Cervical Spine Fixation in a High-Risk Patient Using Continuous Thoracic Spinal Anesthesia With Hypobaric Agents: A Case Report.

BackgroundAwake colorectal surgery is an alternative to general anesthesia, especially in high-risk patients with significant cardiopulmonary comorbidities. Continuous segmental spinal anesthesia offers stable intraoperative conditions while avoiding the complications of cardio depressant effects, airway manipulation and sedation. Despite its advantages, this approach remains underreported in major colorectal procedures.Case presentationWe present the case of a 73-year-old male with a history of ischemic cardiomyopathy, chronic heart failure (ejection fraction 25–30%), chronic kidney disease, and pulmonary complications, classified as American Society of Anesthesiologists (ASA) Risk Class V. The patient was admitted to a tertiary hospital in Palestine with a recurrent sigmoid volvulus, and due to the high risk associated with general anesthesia, the surgical, cardiology and anesthesia teams decided for an awake open sigmoidectomy under continuous segmental spinal anesthesia. The patient remained fully conscious and hemodynamically stable throughout the procedure. Postoperative recovery was uncomplicated apart from a superficial wound infection, which was managed conservatively. At six-month follow-up, the patient remained asymptomatic, tolerated a normal diet, had no recurrent bowel obstruction, and showed complete wound healing without late infectious or anastomotic complications.ConclusionThis case illustrates the feasibility, safety, and potential benefits of awake sigmoidectomy in fragile, multimorbid patients. To our knowledge, it represents the first reported case in Palestine. The successful outcome emphasizes the importance of advanced regional techniques and multidisciplinary collaboration in managing high-risk surgical patients, especially in settings with limited resources.

Continuous Spinal Anesthesia with Invasive Hemodynamic Monitoring for Surgical Repair of the Hip in Two Patients with Severe Aortic Stenosis

Reply

Clinical application of combined fixation in the cervical spine using posterior transfacet screws and pedicle screws

BackgroundLaparoscopic cholecystectomy is usually done under general anesthesia, but many patients with major medical problems sometimes cannot tolerate such anesthesia, and thoracic spinal anesthesia may be beneficial in such patients. A comparative study between two groups of patients submitted to laparoscopic cholecystectomy using either general anesthesia or segmental thoracic spinal anesthesia.Patients and methodsForty patients classified according to American Society of Anesthesiology (ASA) as class I or II undergoing laparoscopic cholecystectomy, divided into two groups, 20 patients each. Group G received conventional general anesthesia with endotracheal intubation and mechanical ventilation, and group S received a segmental (T10-11 injection) thoracic spinal anesthesia (through combined spinal epidural) using 1 ml of plain bupivacaine 0.5% (5 mg) in addition to 25 μg fentanyl. In group S, drugs to manage patient anxiety or hemodynamic perturbations (bradycardia or hypotension) were given when needed. Intraoperative monitoring, postoperative pain, complications, recovery time, and patient satisfaction at follow-up were compared between the two groups.ResultsAs regards the thoracic spinal group, spinal anesthetic was performed easily in all 20 patients, although two complained of paresthesia, which responded to slight needle withdrawal; the block was effective for surgery in all 20 patients, and five experienced some discomfort, which was readily treated with small doses of fentanyl, but none required conversion to general anesthesia; five patients required midazolam for anxiety, eight patients required ephedrine and atropine for hypotension and bradycardia, and recovery was uneventful and without sequelae.AimThe aim of this study is to compare discharge time, patient, and surgeon satisfaction between two groups of healthy patients submitted to laparoscopic cholecystectomy under general and segmental thoracic spinal anesthesia.ConclusionPatients received segmental thoracic spinal anesthesia had shorter discharge time and better satisfaction. Surgeon satisfaction was higher in general anesthesia group. Segmental thoracic spinal anesthesia can be used successfully and effectively for laparoscopic cholecystectomy in healthy patients by experienced anesthetists.

