Clinical Experience with Thoracic Segmental Spinal Anesthesia in High-Risk Surgical Patients: A Case Series

Clinical Experience with Thoracic Segmental Spinal Anesthesia in High-Risk Surgical Patients: A Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Clinical Experience with Thoracic Segmental Spinal Anesthesia in High-Risk Surgical Patients: A Case Series Alhareth M. Amro, Tasneem S. Herbawi, Islam Frijat, Sufian M. Alrajabi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6448669/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background General anesthesia (GA) can pose significant risks in patients with advanced comorbidities. Thoracic segmental spinal anesthesia (TSSA) is an underutilized alternative that offers hemodynamic stability and enhanced postoperative recovery. This case series highlights the application of TSSA in three high-risk surgical patients with complex cardiovascular, renal, or oncologic conditions. Case Presentation: We describe three patients (ASA Class III–IV) undergoing laparoscopic or endourological procedures who received TSSA instead of GA due to high anesthetic risk. Each patient received isobaric bupivacaine combined with dexmedetomidine via thoracic or thoracolumbar spinal injection. All patients remained awake, hemodynamically stable, and spontaneously breathing throughout their procedures. No sedation, vasopressor support, airway intervention, or ICU admission was required. Postoperative pain was minimal, with early ambulation and no reported complications. Conclusion Thoracic segmental spinal anesthesia is a safe and effective anesthetic technique for select high-risk patients undergoing abdominal or urological surgery. It provides excellent intraoperative conditions, avoids the systemic effects of GA, and facilitates rapid recovery. With proper technique and patient selection, TSSA offers a valuable alternative to general anesthesia in complex surgical cases. Thoracic spinal anesthesia high-risk surgery regional anesthesia general anesthesia alternative comorbidities case series Figures Figure 1 Figure 2 Figure 3 Introduction The choice of anesthetic procedure is critical in improving outcomes, especially for patients with numerous comorbidities undergoing surgical procedures [ 1 ]. While general anesthesia (GA) is widely used, it presents significant risks in the elderly and high-risk patients, particularly those with compromised cardiovascular, renal, or pulmonary function. The consequences include increased intensive care unit (ICU) hospitalizations, postoperative mental disorders, hemodynamic instability, and longer recovery [ 2 ]. Thoracic segmental spinal anesthesia (TSSA) has developed as a specialized regional approach that has multiple benefits over general anesthesia in certain clinical settings [ 3 ]. Other advantages include better pain control than opioids and an overall decrease in opioid need before or after a procedure, which reduces the potential side effects of these drugs. Furthermore, bowel function recovers more quickly and problems are reduced, resulting in a shorter in-hospital stay and higher patient satisfaction [ 3 ]. Despite its benefits, TSSA is underutilized, mainly due to safety concerns when injecting at thoracic levels. However, expanding evidence supports its feasibility and safety when performed by expert hands using appropriate technique [ 4 ]. This case series presents three high-risk patients who successfully underwent laparoscopic and endourological procedures under TSSA, demonstrating its value as a safe, effective, and patient-centered alternative to general anesthesia. Case Presentation 1 We report the case of an 84-year-old obese male (body mass index (BMI): 30.9; weight: 89 kg; height: 170 cm) with a history of type 2 diabetes mellitus (T2DM) complicated by retinopathy (total blindness), hypertension (HTN), stage 4 chronic kidney disease (CKD) with baseline creatinine 4–4.5 mg/dL, and coronary artery disease medically managed without percutaneous intervention due to high risk of contrast-induced nephropathy and patient refusal. The patient was classified as American Society of Anesthesiologists (ASA) Physical Status IV. The patient presented with generalized weakness, cough, and decreased oral intake for several days. He had received IV fluids at a governmental hospital and was referred to our ICU as a suspected case of sepsis. On examination, he appeared ill and dehydrated, conscious and oriented (GCS 12). Chest auscultation revealed an irregular heart rhythm and decreased air entry bilaterally. Vital signs were stable: BP 128/79 mmHg, HR 94 bpm, SpO₂ 95% on room air, RR 18 breaths/min, and temperature 