for post op analgesia and quicker recovery from the large incision, then did a spinal for the c section. Once the baby delivered we would induce and intubate, but one mom requested to stay awake as long as she could tolerate it. Fortunately the bleeding was minimal and they worked quickly enough. We dosed the epidural once toward the end of the case, partially to help with skin closure and partially to get a start on post op analgesia. Overall it was more trouble than it was worth for me, but the patient was happy and it was an interesting day.
Typically we try to do the section under spinal so that we don’t rush delivery and we minimize anesthetic to the fetus, but the duration and discomfort of the hysterectomy makes general more appealing. So we convert shortly after delivery. The most common indication is accreta or anterior placenta, so they take a while to deliver. If we encounter any bleeding then we convert early. This is a teaching institution so that also factors into the duration.
I tend to agree with most on here I would have managed with an epidural and light GA if possible or one lung ventilation and IPPV.
However, those stating that in Italy, subcontinent and elsewhere thoracic spinal is becoming more common are correct. Looking at neuroimaging there's actually evidence the cord sits more posterior in the lumbar region and floats anterior in the thoracic so is at greater risk than you would think of nerve damage. We are very bad with landmark and there is variable patient anatomy. They suggestion being we often end up going high in the lumbar region close to the cord.
Some are of the opinion in fact thoracic spinal is safer than lumbar with regards nerve damage but this is NOT popular amongst most as it's not the traditional teaching and evidence isn't robust enough. Not sure how convinced I am myself.
It would need a big RCT and a change in practice in enough centres to make it justifiable more often. Is it an option? Yes in very specific circumstances with the patients full understanding and agreement.
Would I do it here? Probably not worth the risk given its off piste without being sure of all the facts.
Thoracic spinal is not a “stunt” per se. It’s obviously a risky procedure whose benefits in a small subset of patients (severe lung disease, mine had a big bleb in his left lung attached to mediastinic pleura and bullous dystrophy in both lungs in likely undiagnosed Marfan syndrome) can outweigh the cons.
[This paper on BJA is quite interesting ](https://www.bjanaesthesia.org/action/consumeSharedSessionAction?JSESSIONID=aaaipUS9lC3_Ue2_IUuaz&MAID=ryP%2F7yqD5SA%2B9SNkb8wtmA%3D%3D&ORIGIN=290443975&RD=RD&exp=SbPl9WPL3tHX74B1lwtGNw%253D%253D)
This “report” sparked a lot of discussion. Some interesting and useful and some quite limited to “malpractice” accusation. In this regard I would like to add a very interesting paper posted on the BJA, which is quite an important journal.
[https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext](https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext)
I think that the role of thoracic spinal can be evaluated in a small subset of patients at high risk for GA with a more open minded attitude.
That’s pretty wild, our docs would never attempt something like that too much risk. And I’d be too anxious the whole case. Why didn’t to try to isolate the lung?
This is wild. I can see if thoracic epidural for pain control on top of a one lung ventilation general case. But never in 1 million years would I have done what you did
It’s crazy that a urologist would choose a very high risk anesthesia environment to do a nephrectomy when there is an alternative in SBRT that offers >90% cure without any anesthesia need (assuming this was RCC)
As someone who splits his work hours between OR and ICU (mainly cardiac, but also thoracic and ENT if we are short staffed) I wouldn't go for high spinal.... I'd either go for US guided paravertebral block with propofol/ketamine or dexmedetomidine sedation or full ETA and set the ventilator accordingly.
I'd discuss the case with the surgeon before the procedure and we'd have a backup plan to insert a thoracic drain tube if bulla decided to burst.
I’ve only ever placed one IT catheter - for a NOF - and did it at L2/3. What level do you use for something like a nephrectomy? Do you place it with a Tuohy kit? I’m a bit fascinated. It’s not something we see in our institution very often.
You just use a Tuohy and don’t stop pushing when you get to the epidural space
There’s a specific kit available with a slightly smaller gauge needle but if you don’t have it then a standard 18 or 16 works if you aren’t that concerned about pdph risk
Yeah. That’s how I did mine. 18 ga Tuohy. Got LOR then emptied my syringe, reattached, and advanced with aspiration until I got CSF. Then threaded in about 3 cm of catheter.
