The Evolution and Application of Segmental Spinal Anesthesia

good evening everyone i'm very much thankful to his account kerala for providing me this opportunity

again to present my topic on segments final the new era of segments finally began

when 2006 avenger gave spinal at t10 for laparoscopic policies coming in a patient with copd

this 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 most trending regional anesthetic technique

now what is different in short giving spinal near the targeted nerve roots with a very low

volume of local anaesthetic drug is often necessitating durapuncture at high lumber or thoracic levels lower the

volume of the toes of the drug more likely to produce a true segmental block the factors making segments finally

feasible there's natural thoracic kyphosis g765 amount of gasify thoracic levels is very less

thoracic nerve cell is light and thin during its sufficient blockage in thoracic segments the spinal cord is

positioned anteriorly and there is no significant difference in the onset time for iso where you can

have already drugs at thoracic levels few important questions are asked whenever we talk about signature spinal

neurological injury ventilatory impairment bradycardia hypertension the major concern whenever we talk about

cement spinal is damage to the spinal cord on mr imaging the space between

posterior and the spinal cord is measured the spinal cord lies more anteriorly in the thoracic region

while the cord and following one attaches the posterior lumbar levels the distance is widest at a mythological

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 and the spinal cord this is the position of spinal cord at

thoracic thorac number and following one levels did a study on low incidence of

neurological complications during thoracic epidurals and they provided an anatomic explanation for this they

measured exact distance at various levels and they found the distance to be around

seven point seven five millimeters at t high levels lee are indeed study of anatomy of the

spinal canal 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 eight millimeter as compared to 4.5

millimeters at t12 l1 levels there are some additional points fearing safety of signal spinal the incident of

neurological injuries after accidental bureau puncture during thoracic epidural is very less

many anesthesiologists are going to use high lumber or thoracic spaces for green spinal specially in obese 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 cupping may get affected but due to the loads of the drugs used

that preserves the coupling ability due to minimal motor weakness of the abdominal muscles

heart rate may decrease a block extends t1 to t4 but due to the lumbar sacral sparing and

less mineralization the lower limbs right here tail filling is maintained that usually sustains the outflow from

intrinsic chronotropic receptors maintaining the heart rate less hypotension is due to the less

imperative blockage and less volume of the drug used visibility technical feasibility yes

technically it is very much feasible economics very very economic legal still a question mark

and about operational with experienced clinician it is very much feasible practically all the introduction

surgeries lateral position thoracolumbar spine and musculoskeletal surgeries breast and superficial thoracic

surgeries and even some awake thoracoscopic surgeries can be done under segment spinal

there are three different modes that can be used as a single short sequence final for short-term duration surgeries or it

can be combined with epidurals for longer duration surgeries or epidural can be used as a backup in very

morbidity cases when you are using very low dose intrathecally forcing motor spine

the epidural can be handy as a backup by epidural volume extension technique or for post-op analgesia the third

option is continuous segmentation spinal institution using spinal caps some advantages surgery is thought to be

out of domino spinal anesthesia are possible with segmental 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 lumber levels

when you limit another fluctuations early corey and body the special advantages of general

anesthesia in patients with respiratory comorbidities can avoid post-pulmonary complications and ventilatory support

there is also low incidence of post-operationality either isobaric or hyperbaric or even a

combination of these two drugs can be used for some abdominopelvic surgeries in general isomeric drugs are preferred

for laparoscopic thoracoscopic breast and superficial surgeries in morbidly trail patients

and hyperbaric drugs can be choice in some muscular patients some advantages of isobaric drugs they

are less sensitive to position issues in low doses their propensity blocks sensory nerves in reference to motor

ones this is sometimes labeled as selectiveness here the onset is usually gradual humanity

stability 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 evidence with isobaric drugs

some disadvantages of isobaric drugs levels of block cannot be modified by any change of positions

drugs need to be placed under precise dermatomes like in epidural cycle sparing is common

when low doses at higher species are used they usually take some time at lumber 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 where there are wide variations

in temperatures amongst the isobaric drugs chlorophyll and one percent you'll be again point

five rupee you can point and 0.75 percent or hyperbaric drug if you can point five percent can be used for

broken one percent being one percent the volume required is more and this will be useful for short

duration surgeries up to 40 to 60 minutes leo vp you can point five and rupee you

can point seven five percent are comparable rupiah can being less lipid soluble

is nearly half as potent as ppu can you can interactively and there is stronger differentiation between sensory and

motor blocks with throughput king additional small doses of additives like fentanyl

ketamine or clonidine can intensify the sensory blocks dex materially provides a longer

duration than others in a dose dependent manners like 10 micrograms can provide a duration in excess of three hours

academy though potentiating sensory block is known to shorten the motor block time

dprk and heavy can be used in the same dose range as verified trucks the thoracic segmentation can be

produced with just half the dose that is used at the number levels gravity dependence trade 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 or 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 those of local anesthetic and site of injection along the near axis can be

varied in general one ml of the isobaric drug spreads two to three 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 two to two point five

ml of the drug is sufficient to block segments from t2 to l5 s1 if spinal is given at t10

and 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 the regulation of effect from

lumbosacral roots 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 aspheric drugs

for breast and superficial thoracic surgery 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 the experiment is used as

additive or prolonged procedures it 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 t7 mastectomy transfer sector subdivision lab 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 segmental spinal

using isobaric drugs position of the patient forgiving spinal does not matter can use any position plane will begin