37.2°C. ECG confirmed atrial fibrillation. Initial laboratory investigations revealed leukocytosis with neutrophilia, macrocytic anemia, acute kidney injury on top of chronic kidney disease, and severe electrolyte disturbances, including hyperkalemia and hyponatremia. Inflammatory markers were significantly elevated, and arterial blood gases were consistent with high anion gap metabolic acidosis. The full panel is summarized in Table 1 . Table 1 Preoperative Laboratory Findings for Case 1. Parameter Result Reference Range Interpretation White Blood Cell Count (WBC) 51 K/uL (↑) 4.0–10.0 K/uL Leukocytosis Hemoglobin (Hb) 8.7g/dL (↓) 13.5–17.5 g/dL Macrocytic Anemia Platelet Count Not specified 150–400 K/uL — Blood Urea Nitrogen (BUN) 157 mg/dL 7–20 mg/dL Likely Elevated (CKD, Sepsis) Creatinine 5.57 mg/dL 0.7–1.3 mg/dL Stage 4 CKD Sodium 130 mEq/L (↓) 135–145 mEq/L Hyponatremia Potassium 8 mEq/L (↑) 3.5–5.0 mEq/L Hyperkalemia pH / ABG High Anion Gap Metabolic Acidosis 7.35–7.45 Severe Acidosis CRP / Inflammatory Markers Elevated (↑) — Consistent with Sepsis HbA1c Not specified < 7% (T2DM target) — Blood Glucose (Random) Not specified < 140 mg/dL (non-fasting) — Chest CT revealed bilateral atypical pneumonia, and abdominal ultrasound demonstrated a distended gallbladder measuring 8.5 × 3.5 cm with stones impacted at the neck. Echocardiography showed preserved systolic function (EF 60%) and mild aortic, tricuspid, and mitral regurgitations. A diagnosis of sepsis secondary to pneumonia and acute cholecystitis was made. Following intensive supportive care, including fluid correction, electrolyte stabilization, and antibiotic therapy, the patient’s condition gradually improved. After several days, repeat investigations confirmed clinical and laboratory improvement, and the patient was cleared for laparoscopic cholecystectomy Given his advanced age, cardiac history, and renal dysfunction, general anesthesia posed a significant risk. A thoracic segmental spinal anesthesia (TSSA) technique was chosen after multidisciplinary discussion and informed consent from the patient and family. In the operating room, standard ASA monitoring was initiated. Initial vitals were stable: BP 142/90 mmHg, HR 95 bpm, SpO₂ 95%. In the sitting position, the T8–T9 interspace was accessed using the median approach with a 25-gauge pinpoint spinal needle under sterile technique. After confirmation of CSF flow, the subarachnoid block was administered using 7.5 mL of isobaric bupivacaine, along with 5 mcg dexmedetomidine. The patient was then placed supine. The sensory block level achieved was T4–T6 up and L2–L3 down, confirmed by pinprick and cold sensation testing within 5–10 minutes of injection (Fig. 1 ). No sedation was required intraoperatively. The patient remained fully awake, hemodynamically stable, and cooperative throughout the procedure. Pneumoperitoneum was created with CO₂ after Veress needle insertion, and a standard four-port laparoscopic cholecystectomy was performed. The critical view of safety was achieved, and the gallbladder was dissected retrogradely from the liver bed. The procedure lasted 45 minutes, with no intraoperative complications. Intraoperative fluid management included a total of 500 mL crystalloid infusion, with no need for blood transfusion or vasopressors. The patient breathed spontaneously with 6 L/min oxygen via a face mask. Vital signs remained stable: SBP ranged between 110–142 mmHg, DBP 63–90 mmHg, HR 70–110 bpm, and SpO₂ improved to 99%. Motor and sensory block persisted for approximately two hours, after which the patient gradually regained full lower limb function. Postoperative pain was minimal (VAS score < 2/10), and no nausea, hypotension, urinary retention, or neurological symptoms were observed. The patient ambulated the same evening and was monitored in the surgical ward without the need for ICU care. At discharge, the patient was alert, mobile, and satisfied with his anesthetic and surgical experience. This case demonstrates that thoracic segmental spinal anesthesia can be a safe and effective anesthetic alternative in elderly, high-risk patients undergoing laparoscopic cholecystectomy. Case Presentation 2 A 57-year-old female, chronic smoker with a BMI of 34.4 (weight: 85 kg; height: 157 cm), presented to our hospital with abdominal distention and right flank pain. She had a history of type 2 diabetes mellitus, paroxysmal atrial fibrillation, and chronic kidney disease with a baseline creatinine of 1.8 mg/dL. Three months prior to admission, she was diagnosed with metastatic ovarian cancer after presenting with progressive abdominal distention and daily discomfort. A CT scan