Segmental Thoracic

Spinal Anesthesia
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

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 C12 Punctures for Routine Cervical Myelography below the Standard of
Care? A JNR 2009;30:1360-1363

What makes it accepted?!!!!

PROsAnatomical Explanation
5.2mm
3.6mm
4.3mm

7.6mm

Imbelloni L E & Gouveia

2010

T2

5.2 mm

T5

7.75 mm

T10

5.88 mm

3.3mm
5.9mm

Imbelloni L E et al. Magnetic resonance imaging of the spinal column Br. J. Anaesth.
2008;101:433-434
Imbelloni L E , Gouveia Low Incidence of Neurologic Complications during Thoracic

What makes it accepted?!!!!

PROsAnatomical Explanation
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): 6369

Technique
A

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

Technique
The 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

Technique
The dura is then pierced
The 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

Technique
Once 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

Technique
Only 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:

T2

T4
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

Sensory block:
Lower sensory level:
L4
L2

L1
L3

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

Motor block:

2; 25%
1; 25%

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 :

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;37:37074
Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic
epidural catheterization. Anesthesiology 1997;86:5563

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

Recommendations
Patient

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