A Prospective Observational Study on the Effectiveness of Segmental Spinal Anesthesia in Patients Posted for Modified Radical Mastectomies
Richa Chandra1*, Gaurav Misra2, Shabir Ahmad Langoo3
1Anaesthesiology, Subharti Medical College, Meerut, India
2Anesthesiology, Critical Care and Pain management , Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, India
3Consultant Anaesthesia, Director Health Service, Kashmir, India
*Corresponding author: Richa Chandra, Anaesthesiology, Subharti Medical College, Meerut, Bareilly, India
Received Date: 15 June 2023
Accepted Date: 19 June 2023
Published Date: 21 June 2023
Citation: Chandra R, Misra G, Langoo SA (2023) A Prospective Observational Study on the Effectiveness of Segmental Spinal Anesthesia in Patients Posted for Modified Radical Mastectomies. Ann Case Report. 8: 1349. https://doi.org/10.29011/2574-7754.101349
Abstract
Background: Modified radical mastectomy is a treatment of choice in patients having carcinoma breast. The higher chances of complications with general anesthesia lead to a change in our clinical practice towards regional anesthesia. The current literature revealed that the maximum distance between the dura mater and the spinal cord is at the mid-thoracic level, but very few studies are advocating for the use of segmental spinal anesthesia for modified radical mastectomies. Therefore, the present study is planned to assess the effectiveness of segmental spinal anesthesia in patients posted for modified radical mastectomies.
Material and Methods: The present study was conducted at a tertiary care centre between April 2020 to November 2022 after approval by the institute’s ethical and research committee. The study recruited 78 patients aged between 20-70 years with American Society of Anesthesiologists (ASA) physical status I-III who were scheduled for modified radical mastectomy with axillary dissection. A subarachnoid block was performed at T5-T6 or T6-T7 levels with 27 G Quincke Babcock needle using a midline approach with a 45° tilt of the needle in all the patients under aseptic precautions after. Once the free flow of Cerebrospinal fluid (CSF) was confirmed, 1.5 ml isobaric levobupivacaine with 5 mcg of Dexmedetomidine was administered.
Results: In the present study, 97% of the surgeons were satisfied with the procedure. All the patients had stable hemodynamics and adequate sensory and motor blockade. A single episode of hypotension was noted in 9% percent of the patients and 6% of them had bradycardia once during the procedure. However, the alterations in hemodynamics were successfully managed during the procedure. Paresthesia was found during needle insertion in 4% of patients, but none of them had any neurological damage.
Conclusion: Segmental spinal anesthesia is a safe alternative to general anesthesia in cases of carcinoma breast undergoing modified radical mastectomy.
Keywords: Breast Cancer ; Neuraxial Anaesthesia; Thoracic Segmental Spinal Anesthesia; Modified Radical Mastectomy
Introduction
Neuraxial anesthesia is a reliable technique for surgeries involving the lower half of the body. It is performed by blocking the spinal cord transmission through the administration of local anesthetics via the intrathecal route. In the current scenario, various approaches of anesthesia are available for the successful conduction of breast surgeries like general anesthesia and paravertebral blocks with Total Intravenous Anesthesia (TIVA). Modified Radical Mastectomy is considered to be a gold standard while treating patients with carcinoma breast. It is also documented that surgery should be done within 90 days after the disease is diagnosed [1]. It is proven that an early detection and surgery prolong the lives of patients. Patients with carcinoma breast are more prone to infections as they have multiorgan involvement including the liver, kidneys, and lungs. The lung is the second most common site of metastasis. Apart from these, bacterial, viral, and fungal pneumonia are common in these patients. They also always have depleted nutrition levels along with a stressed psychological status [2]. Successful conduction of anesthesia on these patients is the greatest challenge. The literature reveals the use of thoracic epidural anesthesia for surgical procedures on the breast in the past but the results are not appreciable. General anesthesia remains the gold standard in breast surgeries, which includes intubation and ventilation of the patients. However, regional administration anesthesia techniques are always considered superior in maintaining respiratory functions, avoiding airway manipulations, and limiting the complications of laryngoscopy and endotracheal intubation. Segmental spinal anesthesia involves the blockade of specific segments at the thoracic level. In a modified radical mastectomy, the blockade at lower cervical roots C5-6 and T 1-T 12 levels are required [3]. We planned the present study on the basis of the available literature with the aim to evaluate the effectiveness of segmental spinal anesthesia in patients posted for modified radical mastectomies.
Materials and Methods
The present study was conducted at a tertiary care centre from April 2020 to November 2022, after approval by the hospital’s ethical and the research committee vide letter no. GDH/2020/019. The study included 84 patients aged 20-70 years with ASA (American society of Anesthesiologists) physical status I-III scheduled for modified radical mastectomy with axillary dissection. Informed and written consent was obtained from all the patients. The following categories of patients were excluded from the study: those with ASA IV/V status, Body mass index (BMI) > 35 kg/m2, any existing contraindications of regional anesthesia (local infection or coagulopathy), not giving consent for regional anesthesia, any known allergy to the drugs used in the study, those with abnormalities of the spine (kyphosis or scoliosis), patients requiring general anesthesia due to difficulty in placing them in a sitting position, and in cases with a change in surgical plan or more than two attempts for performing regional anaesthesia procedure. During their first visit patients were counseled regarding the need for surgery, the proposed anesthesia plan, its merits and side effects. They were informed about thoracic spinal anesthesia in detail and were reassured that any pain, discomfort, or anxiety would be supplemented with drugs. Moreover, they were also informed that in case of failure of the anesthesia plan, general anesthesia would be administered. A complete clinical examination was done and all standard laboratory investigations including ECG and ECHO were obtained as per the need. All the patients were admitted a day prior to surgery and clinical status was reviewed. On arrival to the operative room, 18 G iv cannula was secured in the contralateral upper limb and 500 ml of Ringer Lactate fluid was started. Standard monitors were placed in the operating room. All patients were positioned in the sitting position with head flexed. The exact level for the block was determined by the landmark method which includes C7 prominent spine, lower level of scapula at T7, and 12th rib corresponding to L1 vertebrae. The depth of the dura mater was ascertained with the use of Ultrasonography. A subarachnoid block was performed at T5-T6 or T6-T7 levels with 26 G Quincke Babcock needle using the midline approach with a 45° angulation of the needle under aseptic precautions after local infiltration with 2ml of 2% xylocaine adrenaline solution. After piercing the Ligamentum Flavum, the needle was advanced in an incremental fashion of 0.5 mm on each advancement and CSF (Cerebrospinal fluid) flow was checked every time. Once the free flow of CSF was confirmed, 1.5 ml of isobaric levobupivacaine with 5 mcg of Dexmedetomidine was administered. The patients were placed in a supine position immediately after the block and supplemental oxygen was started with a mask at the rate of 5 liters per minute. While performing a lumbar subarachnoid block the anaesthesiologist’s eyes are at a certain angle and height to ensure clear view during aspiration of CSF and ease of administration of drug. The usual distance between the lower lumbar level i.e. usual site for lumbar subarachnoid block and mid thoracic level is approximately 10-12 inches. So during mid thoracic subarachnoid block the performer’s eyes remain parallel to level of needle, making it difficult to visualise the aspiration of CSF and leading to increased chances of migration of needle during drug administration. The author recommends standing on a 1012 inches high platform while performing a thoracic subarachnoid block (RICHA’S ANGLE), thereby achieving a angle and position which is similar to performing a lumber subarachnoid block while standing on floor (Figure 1,2).