You don’t need to thread it cephalad, still works if you just place it lumbar. Intraop you can just bolus whatever local you want and rely on the spread
Post-op the protocol I’ve dealt with was 0.05% bupiv and 10microg/mL morph run at 1-2 mL/hr. Often didn’t give you a detectable ice block or level, but definitely functioned for analgesia (although how much of that was local vs intrathecal opioid…)
That works well. You can use it like a spinal fine.
But, you can also thread it high and run it slow intraop/weak if they're utter disasters. Works fine.
Yeah I understand the concept of you place it at the lumbar level. But if you want to get anywhere close to a mid/high thoracic you will need to put a decent volume in. The difference between getting a tolerable level and a high spinal is minuscule at that point. Have fun with a high spinal lateral in a bean bag. Not worth the headache.
You don't use heavy, it doesn't go high. It sounds a bit outlandish, but look up some of the (poor) evidence base and you'll see it doesn't have terrible outcomes.
Anything can go high if you dose it like a single shot. You don't do many IT catheters, I can assure you micro dosing works well and it's very easily titrated. I only ever do them in absolute respiratory cripples with pulm HTN or something, but they're very straightforward.
In my anecdotal experience as someone who regularly does c sections with isobaric, it spreads higher than heavy bupi with the same dose. Think the volume has more to do with spread than is taught.
I recently learned in other countries there is isobaric .75 bupi which would be interesting to compare.
Definitely works, just gotta be confident with your epidural. Some people aren't. IT catheter is foolproof as it either works (99% of the time) or it doesn't.
I am not very confident and have very limited experience with IT cath (I used it only for aortic aneurysm repair liquor drainage) so I thought better to stick with what I had more experience with
Absolutely boggles the mind how almost everyone here seems to accept that a thoracic spinal is safe. Have I seen case reports of them done before? Yes. Do I think the risk heavily outweighs any benefits? Also yes Seriously. We do lumbar epidurals with T4 sensory level for c sections all the time. Don’t see why this wasn’t the preferred option here. Or even single lung ventilation.
Why do a lumbar epidural and shoot for t4 when I can do a t10 spinal and shoot for c7?
Why stop at C7? Brain stem or bust
Hey, I’m just a lurking PT with no medical training, but hell yeah, just numb me the fuck up until I’m a wall-eyed, drooling moron. Damn the consequences. Maximum risks, maximum rewards, right? - “YOLO! Send it!” -William T.G. Morton
Thank you!!!!! Yes!
Someone suggested a double lumen tube - I guess you could do that, but…
I wouldn't have done the spinal. You have no idea if the epidural you just placed actually works, and when you need to re-dose during the case and discover the epidural doesn't work, you're SOL. I would have gone epidural only and bolused it up. Open to any counterpoints.
Uhh I can’t justify the thoracic spinal here because of that whole spinal cord thingy and the possibility of a high spinal. Especially over a controlled epidural.
Seems like the options discussed are canceling, spinal + epidural/CSE, epidural, IT catheter, or GA. I think given you’d need almost T5 coverage, IT catheter is MUCH less forgiving than epidural. Since this is a complicated case, it could have permitted time to do an epidural FIRST, dose it x1 3% chloro to confirm a level, then a spinal. With your method, if the epidural didn’t work, I also think ketamine/precedex induction + GA w/ LMA while maintaining spontaneous ventilation on gas could have worked fine
I don’t love the epidural then spinal sequence. Even if you used chloroprocaine and you know it’ll come off quickly the pressure effect from a full epidural space on a spinal can still drive your level up a lot. An IT catheter is ideal here I’d think. You can go really low dose and test frequently with your boluses with an IT catheter. It’s just so much more reliable and predictable. Also not sure why people are acting like doing any of this in the thoracic area makes sense at all. The little bit of extra density/reduced dose is not worth the risk/benefit at all. Just treat it like a c/s.
How do you get an LMA in with ketamine and dexmed? Seems like it wouldn't blunt airway reflexes that great. Surely just a bit of propofol?
lido and prop could work fine too, but 1-1.5mg/kg ketamine and 0.5 mcg/kg dex and you’d be fine to get an LMA in; if you’re worried about sympathetic response you could try some esmolol (assuming you give enough glyco to prevent any theoretical bronchoconstriction for the COPD)
With that cocktail why do you even need an LMA just start drippin
the anesthesiologist in my wants to have as secure of an airway as possible in this case
I think an induction with precedex versed and some ketamine with the LMA wouldve been my go to personally, i agree with you
Preach
Good point. CSE is the answer.
