Journal of Anaesthesia and Pain. 2022. Vol.3(1):1-4 1
Thoracic Spinal Anaesthesia for Modified Radical Mastectomy (MRM)
Derajad Bayu Atmawan
1, Hanifa Agung Kurniawan
1, Priyambada
21Departement of Anesthesiology Intensive Therapy and Pain Management, Dr. Soehadi Prijonegoro Hospital, Indonesia
2Departement of Oncology Surgery, Dr. Soehadi Prijonegoro Hospital, Indonesia
INTRODUCTION
Breast cancer is the highest incidence of malignancy in Indonesia. According to data from the Ministry of Health in 2019, it was 42.1 per 100,000 population suffering from breast cancer with the mortality rate rates of 17 per 100,000 inhabitants.1
Epidemiological studies have shown that the incidence of breast cancer increases with age. More than 65% of patients diagnosed with breast cancer in the age of above 65 years. In the geriatric group, the possibility of coexisting major medical problems is high, which makes anesthetic management is challenging. Because of that, regional anesthesia is a preferable option for breast cancer surgery in the geriatric group. In previous studies, there is a feasibility study of spinal anesthesia for breast surgery that can be used effectively.2 The use of regional anesthesia can reduce inhalation agent exposure and diminish oxygen consumption during high demand in this COVID-19 pandemic. These situations encourage us to perform thoracic spinal anesthesia for Modified radical mastectomy (MRM).
CASE
There are three cases of breast cancer during August-
September 2021 that were scheduled for MRM at Dr. Soehadi Prijonegoro Hospital. All patients have finished receiving neoadjuvant chemotherapy treatment, scheduled by Oncology Department. The perioperative data is described in Table 1.
In the preoperative visit, patients received a preoperative evaluation, including history taking, general examination, and laboratory test. The procedure and intended anesthetic technique were explained to every patient, and written informed consent was obtained. Patients were informed that administration of systemic medication would be done to diminish any pain, discomfort, anxiety, or if they preferred, conversion to general anesthesia might be done.
Before surgery, routine monitors devices were installed, including ECG, non-invasive blood pressure, and pulse oximeter.
The patient was placed in the sitting position with the head flexed. The addressed puncture level is T7-8 space. It was determined by a marked line between the inferior tip of the left and right scapula. The procedure was performed under aseptic conditions. The patient's back was sterilized before the block was performed. Using a paramedian approach, a 26G spinal needle (Spinocan®) was introduced slowly until it reached subarachnoid space.
ABSTRACT
Background
:
Breast cancer mostly affects patients older than 65 years old. Geriatric patients may have comorbidities, so the selection of anesthesia for breast cancer surgery is challenging. In the past decade, thoracic spinal anesthesia as regional anesthesia was feasibly performed for laparoscopic cholecystectomy and minor breast surgery. This article aims to evaluate thoracic spinal anesthesia for Modified radical mastectomy (MRM) in our hospital settings.Case: Three cases of thoracic spinal anaesthesia were carried out for MRM surgery after neoadjuvant chemotherapy treatment. This procedure consists of the removal of breast tissue and the ipsilateral axillary contents. The comorbidities include hypertension, cardiomegaly, and mild anemia. There was no conversion to general anesthesia during surgery until completion. Duration for surgery is less than 120 minutes. No significant hemodynamic instability and complaint were found during intra and postoperative.
Conclusion: From these cases, thoracic spinal anesthesia was acceptable as regional anesthesia for MRM in geriatric patients.
Keywords: breast cancer, thoracic spinal anesthesia, geriatric, modified radical mastectomy Correspondence:
Derajad Bayu A, MD*
Department of Anesthesiology Intensive Therapy and Pain Management, Dr. Soehadi Prijonegoro Hospital, Indonesia
e-mail:
Received: November 2021, Revised: December 2021, Published: January 2022
How to cite this article: Atmawan, DB, HA Kurniawan, Priyambada. Thoracic Spinal Anaesthesia for Modified Radical Mastectomy (MRM). Journal of Anaesthesia and Pain. 2022:3(1):1-4. doi: 10.21776/ub.jap.2022.003.01.01
Case Report
Journal of Anaesthesia and Pain, 2022, Volume: 3, No.1: 1-4 P-ISSN : 2722-3167https://jap.ub.ac.id E-ISSN : 2722-3205
Journal of Anaesthesia and Pain. 2022. Vol.3(1):1-4 2 Table 2. Patient’s data during and after the surgery
Parameters Patient 1 Patient 2 Patient 3
Sensory blockade T 1-T10 T2-T8 T2-T10
Consciousness Conscious Conscious Conscious
Complaints - - -
Duration (minutes) 90 75 100
Blood loss (ml) 200 190 250
Event - - -
Analgesic Paracetamol 1000 mg
Dexketoprofen 50 mg Paracetamol 1000 mg
Dexketoprofen 50 mg Paracetamol 1000 mg Dexketoprofen 50 mg
Blood Pressure (mmHg) 132/75 144/80 141/83
HR (beats/minutes) 78 83 80
RR (respirations/minutes) 19 20 21
VAS 2 1 2
HR: Heart rate; RR: Respiratory rate; VAS: Visual analogue scale Once a free flow of clear cerebrospinal fluid was obtained, a mixture of 0.5% hyperbaric bupivacaine 10 mg and fentanyl 25 µg was injected. The patient then returned to the supine position, and nasal oxygen supplement 3 liters per minute started.