The aim of the present study was to determine the optimal intensity of anticoagulation therapy in elderly patients with paroxysmal atrial fibrillation (PAF), using aspirin and varied concentrations of warfarin. Elderly patients with PAF (n=1,162) who met the inclusion criteria of the study and were at middle or high-risk of a stroke were investigated. Patients were divided into six groups (four high-risk groups and two middle-risk groups). Patients were treated with aspirin or varied concentrations of warfarin. The primary endpoint events, secondary endpoint events, major bleeding events and minor bleeding events were observed and compared. In high-risk elderly patients, warfarin significantly reduced primary and secondary endpoint events, total primary events and total events compared with aspirin. In middle-risk elderly patients, for all the events warfarin demonstrated no significant difference compared with aspirin. In high-risk patients with PAF, when the concentration of warfarin was adjusted to target international normalized ratio (INR) range 1.7–2.5, the primary and secondary endpoint events, total primary events and total events were significantly lower (P<0.05), compared with aspirin and warfarin at INR 1.2–1.6. When the intensity of warfarin was adjusted to the target INR 2.6–3.0, the primary and secondary endpoint events were significantly lower (P<0.05) compared with aspirin and warfarin INR at 1.2–1.6. This study determined that in high-risk elderly patients with PAF, warfarin is recommended for anticoagulation with an optimal INR range of 1.7–2.5. In patients at a middle-risk of a stroke, aspirin is the recommended treatment as an antithrombotic as results have indicated that there is limited benefit in the use of warfarin.

Cervical spine decompression, fusion and fixation are required when pathologies like trauma, degeneration, infection or tumor destabilizes the spine or cause compression on neurovascular structures. Many approaches and instrumentation technique have evolved to achieve a stable spine closest to its natural state, preserving the anatomy and the function. Transpedicular approach to cervical spine has been a new addition to the attempt. Here, our experience of the procedure is presented.Total of 38 cases underwent this procedure from 2014 February to 2015 December. Twenty-four cases had unstable spine due to trauma, twelve had severe multilevel spondylotic cord compression and two had dump bell schwannomas. Their age ranged from 24 to 76 years with 22 males and 16 females. The procedures were done under general anesthesia in prone position on Gardner-Wells pins and a horseshoe headrest. After exposing the pedicles, 3.5 mm by 22 mm titanium poly-axial screws where inserted through the pedicles using the technique described by Professor Abumi. The pedicle screws were connected by a connecting rod, which had been bent in accordance with the normal cervical lordosis. Fusion was done using the bones obtained from the spinous process and laminae.There were fifty-six screws which were mis-directed, and had to be immediately corrected. There was no incidence of significant pedicle penetration or injury to neuro-vascular structures. There was temporary weakness of upper limbs postoperatively in seven patients, which recovered fully in two months’ time. There were six deaths due to uncontrolled septicaemia triggered by chest infection. The rest of the patients were discharged between one to six weeks after surgery.Transpedicular fixation of unstable cervical spine provides biomechanically a very rigid and good correction of sagittal alignment with a high-fusion rate and a few surgical complications. After realizing these advantages, transpedicular screw fixation in cervical spine is becoming an increasingly popular spine surgeon's armamentarium.Nepal Journal of Neuroscience 13:11-18, 2016

IntroductionSpinal Anesthesia (SA) continues to be an emerging technique for lumbar fusion surgery in the elderly population. SA is an appealing option in the high-risk geriatric population for several reasons, including the potential for reduced systematic stress, reduced blood loss, and reduced post-operative delirium. The safe limits of spine surgery under SA remain undetermined. Presentation of caseThe following case-study describes an elderly high-risk patient (ASA III) with severe spinal stenosis and degenerative scoliosis who presented with lower back and right leg pain and underwent a 3-level lumbar fusion surgery with spinal anesthesia. The procedure lasted 3 h and 44 min with sufficient anesthesia maintained throughout. The patient experienced minor post-operative complications, but had an excellent clinical outcome at 3-month follow-up. DiscussionFurther research should be conducted to define the temporal limits of SA in elderly patients and the etiology of post-operative complications following lumbar fusion surgery under spinal anesthesia in the geriatric population. ConclusionThe case reported, herein, demonstrates the feasibility of SA in elderly patients undergoing lengthy complex lumbar surgeries who have been designated “high-risk” patients (ASA > II) and provides support for future investigation into surgical and anesthesia treatment options for geriatric high-risk patients presenting with complex lumbar spine pathologies.