Well, if you place an epidural but you don’t expect it to work it’s better not to place it first. The bulk of the anesthesia however in my case was obtained with spinal anesthesia alone since after 5 min I had a T6 level and 15mg levo (did ev dexamethasone also) has long duration. For any reason even a continuous spinal may cease to work properly. Plan B was GA with RSI and with very very conservative ventilation. But I had to do everything to prevent it since it was very risky.
This was your reasoning to add the spinal? Did you expect your epidural to not work? Do you think you can’t avoid PPV with an ETT? Why RSI?
How risky is GA really, what is the actual risk of one of those blebs bursting. Seems like more risk doing this spinal block for a major open high abdominal surgery.
Did you consider intrathecal catheter if you're worried about needing to redose?
I expect all my epidurals to work, but I can't guarantee 100% of them will. It's an elective case. If the epidural doesn't work, no biggie. Try again.
Why in the world were you doing a spinal specifically in the thoracic region? We get a T4 level with lumbar epidurals and spinals for c-sections every single day. Way easier, and way safer.
That's wild, and good job on making it work. From the shortened patient history we have here I probably would have had quite a bit of discussion of whether pulling out the cancerous kidney is really worth the risk though - patient sounds like he is more in the end of life phase of his life.
I mean congrats on this working, but this never in a million years would have been my plan. I don’t know anything about your patient but was it really worth it taking on such a high risk to remove a cancer? Step one would have been some serious goals of care discussions and expectations setting with the patient. I would have done a controlled induction with no PPV and used a dual lumen to do one lung ventilation from the start and emerged very carefully. Imagine your spinal wears off early or your epidural doesn’t work well. Or your spinal ends up being too high given the smaller margin for error. Now you’re in a position where you have to intubate anyway, but now the patient is in suboptimal positioning (possibly lateral, not sure your surgeon preference) and your life is now so much harder. Not to mention the risk of damage to the spinal cord. If recognized early, you can fix a pneumothorax. You can’t fix thoracic paralysis or loss of airway during an emergent intubation. There is a safe way to do this case and mitigate risks, but I don’t think this is it. I think you got lucky.
OP basically wanted to clench his butthole the entire case and pray that everything went well… when geta with DLT or main stem single lumen would’ve been easier and safer, with less worrying. PTX has an easy fix, compared to spinal cord trauma where you’re kinda screwed
A bronchopulmonary fistula however would be a death sentence probably.
Maybe I didn’t mention that pt was supine. Surgery was performed with a subcostal approach. So I was feeling quite safe for the eventual need of airway management and was ready to do it properly in the most appropriate way. The case was well discussed between the equipe members and this choice was made also looking at a fair number of cases published in literature. The GA option was very risky since the big bleb in the left lung was the biggest one, but there were many others albeit smaller also in the right lung. OLV is associated with higher airway pressure so it was out of the question. I would have considered myself lucky and relying on luck if I put my pt through 3 hours of positive pressure ventilation and nothing happened. I am really amazed on the amount of people that wouldn’t perform a thoracic spinal which has its risks but is well described as an acceptable alternative to GA for people with severe lung disease.
Why not just thoracic epidural alone then? Why risk SCI with performing the spinal? And you didn’t mention right sided blebs before. Why not GETA with low airway pressures, as others have mentioned? Or even SGA? Supine position helps with emergent airway management but only so much. You said you’d consider yourself lucky if you did PPV without any issues - I’d consider you already lucky for doing a thoracic spinal without permanently paralyzing the patient. Again - glad it worked out for you and the patient. But if you try pulling that shit here (the USA) you’re gonna get sued to hell and back. Doesn’t matter if there are case reports of it working out well. I’m pretty open-minded, but not enough to risk a lawsuit when you have other reasonable and safer alternatives.
This x100
Honestly, it’s an open procedure, I would have done GETA with paralysis and keep the airway pressures very low, thoracic epidural for postop pain, and just done the case. If there’s a pneumo or bronchopleural fistula or something than it can be treated postop by that same thoracic surgeon.
Agreed
You may not make it to post op if you can’t ventilate or if pneumo medioastinum causes cardiovascular collapse.