Surgery was started when the sensory block at T1-T7 dermatome sensory block was adequately achieved. Vital signs and SpO2 monitoring continued during surgery. Episodes of bradycardia and hypotension were monitored. Hypotension is defined as systolic blood pressure<90 mmHg, or diastole blood pressure <60 mmHg, treated with ephedrine 10 mg intravenously. Bradycardia is defined as a heart rate less than 60 beats/ minute, treated with atropine 0.5 mg intravenously.
In MRM, the entire breast tissue and the ipsilateral axillary contents (fatty tissue and lymph nodes) are removed, while the pectoral muscles are spared. From the three cases above, there are no difficulties in surgery associated with the anesthetic technique. The block is adequate for MRM surgery that lasts 75-100 minutes. Before surgery ends, patients receive dexketoprofen 50 mg and paracetamol 1000 mg intravenously.
Of the three cases, the duration of anesthesia was adequate for surgery (Table 2). The patient was monitored postoperatively in the recovery room. The patient appeared to be fully conscious, vital signs were stable with the ability to move all extremities, and there were no symptoms of pain while in the recovery room.
There were no complaints from the surgeon during the procedure. In the ward, the patient could immediately drink and
eat, while the second patient complained of vomiting 6 hours after surgery. Analgesia was continued by injection of dexketoprofen 50 mg and oral paracetamol 1000 mg every 8 hours.
DISCUSSION
Many literatures agree that anterior and lateral cutaneous branches innervate the mammary gland. Both anterior and cutaneous branches come from the second and sixth intercostal nerves. They then form a plexus under the areola. This nerve innervation supply the nipple and the areola. The nipple and areola are highly sensitive to touch. T4 spinal nerve dermatome is responsible for this sensation. Because of that, nipples and areola are essential to be preserved during breast surgical reconstruction.3
Ahmed et al. found that segmental spinal anesthesia for minor breast surgery performed at T5 level was effective and associated with minimal hemodynamic instability and a high patient satisfaction rate. While performing segmental spinal anesthesia, there were three main concerns includes the risk for spinal cord injury; cephalad spread of local anesthesia causing high or total block; and hemodynamic or respiratory compromise due to block of cardio accelerator fibers or intercostal nerves.2
Regarding the first concern, we rely on the fact that the posterior subarachnoid space is wider in the middle thoracic region than the upper and lower thoracic regions. General consideration of the low potential for cord injury with segmental Tabel 1. Characteristics of preoperative patient
Parameters Patient 1 Patient 2 Patient 3
Age (years) 74 50 57
Sex female female female
Blood Pressure (mmHg) 168/100 158/87 165/98
HR (beats/minutes) 87 90 81
RR (respirations/minutes) 18 20 18
Comorbidity hypertension hypertension hypertension
ECG sinus rhythm sinus rhythm sinus rhythm
CXR cardiomegaly cardiomegaly cardiomegaly
Laboratory mild anemia mild anemia mild anemia
HR: Heart rate; RR: Respiratory rate; ECG: electrocardiogram; CXR: Chest X-ray
Journal of Anaesthesia and Pain. 2022. Vol.3(1):1-4 3
spinal anesthesia technique is given in a previous case report, in which it was noted that the thoracic cord segment was located anteriorly.4 It is similar to study by Imbelloni and colleagues finding with magnetic resonance imaging (MRI) investigation that the posterior dural-spinal cord distance is significantly greater at the mid-thoracic region (5th thoracic = 5.8 +/- 0.8 mm) than at the upper (2nd thoracic= 3.9 +/- 0.8 mm) and lower thoracic levels (10th thoracic = 4.1 +/- 1.0 mm).5 Previous study by Lee et al. found the similar result that the posterior dura - spinal cord distance is significantly greater in the middle thoracic region than at upper and lower thoracic levels (e.g., T6 9.5 +/- 1.8 mm, T12 3.7 +/- 1.2 mm, T1 4.7 +/- 1.7 mm.6
We performed this procedure in the head-down sitting position. This position will make the posterior separation of the dura mater, and the spinal cord is increased compared with the supine and lateral positions. This again will decrease the potential risk for spinal cord injury while performing the block at the thoracic level. We also choose the paramedian approach because the extreme angulation of the thoracic spinous processes makes the midline approach to the thoracic epidural space more difficult.2