at that time revealed a 9.5 × 9.2 cm right adnexal mass, moderate ascites, multiple pathologically enlarged intra-abdominal lymph nodes, two uterine fibroids, and three hepatic hemangiomas. A core biopsy confirmed the diagnosis of ovarian adenocarcinoma, and she began chemotherapy, with her first cycle administered 10 days prior to this admission. Her ASA physical status was classified as class IV. She was not on any medications other than metformin and had no known drug allergies. On physical examination, she appeared ill and pale, though conscious and oriented. Her abdomen was tense and distended with shifting dullness, and she exhibited + 2 bilateral lower limb edema. Cardiopulmonary examination revealed no abnormalities. Vital signs were stable: BP 113/67 mmHg, HR 86 bpm, SpO₂ 95% on room air, RR 16 breaths per minute, and temperature 38.0°C. Laboratory investigations on admission revealed leukopenia (WBC 0.78 K/uL), anemia (Hb 8.9 g/dL), platelet count of 228 K/uL, markedly elevated BUN (106 mg/dL), and a creatinine level of 4.5 mg/dL—significantly above her baseline. Hemoglobin A1c was 6.8%. ECG showed a regular rhythm with no acute changes, and chest radiography was unremarkable (Table 2 ). Table 2. Preoperative Laboratory Findings for Case 2. Parameter Result Reference Range Interpretation White Blood Cell Count (WBC) 0.78 K/uL (↓) 4.0 – 10.0 K/uL Severe Leukopenia (post-chemo) Hemoglobin (Hb) 8.9 g/dL (↓) 12.0 – 15.5 g/dL (female) Anemia Platelet Count 228 K/uL 150 – 400 K/uL Normal Blood Urea Nitrogen (BUN) 106 mg/dL (↑↑) 7 – 20 mg/dL Severe Renal Impairment Creatinine 4.5 mg/dL (↑) 0.6 – 1.1 mg/dL (female) Acute on CKD Sodium Not specified 135 – 145 mEq/L — Potassium Not specified 3.5 – 5.0 mEq/L — pH / ABG Not specified 7.35 – 7.45 — CRP / Inflammatory Markers Not specified — — HbA1c 6.8% < 7% (T2DM target) Controlled Blood Glucose (Random) Not specified < 140 mg/dL (non-fasting) — A contrast-enhanced abdominal CT scan was performed and showed moderate ascites and severe right-sided hydronephrosis, for which urological intervention was indicated. A right-sided double J stent insertion was scheduled for the following day. In the operating room, full ASA monitoring was applied. Pre-anesthesia vitals remained stable: BP 105/60 mmHg, HR 86 bpm, and SpO₂ 95%. With the patient in the sitting position, the T11–T12 interspace was identified and disinfected using a full sterile technique. Local infiltration with 2% lidocaine was administered. Using the median approach, a 25-gauge spinal needle was inserted, and cerebrospinal fluid was obtained on the first attempt. Intrathecal injection of 7.5 mg isobaric bupivacaine and 5 mcg dexmedetomidine was performed slowly and without complications (Fig. 2 ). Sensory block to the T8–L4 dermatomes was achieved within five minutes, assessed by cold sensation and pinprick testing. No sedation was needed, and the patient reported comfort throughout the procedure. Motor block was mild and appropriate for the surgical area. The patient was placed in the lithotomy position, and cystoscopy was performed. A 6 French double J stent was inserted into the right ureter under fluoroscopic guidance without difficulty. The surgery lasted approximately 45 minutes, during which the patient remained fully awake, breathing spontaneously with stable vitals, and without the need for supplemental oxygen or vasoactive medications. Estimated blood loss was negligible, and 500 mL of crystalloid was administered intravenously. Postoperatively, the patient was transferred to the surgical department for observation. She regained full motor function within two hours, experienced minimal pain (VAS score 1–2), and ambulated on the same day. No nausea, hypotension, headache, or neurologic complications were observed. She remained hemodynamically stable and satisfied with the anesthetic experience. This case highlights the effective use of thoracic segmental spinal anesthesia in a high-risk, immunocompromised patient undergoing endourological intervention. Regional anesthesia techniques such as this offer a safer alternative to general anesthesia in select populations, particularly in the setting of renal impairment and active oncologic treatment. Case Presentation 3 A 67-year-old male patient with a BMI of 36.3 (weight: 105 kg; height: 170 cm) presented with a two-month history of intermittent, colicky right upper quadrant abdominal pain exacerbated by fatty meals and alleviated by fasting and analgesics. His medical history included T2DM, HTN, ischemic heart disease (IHD) with three percutaneous coronary interventions (PCIs), the most recent in 2019, coronary artery bypass