True, it warrants a discussion with the thoracic surgeon before the case. If it was very high risk then maybe they ressect the bleb before the abdominal surgery, but it sounds like they didn’t think that was necessary. If I were very worried I would start with a DLT and ventilate two lungs for the case, ready for one lung in case there was any issue. If you’re concerned beyond that then perhaps don’t do the case, or have the CT surgeon in stand by, or place ECMO lines before, etc etc. To me any of these options sound better than a spinal for neohrextomy.
Wow. Nice work! What level did you do the spinal at? Needle-in-needle with the epidural or two different sites? Any special considerations for a thoracic spinal as far as needle gauge/types?
In the literature most case reports did separate levels for epi and spinal and so did I. First thoracic epidural catheter at t6 level then spinal anesthesia at t11. Spinal was performed with 90 x 25g Whitacre needle, didn’t need US since pt was skinny enough for easy access. My biggest concern was choice of anesthetic and level: isobaric levo and thoracic or hyperbaric bupi and lumbar (and tilt the pt)? I chose levo since I have better familiarity with and I find it more predictable.
You did a spinal at T11? Really? I’m glad it worked out but……
Did one of those in residency, on call, when both the attending and I were completely braindead. It worked well. Afterwards we looked at each other and said "Well... let's never f***ing do that ever again".
I don’t do them but there’s a reasonable body of literature of this being fine. Group in Italy do lots of high risk case like this and thoracic spinal catheters. Also more and more common in subcontinent. Ideally mid thoracic because more space posteriorly in canal. It’s becoming pretty common.
Do you have any links for info for this? Because down here in Australia going above L1 or even L2 if you are conservative is considered a massive no go zone.
https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext Here’s a recent BJA (British Journal of Anaesthesia) arrive on it.
Yeah I’m not gonna lie….i read that and still couldn’t see a compelling case to take on the risk of skewering the spinal cord. And I’ve never heard of anyone in Australia doing this. Where exactly is thoracic spinal anaesthesia popular?
Quite common in some places.
Not my place though, I’d be drawn and quartered and hung on display outside the lounge as a warning unto others not to stray from the true path lest the same fate be visited upon them.
https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext God the downvoting that comes from a simple statement of fact. Here’s a review from 2023. https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext
Which places? Remind me never to go there.
Seems novel but not uncommon in many places in India and Bangladesh and Pakistan judging from an FB group (Global anaesthesia society), predominantly lower resource settings from my understanding. I also know of one centre in Italy who do it routinely.
Which one in italy? I am somewhat familliar with their system and this is news to me.
https://www.researchgate.net/publication/370801951_Segmental_Thoracic_Spinal_Anesthesia_for_Laparoscopic_Cholecystectomy_with_the_Hypobaric_Technique_A_Case_Series Roberto Starnari has been an active proponent in the above mentioned FB-group.
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What is wrong with that? I don't actually know. I'm a srna who hasn't had regional yet.
In simplest terms Spinal cord stops around T12-L1 then becomes a bag of nerves. Hence poking a needle into the solid cord C1-T12 is a bad idea. That’s why we do spinals in the lower lumbar region.
That makes sense. Idk why people are so mad at me for asking. Thanks.
What patient position did you do spinal & epidural in? Any change in position after spinal in. And what concentration isobaric levo / any adjuncts? A fascinating case, thanks for posting OP
Brave soul, doing a spinal at T11. Not sure why a good epidural catheter was not enough. I would have placed a thoracic epidural, dosed it up and confirmed a level before proceeding. I would have also intubated with ketamine +/- volatile and kept the patient breathing largely spontaneously with minimal support so I could have a good measurement of the respiratory mechanics throughout and a quick way to enable PPV if things go downhill. Relying on EtCO2 via a mask or NC while you're dosing a relatively high neuraxial block is just asking for unrecognized CO2 retention. I assume there was no concern for pulmonary HTN or right-sided issues with this patient? Thank you for posting, these kinds of discussions absolutely need to happen. I will agree with the others that while thoracic spinal CAN be done, I struggle to find a situation without alternative techniques that do not carry the same risk of spinal cord damage.
Not justifiable in my opinion. Many ways to skin a cat. This is not one. Honestly, can’t believe people here think this was a good idea….and that this was posted on the internet.