We performed the puncture at T7-8 space because it was easily found with the surface landmark, conventionally as an imaginary line between left and right of the inferior tip of the scapula. However, this landmark is not achieved the right segment individually, but it can be used as a simple landmark in the rural hospital that did not have any imaging device. Arzola et al. found that the T7-8 intervertebral space determined by ultrasound coincided with the landmark findings in the anatomical position (AP) and in the epidural position (EP) in 18%
and 36% of the cases, respectively. This study also demonstrated that the accuracy of the surface landmark method increased in epidural position rather than anatomical position. As noted, EP is seated, back arched, neck flexed, and arms across the chest. AP subjects stand upright, back straight, arms at the sides, and palms forward. From 55 samples, interscapular line in epidural position mostly confirmed at T7-8 by ultrasound (T6-7=13%, T7-8=36%, T8-9=20%, T9-10=18%).7 It is similar to a previous study performed by Desiree et al. that interscapular line mostly (37%
sample) cut T7-8 confirmed by X-ray.8
Thoracic spinal anesthesia has been considered an effective and safe technique for a variety of surgeries, including breast cancer lumpectomy, stomach cancer surgery, and laparoscopic cholecystectomy. In performing thoracic anesthesia, thoracic and lumbar anatomy is important. Both are similar but have several distinct differences. Anatomically, the spinal cord's middle and lower segment lies anteriorly. Space between the dura and spinal cord is filled with cerebrospinal fluid. On the other hand, the spinal cord and cauda equina touch the dura mater posteriorly in the lumbar region. The posterior subarachnoid space in the thoracic spinal cord is deeper. It has been shown that there is a greater depth of the posterior subarachnoid space in the thoracic spinal cord. Moreover, the interlaminar space in the thoracic spine is narrow and overlaps
over the vertebral lamina, making it more difficult to access using a needle. In contrast, the laminae of lumbar vertebrae do not overlap, and the space between them is larger. Other than that, thoracic vertebrae spinous processes point inferiorly versus the lumbar vertebrae that point posteriorly. When using the midline approach, the oblique position of the thoracic spinal processes will affect the needle angle, and it may complicate the procedure.
When using a paramedian approach, the needle does not pass through the supraspinous ligament, the interspinous ligament.9 It makes the paramedian approach easy to perform.2
The second concern is the cephalad spread of local anesthesia in subarachnoid space. Spinal anesthesia is known to have complications, including high or complete spinal block. It is difficult to define the high spinal. Clinically, a high block is defined as a block above the level required for surgical anesthesia. In some situations, a high block is acceptable due to the absence of significant sequelae such as bradycardia or respiratory compromise. Complete spinal block is not well defined in the literature.10 All the patients in this report did not show any cranial nerve symptoms.
The last concern is about hemodynamic or respiratory compromise. Hypotension is a well-adverse event of spinal anesthesia. However, it was quickly managed and did not significantly affect the procedure. Hypotension happens due to sympathetic block and mechanical effect of pneumoperitoneum.
The incidence of hypotension is lower in segmental thoracic spinal anesthesia (10%) compared with conventional lumbar spinal (41-59%).11 In all patients above, none received ephedrine against hypotension perioperative caused by spinal anesthesia.
The hypotension in the elderly occurred was caused by a decrease in stroke volume (SV) rather than a decrease in systemic vascular resistance (SVR). Bradycardia may be induced by decreased sympathetic tone nerve system, the secondary impact of cardio accelerator fibers blockade (T1-4), and thoracolumbar blockade spread.11,12
Thoracic spinal anesthesia in MRM may provide better patient safety, shorter post-operative care, reduced postoperative pain, early mobilization, recovery, and peristaltic movement compared to the other common surgeries. Thus, thoracic segmental spinal anesthesia potentially becomes an alternative anesthetic to general anesthesia, especially in patients who are at high risk in general anesthesia. Even not regularly used, thoracic segmental spinal anesthesia has been shown as a promising anesthesia technique by providing a stable hemodynamically and minimal side effect compared with general anesthesia.9,13
CONCLUSION
From these cases, we found that thoracic spinal anesthesia was an effective technique for MRM within a duration of less than 120 minutes. No hemodynamic instability intra and postoperative. Patients satisfy with this method and recover earlier.
ACKNOWLEDGMENT -
CONFLICT OF INTEREST None
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