grafting (CABG) in 1996, benign prostatic hyperplasia (BPH), and L4-L5 discectomy in 2022. His medication regimen comprised metformin 850 mg, bisoprolol 5 mg, atorvastatin 40 mg, aspirin 100 mg, tamsulosin 0.4 mg, furosemide 40 mg, and dapagliflozin 10 mg. He reported an allergy to sulfa drugs. On examination, the patient appeared ill and pale but was conscious and oriented. His abdomen was tense and distended, with bilateral + 2 pitting edema in the lower limbs. Cardiopulmonary examination revealed no additional sounds or murmurs. Vital signs were: blood pressure (BP) 110/60 mmHg, heart rate (HR) 65 bpm, respiratory rate (RR) 14 breaths per minute, oxygen saturation (SpO₂) 97% on room air, and temperature 38.0°C. Laboratory investigations revealed a white blood cell (WBC) count of 8.4 K/uL, hemoglobin level of 17.05 g/dL, hematocrit at 52.5%, and platelet count of 156.1 K/uL. Renal function tests showed a blood urea nitrogen (BUN) of 22 mg/dL and creatinine at 0.9 mg/dL. Glycemic assessment indicated an HbA1c of 5.4% and a random blood sugar of 121 mg/dL. Electrolyte analysis revealed sodium at 140 mEq/L and potassium at 4.4 mEq/L. These findings suggest stable renal function and adequate glycemic control (Table 3). Table 3. Preoperative Laboratory Findings for Case 3. Parameter Result Reference Range Interpretation White Blood Cell Count (WBC) 8.4 K/uL 4.0 – 10.0 K/uL Normal Hemoglobin (Hb) 17.05 g/dL (↑) 13.5 – 17.5 g/dL Elevated Platelet Count 156.1 K/uL 150 – 400 K/uL Normal Blood Urea Nitrogen (BUN) 22 mg/dL (↑) 7 – 20 mg/dL Mildly Elevated Creatinine 0.9 mg/dL 0.7 – 1.3 mg/dL Normal Sodium 140 mEq/L 135 – 145 mEq/L Normal Potassium 4.4 mEq/L 3.5 – 5.0 mEq/L Normal pH / ABG Not specified 7.35 – 7.45 — CRP / Inflammatory Markers Not specified — — HbA1c 5.4% < 7% (T2DM target) Excellent Control Blood Glucose (Random) 121 mg/dL < 140 mg/dL (non-fasting) Normal Table 4: Comparison of Anesthetic Techniques and Outcomes in All Three Cases. Case No. Age / Gender ASA Class Surgery Type Level of LA Injection LA and Adjuvants Injected Sensory Block Level Surgery Duration (min) Sedation Used Airway Support Hemodynamic Stability Post-op Recovery 1 84 / M IV Laparoscopic cholecystectomy T8–T9 7.5 mL isobaric bupivacaine + 5 mcg dexmedetomidine T4–T10 45 No Spontaneous (O₂ mask) Stable Mobilized same day 2 57 / F IV Ureteric stent insertion (endourological) T11–T12 7.5 mL isobaric bupivacaine + 5 mcg dexmedetomidine T8–S2 45 No Room air Stable Mobilized same day 3 67 / M III Laparoscopic cholecystectomy T8–T9 7.5 mg isobaric bupivacaine + 5 mcg dexmedetomidine T6–T12 40 No Room air Stable Mobilized same day Electrocardiography (ECG) demonstrated a right bundle branch block (RSR pattern) with Q waves in anteroseptal leads. Chest X-ray was unremarkable. Abdominal ultrasound revealed multiple gallbladder stones without signs of cholecystitis and an enlarged prostate. Transthoracic echocardiography indicated an ejection fraction (EF) of 40%, with septal, anterior, and apical hypokinesia, mild mitral and tricuspid regurgitation, and a pulmonary artery pressure (PAP) of 27 mmHg at rest. He was classified as ASA Physical Status Class III. Given his significant cardiac history and multiple comorbidities, the decision was made to perform laparoscopic cholecystectomy under segmental thoracic spinal anesthesia (STSA) to minimize the risks associated with general anesthesia. In the operating room, standard monitoring was applied, revealing BP 105/57 mmHg, HR 67 bpm, and SpO₂ 96%. With the patient in the sitting position, the T8-T9 interspace was identified and prepared under sterile conditions. Local infiltration with 2% lidocaine was administered. Using the paramedian approach, a 25-gauge spinal needle was inserted, and clear cerebrospinal fluid (CSF) was obtained on the first attempt. Intrathecal injection of 7.5 mg isobaric bupivacaine combined with 5 mcg dexmedetomidine was performed slowly (Fig. 3). A sensory block from T6 to L3 was achieved within five minutes, confirmed by cold sensation and pinprick testing. No significant hemodynamic changes occurred post-anesthesia. The patient was positioned with a head-up tilt toward the surgeon's side. Pneumoperitoneum was established, and laparoscopic cholecystectomy was completed uneventfully over 40 minutes. The patient remained awake, breathing spontaneously, and hemodynamically stable throughout the procedure without complications. Postoperatively, the patient was transferred to the surgical department for observation. He reported minimal pain (Visual Analog Scale score 1–2) and regained full motor function within two hours. No postoperative nausea, vomiting, or