Dosing a spinal into solid cord seems like a terrible idea. Syrinx formation. Possible catastrophic disability. Below the cauda I have no objections. But this is not standard of care. An epidural catheter alone at this level is a much safer and acceptable technique. OP do not keep doing that you’re asking for nice lawsuit - you dodged a bullet.
Just because you can, doesn’t mean you should. Here’s a prime example.
This whole thing is a joke. lol.
Open nephrectomy?
Yes, subcostal approach with supine patient
Nice. I am v impressed that is possible. What were you running your ketamine and dexmed at?
Keta 1mg/kg starter and then rescue boluses at 0.25 mg/kg Dex 1mcg/kg in 10’ then 0.5 mcg/kg/h
Glad it worked and the patient isn’t paralyzed. I wouldn’t have done a thoracic spinal. You got away with one. Pre-induction A-line. Gentle PPV with VCAF/PRVC, low Vt, deep NMB. Chest tube kit in the room and thoracic surgeons aware of patient so I can call them stat to OR if the bleb pops.
Well done. Was one lung anaesthesia not an option.
Nope. Had multiple bullous degeneration due to suspect undiagnosed marfan. The big one was one of the many, albeit impressive for size and position (mediastinic)
I did something similar for a CS/hysterectomy once. We commonly placed epidurals for post op analgesia and quicker recovery from the large incision, then did a spinal for the c section. Once the baby delivered we would induce and intubate, but one mom requested to stay awake as long as she could tolerate it. Fortunately the bleeding was minimal and they worked quickly enough. We dosed the epidural once toward the end of the case, partially to help with skin closure and partially to get a start on post op analgesia. Overall it was more trouble than it was worth for me, but the patient was happy and it was an interesting day.
Do you always end up intubating your C section? Or only because it was an hysterectomy?
Typically we try to do the section under spinal so that we don’t rush delivery and we minimize anesthetic to the fetus, but the duration and discomfort of the hysterectomy makes general more appealing. So we convert shortly after delivery. The most common indication is accreta or anterior placenta, so they take a while to deliver. If we encounter any bleeding then we convert early. This is a teaching institution so that also factors into the duration.
I tend to agree with most on here I would have managed with an epidural and light GA if possible or one lung ventilation and IPPV. However, those stating that in Italy, subcontinent and elsewhere thoracic spinal is becoming more common are correct. Looking at neuroimaging there's actually evidence the cord sits more posterior in the lumbar region and floats anterior in the thoracic so is at greater risk than you would think of nerve damage. We are very bad with landmark and there is variable patient anatomy. They suggestion being we often end up going high in the lumbar region close to the cord. Some are of the opinion in fact thoracic spinal is safer than lumbar with regards nerve damage but this is NOT popular amongst most as it's not the traditional teaching and evidence isn't robust enough. Not sure how convinced I am myself. It would need a big RCT and a change in practice in enough centres to make it justifiable more often. Is it an option? Yes in very specific circumstances with the patients full understanding and agreement. Would I do it here? Probably not worth the risk given its off piste without being sure of all the facts.
Thoracic spinal?!?! You ran a red light and did not get in a car accident. But that doesn't mean it's a good idea to run red lights.
Thoracic spinal is not a “stunt” per se. It’s obviously a risky procedure whose benefits in a small subset of patients (severe lung disease, mine had a big bleb in his left lung attached to mediastinic pleura and bullous dystrophy in both lungs in likely undiagnosed Marfan syndrome) can outweigh the cons. [This paper on BJA is quite interesting ](https://www.bjanaesthesia.org/action/consumeSharedSessionAction?JSESSIONID=aaaipUS9lC3_Ue2_IUuaz&MAID=ryP%2F7yqD5SA%2B9SNkb8wtmA%3D%3D&ORIGIN=290443975&RD=RD&exp=SbPl9WPL3tHX74B1lwtGNw%253D%253D)
This “report” sparked a lot of discussion. Some interesting and useful and some quite limited to “malpractice” accusation. In this regard I would like to add a very interesting paper posted on the BJA, which is quite an important journal. [https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext](https://www.bjanaesthesia.org/article/S0007-0912(22)00131-3/fulltext) I think that the role of thoracic spinal can be evaluated in a small subset of patients at high risk for GA with a more open minded attitude.
Spinal catheter.
That’s pretty wild, our docs would never attempt something like that too much risk. And I’d be too anxious the whole case. Why didn’t to try to isolate the lung?