&lt;p&gt;Background : Managing anesthesia in high-risk patients with multiple comorbidities is a significant challenge, particularly when general anesthesia may increase perioperative risks. Peripheral nerve block offers a safer alternative by minimizing systemic involvement and avoiding complications associated with general anesthesia.&lt;/p&gt;&lt;p&gt;Case Illustration : This case report presents a 68-year-old male with uncontrolled hypertension and a history of stroke who underwent surgery for a clavicle fracture. Due to the patient's cardiovascular and neurological risks, regional block anesthesia was chosen as the preferred technique. The approach allowed for stable perioperative management without complications.&lt;br /&gt;Conclusion : This case emphasizes the potential benefits of peripheral nerve block in high-risk surgical patients, offering a safer and effective alternative to general anesthesia.&lt;/p&gt;

To analyze the efficacy of Green Light photoselective vaporization of the prostate (PVP) in elderly high-risk benign prostatic hyperplasia (BPH) patients with glands over 80ml. From December 2013 to February 2016, we allocated 84 elderly (age 71-97) high-risk patients who underwent preoperative transrectal ultrasound (TRUS) examination with glands over 80ml and divided them into two groups to receive 120W (n = 40) and 180W (n = 44) PVP. All the patients have been observed at least one intraoperative comorbidity: hypertension, diabetes mellitus, NYHA II, or combined. They were followed up for 12months. All the conventional parameters were compared in this study. All the patients received successful operations without severe complications, and no patient needed blood transfusion. The operation time and catheterization time of the 180W patients were significantly shorter than that of the 120W patients (p < 0.05). The International Prostate Symptom Scores (IPSS), quality of life (QoL) scores, maximum flow rate (Qmax), and residual urine volume (RUV) in both groups have been significantly improved. PVP is safe and effective for high-risk aging patients with gland over 80ml. In addition, 180W XPS system has a short operation time and catheterization time and less inflammatory response.

Background: Heart disease is the third most common cause of maternal death. In the anaesthesia protocol for cesarean sections in pregnant individuals with heart disease, especially those facing severe mitral stenosis, general anaesthesia and/or epidural anaesthesia are generally preferred choices, but there is one article which emphasises potential benets of low dose subarachnoid block in certain cases. The primary aim of an anaesthesiologist is to prevent intraoperative hemodynamic instability. Thoracic segmental spinal anaesthesia stands out as an additional method offering remarkable hemodynamic stability and fostering elevated patient satisfaction levels . LSCS can be effectively and safely conducted through the procient application of segmental thoracic spinal anaesthesia. This case study aims to observe the outcome of my patient with heart disease undergoing emergency LSCS under low dose thoracic segmental spinal anaesthesia with isobaric levobupivacaine. Case Study: 24-year-old, G2P1L1, previous 1 cesarean scar, DCDA twins, with rheumatic origin severe mitral stenosis complicated with severe pulmonary artery hypertension and severe tricuspid regurgitation with severe pre-eclampsia, posted for an emergency LSCS under ASA IV(E). Thoracic segmental spinal anaesthesia was administered at T10-T11 space using a 25G Quincke's needle. This procedure utilized a 1.3 ml injection of 0.25% isobaric levobupivacaine, with the addition of 30 micrograms of buprenorphine. Post-operative pain relief was achieved through a transverse abdominis plane block using a 0.25% bupivacaine injection 40ml and 8mg dexamethasone injection provided bilaterally. The patient's intraoperative occurrences, hemodynamic stability, post-operative ICU care, and pain management were all carefully observed and noted. Result: The procedure went smoothly without any complications, exhibiting notable hemodynamic stability and effective post-operative pain relief for a duration of 18 hours. In resource-limited peripheral centers lacking dedicated postoperative cardia Conclusion: c intensive care, low- dose thoracic segmental spinal anaesthesia emerges as a viable alternative for emergency cesarean sections in patients with severe heart disease experiencing fetal distress.