0.5 percent specific gravity of 9990 0.9990 is slightly hypovariant given in sitting position and kept seated for

some time can lead to highly also block at times temperature of the drug has inverse

relation with vericity and cooled at 24 degrees density of 1.0032 becomes slightly hyperbaric and warmed

at 37 degrees it can become 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 drug sitting position is

mandatory for giving spinal either quincy or pencil point can be used

for giving spinal combined with epidurals ca secret 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 the 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

some anatomical hurdles for polarizing spinal the thoracic spinous processes are sharply angled and point quality

between t4 to t9 it may be little difficult in this in this area but beyond t10 it resembles those in the

lumber region the interlaminal spaces in thoracic spine are very narrow

and more challenging to access with the midline approach so a paramedicine approach can be very handy in such cases

these are some tips to use the paramedic approach for thoracic spine those who have the facilities of

ultrasound they can have a pre-procedure scan at my thoracic for guiding thoracic spinal either a

transverse juxtapedian scan to locate the lfd complex or a transverse extra median scan can be

done coming to my segment swan profile now more than around 3000 surgeries uh till

date initially used for only highest cases but now occupy is nearly 50 percent of my sap profile

till that very few partial failures but no mishaps completely anaesthetic evaluation of the patient is done venus

access minimum mandatory monitoring no sedative premedications lateral decreases 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 chloropropane 2.5 to 3.5 ml with or without added use for maturation surgeries i will leave if

you can point five rupees in point seven five or bp you can have point five percent with fentanyl

ketamine or dexmit according to need and this is if this you can remember you can do any

abdominal surgery of mid duration and this dose is

for average female patient 2 ml plus additive and for average veil 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 uh segmented spinals with various blocks

like transverse have downwards plane lock directly sheet block or erector spinae

plane law for open surgery or local anesthesia at the foresight in laparoscopic surgeries

for breast surgeries i use lubricant 0.5 european 0.75 percent is 1.5 to 2 ml maximum with additive

like quentin l ketamine or dexmed at mid thoracic levels and combine with epidurals or some

blocks like one pack two cylinder centigrade plate block or electrospinal plane block or

analgesia this is true drug technique you can combine isobaric and hyperbaric drugs

for procedures like tlh pcnl colorectal surgeries

spinal needs to be given sitting position with 0.5 to 1 ml of hyperbaric drug

initially and then one point five to two ml of is a very drug in different ranges the patient usually turns supine

immediately after spinal or can be kept in the lateral position with operative side of lateral position

surgeries sensory block tested by pinprick usually sets in three to four minutes and complete block in eight to

ten minutes some human expectations can occur but usually within ten minutes and very minimum and gradual

no respiratory embarrassment is usually seen even with hypothyroidism or cervical routine hormones

initial partial environment of combo sacral groups can be seen which usually requires by the end of surgery no

additional supplements are usually required except in few laparoscopic surgeries patient can be mobilized in

four to six 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 material 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 and keep our fingers crossed it's a very useful technique with many advantages minimal risk we do

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 usg can be helpful and the technique is reserved for

experienced clinicians with good learning curve i just 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 t12 l1 for probably

epigastric hernia 27 gauge continue this was a more widow-based patient for

hysteroscopic removal of polyp spinal in sitting position t12 l1 has

wanted some lumbosacral environment also 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 atmospheric level the level is

being tested 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 the mrm being done this is uh

the surgeons can give back one pick two 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 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 halvingthorax filled with intestinal contents diagrammatic measure repair being done

the same patient at the end of surgery next x-ray of the same patient this was

ventral hernia along with polycystic tommy

she was having multiple comorbidities a lot of allergens

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 transverse incision over the polar peptide

this is usually i monitor it is u2 in patients nowadays the newer machines are provided

with some tco2 probe for monitoring under spontaneous ventilation

happen is appendisectomy laparoscopic patient shifting herself this is laparoscopic polycystomy gcode

monitoring this procedure went on for two hours i used x-men as additive 10 micrograms

so the huge audience is probably malignant compressing all the interruption

structures done under 2 drug technique 0.5 ml of the hyperbaric and two ml of isobaric

t12 l1 level this is the patient during operation the system to be ruptured it was a very

large cyst cystectomy momentectomy and hysterectomy was done

this is pcnl patient the true drug technique so again ruptured ectopic

patient being interviewed during surgery the whole of the abdomen was filled with blood

the old morbid patient known case of ca opal cord apparatus office showed near total

occlusion the post required region is feeding astrostomy was done the segment spanning

see the patient moving his legs the patient of atlanta axial dislocation with

bacillary imagination for laparoscopic hysterectomy she was given the option of general

anesthesia but she happily accepted the signature span

this is again two drug technique for laparoscopic stratum

and see the patient moving her legs at the end of surgery the colorectal anastomosis was done for

ca atom some six days back the patient developed bilateral pneumonia and the distance of the

anastomosis he was taken again for surgery you can see

under segmented spinal his initial parameters he was in sepsis this was a ruptured lyrexes in a young

lady hemoglobin was just 4.9 a c reactive proteins were rest

the whole of the abdomen was filled with pus then under single shot segmenters final

you can see the first video in lecture this was

sigma volumized and 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 segment span thank you you