neurologic complications were observed. He was mobilized on the same day and discharged in stable condition after an uneventful recovery. This case illustrates the successful use of STSA in a high-risk patient undergoing laparoscopic cholecystectomy. STSA offers advantages such as stable hemodynamics, effective analgesia, and reduced postoperative complications compared to general anesthesia, particularly in patients with significant cardiopulmonary comorbidities. STSA is a viable and effective anesthetic technique for laparoscopic cholecystectomy in patients with multiple comorbidities, providing stable intraoperative conditions and favorable postoperative outcomes. The three patients in this series were classified as American Society of Anesthesiologists (ASA) Physical Status Class III and IV and presented with significant comorbidities, including cardiovascular disease, chronic kidney disease, and/or active malignancy. In each case, thoracic segmental spinal anesthesia (TSSA) was selected over general anesthesia to minimize systemic impact, reduce perioperative risk, and promote rapid postoperative recovery. Despite differences in surgical indication and individual comorbidity profiles, the anesthetic approach was similarly structured: a thoracic or thoracolumbar spinal block using hyperbaric bupivacaine with intrathecal or intravenous adjuvants. All patients remained awake, spontaneously breathing, and hemodynamically stable throughout the procedures. None required sedation, vasopressors, airway management, or ICU-level care postoperatively. Pain control was excellent, and all patients ambulated on the same day of surgery. A comparative summary of the anesthetic details and outcomes is provided in Table 4. Discussion Thoracic segmental spinal anesthesia (TSSA) has emerged as a valuable alternative to general anesthesia (GA) in select high-risk surgical patients [ 5 ]. This case series demonstrates the successful use of TSSA in three individuals with significant comorbidities, including chronic kidney disease, ischemic heart disease, diabetes, and malignancy. In each case, TSSA was chosen to mitigate the systemic impact of GA, reduce perioperative risk, and facilitate faster postoperative recovery. The outcomes were consistently favorable: all patients remained awake, spontaneously breathing, and hemodynamically stable during surgery, with no need for sedation, vasopressor support, or airway intervention. Pain control was excellent, and early ambulation was achieved, contributing to an efficient and uncomplicated recovery process. In TSSA, the anesthetic drug used is critical to provide a controlled, segmental sensory block while maintaining hemodynamic stability and decreasing motor injury [ 6 ]. Isobaric bupivacaine is commonly preferred for TSSA due to its predictable spread, slower onset, and prolonged duration of action compared to other local anesthetics [ 7 ]. Unlike hyperbaric solutions, isobaric formulations tend to remain localized around the site of injection, allowing for more precise control of dermatomal spread, which is essential for thoracic applications where excessive cephalad or caudal distribution could result in high spinal block or unnecessary motor block [ 8 ]. Adjuvants such as dexmedetomidine, fentanyl, or clonidine are often added intrathecally to enhance the quality and duration of the block, reduce the required dose of local anesthetic, and provide superior postoperative analgesia without increasing systemic side effects [ 9 ]. In our case series, a consistent anesthetic regimen was employed across all three patients: 7.5 mg of isobaric bupivacaine combined with 5 mcg of dexmedetomidine administered at either the T8–T9 or T11–T12 interspaces. This combination facilitated rapid onset of an adequate sensory block covering the necessary dermatomes for laparoscopic and endourological procedures, while preserving motor function in the lower limbs. The use of dexmedetomidine as an intrathecal adjuvant enhanced intraoperative analgesia, prolonged block duration, and contributed to the stable hemodynamic profiles observed in all cases. Importantly, none of the patients required supplemental opioids, sedation, or vasopressor support, and all reported minimal postoperative pain, supporting the efficacy and safety of this anesthetic approach in high-risk surgical populations. TSSA remains underutilized in clinical practice, because of concerns about spinal cord injury when injected at thoracic levels. However, growing evidence indicates it is safe in the hands of professionals [ 10 ]. Previous studies, such as those by Elakany et al. and Aljuba et al., found equally positive