Segmental Spinal Block

(Dr Naresh Paliwal)

Few important questions and answers related to segmental spinal

1) Advantages of segmental spinal over routine spinal or GA at times?
Ans-
a) surgeries which were thought to be out of domain of spinal anaesthesia are
possible with segmental spinal , like upper abdominal surgeries, superficial
thoracic and breast surgeries, thoracoscopic procedures like bullectomy,
thymectomy, lung volume reduction and wedge resection.
b) higher levels of blocks can be achieved with just half the dose which would
have required with spinal given at lumber levels. That means fewer
haemodynamic fluctuations, early recovery, and voiding.
c) special advantages over GA in patients with pre existing respiratory co
morbidities. It can avoid postop pulmonary complications and patients going on
ventilatory support.
d) lower incidence of postop nausea and vomiting

2) W hich drugs can be used for segmental spinal? Can hyperbaric drugs be used?
Ans –
both isobaric and hyperbaric drugs can be used for segmental spinal and even a
combination of both also can be used for some abdominopelvic surgeries. In
general, isobaric drugs are preferred for laparoscopic and thoracic surgeries and
hyperbaric can be a choice in open surgeries specially in male muscular patients
where relaxation can be an issue.
Amongst the available drugs - Chlorprocaine 1%, Levobupivacaine 0.5%,
Ropivacaine 0.5 & 0.75 % , Bupivacaine 0.5 % heavy all can be used as per
need.
Chlorprocaine 1% - is isobaric with sp gravity of 1.0070 to 1.0080. Being 1% the
volume required is more and is useful for very short procedures of 40 to 50
minutes duration either open or laparoscopic. As the volume required is more ( 3
to 5 ml ) , spinal given at high lumber levels(L1/2/3 ) is sufficient for lap
surgeries. Pre emptive analgesia before the effect wears off is mandatory
( either in form of blocks, or MMA ) as the wears off abruptly. Patients can be
mobilised within 2 to 3 hrs.
Levobupivacaine 0.5 % - is the preferred drug for laparoscopic , upper
abdominal / thoracic superficial surgeries and in morbid ill patients for mid
duration surgeries (90 to 120 mins )
Ropivacaine 0.5 & 0.75 % - being less lipid soluble , intrathecally it is half as
potent as levobupivacaine and have more propensity for a preferential sensory
blockade over motor one. Can be used in place where relaxation is not
important. Levobupivacaine 0.5 % and Ropivacaine 0.75 % are comparable.
Hyperbaric Bupivacaine 0.5 % - can very well be used in segmental spinal in the
same dose range as isobaric drugs at the same levels. But the gravity
dependant spread can lead to unpredictable levels specially in lap surgeries
where steep tilts are quite often required. For open surgeries it can be a better
choice specially in male muscular patients where isobaric drugs may not provide
adequate relaxation.
3) Advantages / disadvantages and special utility of isobaric drugs
Ans
Advantage - Being isobaric they are not position dependant for spread
intrathecally. This feature can be utilised with good results in lateral and some
prone position surgeries. (like lateral position lower limb ortho surgeries, kidney
surgery, or prone position spine surgery etc. ). Patients can be placed directly in
operative position and then spinal can be given. During CSE spinal can be given
before epidural and a space higher than epidural without worrying for unilateral
blocks. Less h/d fluctuations. Low doses usually block sensory nerves in
preference to motor ones (selective spinal ) leading to early recovery and
ambulation.
Disadvantage - Levels of block can not be modified by any change of position ,
drugs need to be placed at the precise dermatomes , like in epidurals sacral
sparing is common , less muscle relaxation

4) Reasons for unpredictable levels achieved at times when isobaric drugs are
used ?
Ans –
Sitting position and temperature of drug / room temperature - plain isobaric
solutions being on the slightly hypobaric side ( 0.9990 ) , if given in sitting
position and patient kept seated for a while can lead to higher spread.
Bupivacaine plain is slightly hyperbaric at 24 degrees C( density- 1.0032 ) but
slightly hypobaric at 37 degrees C ( density 0.9984 ) . Even such minor
differences in baricity can cause completely opposite distribution patterns and
may account for the large variability of spread of plain bupivacaine when
injected at " room " temp. ( which may vary considerably )
5) How to decide which space and what dose for a particular surgery ?
Ans –
It depends on the type of surgery (open / lap ) , site of surgery ( upper
abdominal/ lower abdominal / thoracic ) , average duration , co-morbidities and
whether combined with epidural or not . On an average one ml of isobaric drug
spreads two to three segments above and below the site of injection. That
means 2 to 2.5 ml of drug is sufficient to block segments from T2 to L5/S1 if
spinal given at T10 In general
for all lap abdominal surgeries of 60 to 90 mins duration , a dose of 2ml of
isobaric levobupivacaine with fentanyl 25 mcg for Female patients and 2.5 ml
levobupivacaine + 25 mcg fentanyl for male patients given at T10/12 level.
Levels from lumbosacral roots start regressing after about 70 to 80 minutes , so
if surgeries involving pelvic manipulations( like in TLH ) go beyond this time then
some supplemental sedation is required OR if time span can be anticipated
before hand ( slow surgeon/ difficult case ) then a combination of hyperbaric and
isobaric drugs can be used. 0.5 ml of hyperbaric bupivacaine followed by 2ml of
isobaric levobupivacaine from different syringe , in sitting position spinal at T
10/12 level. This can work for procedures like TLH or other abdominopelvic
surgeries for upto 2 hrs or more depending on additive used. For prolonged
surgeries and in patients with multiple co-morbidities where we want to use very
minimal dose in spinal (just 1 to 1.5 ml ) , epidural can be placed at same level
(CSE kit ) or one space above . Epidural can be helpful not only during surgery
and postop analgesia but also by EVE (epidural volume extension technique )
low dose of spinal can be spread to more segments.
For thoracic and breast surgeries - spinal at midthoracic levels (T5/6/7) with 1 to
1.2 ml of isobaric levobupivacaine ( max 1.5 ml with additive ) with 25 mcg
fentanyl can work for 60 minutes . For longer duration surgeries better to
combine with epidural rather than increasing the intrathecal dose, to avoid
haemodynamic and respiratory complications.