The effect of telehealth, telephone support or usual care on quality of life, mortality and healthcare utilization in elderly high-risk patients with multiple chronic conditions. A prospective study

Over time, the indications for large-scale spinal anesthesia have fluctuated between cycles of popularity and periods of ostracism. Continuous technological advances in the manufacture of needles and catheters, in the synthesis of safer anesthetics, in the knowledge of nociceptive mechanisms, in the introduction of pharmacological adjuvants and in better control over the physiological changes resulting from the technique, have allowed this secular method, characterized by its simplicity, efficiency and safety, to continue to be useful and current in the anesthesiologic arsenal. Most anesthesiologists worldwide use thoracic epidural anesthesia, which has been shown in four studies with 6,609 patients to have an incidence of accidental perforation in 50 patients of (0.75%). However, they are reluctant to consider higher levels for spinal anesthesia because of the possibility of direct spinal cord injury. This article shows that thoracic spinal anesthesia began in the 20th century and has gained numerous followers worldwide in the 21st century, with effectiveness and safety, with no reports of neurological injury. TSA began with CSE for laparoscopic cholecystectomy and was used in several other procedures worldwide. Finally, its safety led several researchers to enthusiastically pursue the technique allowed the study of continuous thoracic spinal anesthesia and other indications such as breast surgery and spinal fractures. More importantly, although the incidence of paresthesia is like lumbar puncture, which was transient and lasted a maximum of three days, the incidence of cardiocirculatory complications is lower than that of lumbar spinal anesthesia and, to date, there have been no reports of serious and permanent neurological complications, even with the catheter within the subarachnoid space. After numerous published studies and all referenced in this Narrative Review, we can conclude that TSA is safe and without complications and that possibly the anatomy of the subarachnoid space that places the spinal cord more anteriorly prevents its injury.

Laparoscopic cholecystectomy (LC) is the preferred approach for treating gallstone disease because of its minimally invasive characteristics. However, factors such as increased intra-abdominal pressure, pneumoperitoneum, and positional changes present significant challenges in anesthetic management. While LC is typically performed under general anesthesia, thoracic segmental spinal anesthesia and cervical plexus block have emerged as effective alternatives in patients for whom general anesthesia poses a high risk. This study reports the use of thoracic spinal anesthesia combined with cervical plexus block in patients where general anesthesia is considered risky. After obtaining informed consent for awake laparoscopic surgery, anesthesia was managed under appropriate monitoring. The combination of spinal anesthesia and cervical plexus block allowed for the successful completion of the procedure, with minimal complications observed in the early postoperative period. In conclusion, thoracic segmental spinal anesthesia and intermediate cervical plexus block offer a safe and effective alternative for patients at high risk for general anesthesia.

Aim:A double-blinded randomized controlled study to compare discharge time and patient satisfaction between two groups of patients submitted to open surgeries for abdominal malignancies using segmental thoracic spinal or general anesthesia.Background:Open surgeries for abdominal malignancy are usually done under general anesthesia, but many patients with major medical problems sometimes can’t tolerate such anesthesia. Regional anesthesia namely segmental thoracic spinal anesthesia may be beneficial in such patients.Materials and Methods:A total of 60 patients classified according to American Society of Anesthesiology (ASA) as class II or III undergoing surgeries for abdominal malignancy, like colonic or gastric carcinoma, divided into two groups, 30 patients each. Group G, received general anesthesia, Group S received a segmental (T9-T10 injection) thoracic spinal anesthesia with intrathecal injection of 2 ml of hyperbaric bupivacaine 0.5% (10 mg) and 20 ug fentanyl citrate. Intraoperative monitoring, postoperative pain, complications, recovery time, and patient satisfaction at follow-up were compared between the two groups.Results:Spinal anesthesia was performed easily in all 30 patients, although two patients complained of paraesthesiae, which responded to slight needle withdrawal. No patient required conversion to general anesthesia, six patients required midazolam for anxiety and six patients required phenylephrine and atropine for hypotension and bradycardia, recovery was uneventful and without sequelae. The two groups were comparable with respect to gender, age, weight, height, body mass index, ASA classification, preoperative oxygen saturation and preoperative respiratory rate and operative time.Conclusion:This preliminary study has shown that segmental thoracic spinal anesthesia can be used successfully and effectively for open surgeries for abdominal malignancies by experienced anesthetists. It showed shorter postanesthesia care unit stay, better postoperative pain relief and patient satisfaction than general anesthesia.