Thoracic spinal anaesthesia for paediatric upper extremity surgery in limited-resource hospital: a case report

Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure. We report a case in which thoracic spinal anaesthesia (T3–T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery. A 15 years old man with distal radius fracture ORIF was scheduled to undergo remove of implant. His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential. We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg). Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block.


Background
Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure (Shatri and Singh 2022).General anaesthesia is currently the standard technique anaesthesia used for upper extremity surgery (Douglas Hale McMichael 2015).The disadvantages of general anaesthesia include, inadequate pain control due to lack of residual analgesia, increasing the length of hospitalization, high incidence of nausea and vomiting, increased length of stay, and increasing of postoperative pulmonary complications.We report a case in which thoracic spinal anaesthesia (T3-T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery.

Case presentation
A 15-year-old man with distal radius fracture ORIF (Fig. 1) was scheduled to undergo remove of implant.His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential.We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg).
We decided to perform spinal anaesthesia at T3-T4 intervertebral space with the patient in the sitting position.We performed informed parental consent to the parents of patient that there were two particularly serious risks.The first risk was injury to the spinal cord from the needle with the possibility of permanent paralysis or of loss of feeling or both in one or more limbs.The second risk was the development of total spinal anaesthesia.The parents of patient understood and accepted the risks.
The patient was placed supine position on the operating table and placed lead electrocardiography, pulse oximeter, and blood pressure cuff.His vital signs are stable.While the patient was held seated, a 27-gauge Quincke-Babcock spinal needle was inserted paramedian under aseptic conditions in the T3-T4 intervertebral spaces.After removing the obturator stylet, the Quincke-Babcock needle is advanced slowly until the cerebrospinal fluid appears (Fig. 2).Hyperbaric bupivacaine (0.75%; 5 mg) is injected in the subarachnoid space in 30 s with a barbotage one time.Hemodynamically stable and no hemodynamic changes after C4 block is achieved.After the sensory block is achieved, the patient can still move both hands, with muscle strength grading 3 (movement against gravity only), but the sensory is completely blocked.The patient is performed remove of implant and the duration of the procedure during 1 h.During surgery hemodynamically stable with SBP in the range 110-120, and HR 60-75 bpm.

Discussion
Spinal anaesthesia has several advantages compared with general anaesthesia.This is because spinal anaesthesia has little effect on respiration and cardiac complications, the avoidance of airway instrumentation and its potential complications, can suppress the neuroendocrine response from surgery, adequately managed acute postoperative pain, earlier recovery of gastrointestinal function, less effect of postoperative nausea and vomiting, earlier ambulation and discharge from hospital, a lower incidence of deep vein thrombosis, lower surgical site infection rates, reduced need for blood transfusions, and reduced costs (Roux et al. 2023).
Thoracic spinal anaesthesia has been performed for a variety of surgical procedures.These include lower limb orthopaedic surgery, abdominal cancer surgery, breast surgery, laparoscopic cholecystectomy, and caesarean delivery.However, no one has reported upper limb orthopaedic surgery under thoracic spinal anaesthesia.This case report shows that thoracic spinal anaesthesia with cervical level (C4) block results good outcome and safe in patients undergoing upper limb surgery.Although this action was avoided by the anaesthesiologists because fear of iatrogenic injury to the spinal cord, cephalad spread of local anaesthetic causing a complete spinal block, and haemodynamic instability owing to blockade of cardioaccelerator sympathetic fibres, but no cases of complete spinal block were identified in the literature where thoracic spinal anaesthesia was performed (Roux et al. 2023;Imbelloni and Gouveia 2014;Kour and Wani 2019;Spannella et al. 2020;Hobaika et al. 2015;Mahmoud et al. 2014;Daszkiewicz et al. 2016;Chauhan et al. 2021).

Conclusions
Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block.