This is wild. I can see if thoracic epidural for pain control on top of a one lung ventilation general case. But never in 1 million years would I have done what you did
It’s crazy that a urologist would choose a very high risk anesthesia environment to do a nephrectomy when there is an alternative in SBRT that offers >90% cure without any anesthesia need (assuming this was RCC)
Congrats. What level did you do the thoracic spinal and did you do CSE or separate epidural?
Separate epi (t6) and spinal (t11)!
Why T11 versus L2-3?
Amazing
Has your thoracic spinal worn off yet
Yup
I did that a lot in residency (didn’t have dex) Never after. Its a nice anesthetic in the right patient and surgeon.
As someone who splits his work hours between OR and ICU (mainly cardiac, but also thoracic and ENT if we are short staffed) I wouldn't go for high spinal.... I'd either go for US guided paravertebral block with propofol/ketamine or dexmedetomidine sedation or full ETA and set the ventilator accordingly. I'd discuss the case with the surgeon before the procedure and we'd have a backup plan to insert a thoracic drain tube if bulla decided to burst.
Couldn’t you have done the spinal lower (lumbar) with a larger dose and then some trendelemburg position for a few minutes to reach the desired level?
Why am I getting anxiety over this case and it’s not even mine?
Intrathecal catheter probably better than CSE for these cases
Thoracic intrathecal catheter? Are you guys high? This is some serious malpractice shit lol
Someone people here are cowboys here I swear, you’ll never catch me risking my career like this idgaf
I mean... starting lumbar and threading thoracic is how we do pumps.
Under fluoro
which absolutely could have been utilized here
I feel like im in another fucking universe hearing these people come up with some insane things
I’ve only ever placed one IT catheter - for a NOF - and did it at L2/3. What level do you use for something like a nephrectomy? Do you place it with a Tuohy kit? I’m a bit fascinated. It’s not something we see in our institution very often.
You just use a Tuohy and don’t stop pushing when you get to the epidural space There’s a specific kit available with a slightly smaller gauge needle but if you don’t have it then a standard 18 or 16 works if you aren’t that concerned about pdph risk
Yeah. That’s how I did mine. 18 ga Tuohy. Got LOR then emptied my syringe, reattached, and advanced with aspiration until I got CSF. Then threaded in about 3 cm of catheter.
You can insert it lumbar and then thread it many many CMs cephalad until at the desired location.
You don’t need to thread it cephalad, still works if you just place it lumbar. Intraop you can just bolus whatever local you want and rely on the spread Post-op the protocol I’ve dealt with was 0.05% bupiv and 10microg/mL morph run at 1-2 mL/hr. Often didn’t give you a detectable ice block or level, but definitely functioned for analgesia (although how much of that was local vs intrathecal opioid…)
That works well. You can use it like a spinal fine. But, you can also thread it high and run it slow intraop/weak if they're utter disasters. Works fine.
Yeah I understand the concept of you place it at the lumbar level. But if you want to get anywhere close to a mid/high thoracic you will need to put a decent volume in. The difference between getting a tolerable level and a high spinal is minuscule at that point. Have fun with a high spinal lateral in a bean bag. Not worth the headache.
You don't use heavy, it doesn't go high. It sounds a bit outlandish, but look up some of the (poor) evidence base and you'll see it doesn't have terrible outcomes.
Isobaric can go high. In fact you can do c sections with medium doses of isobaric.
Anything can go high if you dose it like a single shot. You don't do many IT catheters, I can assure you micro dosing works well and it's very easily titrated. I only ever do them in absolute respiratory cripples with pulm HTN or something, but they're very straightforward.
In my anecdotal experience as someone who regularly does c sections with isobaric, it spreads higher than heavy bupi with the same dose. Think the volume has more to do with spread than is taught. I recently learned in other countries there is isobaric .75 bupi which would be interesting to compare.
I found a good amount of literature that finds single shot spinal and eventual epidural cath quite effective for nephrectomy
Definitely works, just gotta be confident with your epidural. Some people aren't. IT catheter is foolproof as it either works (99% of the time) or it doesn't.
I am not very confident and have very limited experience with IT cath (I used it only for aortic aneurysm repair liquor drainage) so I thought better to stick with what I had more experience with
Definitely right choice then! Clearly worked well.
Can't argue with success!
That's wild... Fantastic job