outcomes in patients undergoing breast or abdominal procedures, particularly in high-risk or elderly populations [ 3 , 4 ]. The present series reinforces these findings by extending the application of TSSA to laparoscopic and endourological procedures in patients with ASA Class III status. The hemodynamic stability and minimal postoperative morbidity observed in our cases highlight the physiologic advantages of avoiding GA in patients with compromised cardiac or renal function. Each case presented unique challenges that illustrate the versatility of TSSA. In the first case, an elderly male with sepsis and stage 4 chronic kidney disease successfully underwent laparoscopic cholecystectomy without deterioration in renal function or cardiovascular status. The second case involved a patient with advanced ovarian cancer, chemotherapy-induced leukopenia, and acute on chronic renal failure TSSA offered a low-risk anesthetic plan that avoided further nephrotoxicity. In the third case, a cardiac patient with reduced ejection fraction and previous coronary interventions underwent surgery safely without myocardial stress, arrhythmia, or hypotensive episodes. These examples demonstrate how TSSA can be adapted to reduce risks in complex clinical situations when GA is potentially harmful. This case series demonstrates that thoracic segmental spinal anesthesia, when performed by experienced clinicians with careful patient selection, offers a safe and effective alternative to general anesthesia in high-risk surgical patients. It enables stable intraoperative conditions, rapid postoperative recovery, and reduced systemic complications. As awareness and technical proficiency grow among anesthesiologists, TSSA may assume a more prominent role in perioperative care for vulnerable patient populations. Conclusion This case series highlights the feasibility, safety, and effectiveness of thoracic segmental spinal anesthesia in high-risk surgical patients. In all three cases, TSSA provided excellent intraoperative conditions, stable hemodynamics, and rapid postoperative recovery without the need for sedation, airway support, or ICU admission. The absence of complications and early mobilization underscore its potential as a viable alternative to general anesthesia, particularly in patients with significant cardiovascular, renal, or oncologic comorbidities. With growing clinical experience and careful patient selection, TSSA may play an increasingly important role in the anesthetic management of complex surgical patients. Declarations Acknowledgements: None. Data Availability The data supporting the findings of this study are included within the article. Additional patient information and clinical details are available from the corresponding author upon reasonable request, subject to institutional and ethical guidelines to protect patient confidentiality. Funding: No funding sources are available. Ethics Approval and Consent to Participate All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was designed and carried out in accordance with the ethical principles established by Al-Quds University. Ethical approval was obtained from the Institutional Review Board (IRB) Committee at Al-Quds University. Written informed consent was obtained from all participants for their participation in this study and for the publication of accompanying images. A copy of the signed consent forms is available for review by the Editor-in-Chief of this journal upon request. Clinical trial number: not applicable. Consent for Publication Written informed consent was obtained from all patients for the publication of this case series and any accompanying images. The patients were informed that their anonymity would be preserved and that no identifying information would be published. Contributions Alhareth M. Amro and Tasneem S. Herbawi contributed equally to the conception, data collection, clinical analysis, literature review, and writing of the manuscript. Islam Frijat, Mohammad A. Abudayyeh, and Yahya M. Aljuba performed the anesthesia procedures and assisted in clinical case documentation. Majde G. Hamamdh supervised the clinical work and provided critical revisions to the manuscript. All authors read and approved the final version of the manuscript. References Nordquist D, Halaszynski TM. Perioperative multimodal anesthesia using regional techniques in the aging surgical patient. Pain Res Treat. 2014;2014:902174. doi: 10.1155/2014/902174. Epub 2014 Jan 20. PMID: 24579048; PMCID: PMC3918371. Das S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging. 2010 Apr 1;27(4):265-82. doi: 10.2165/11534990-000000000-00000. PMID: 20359259. Elakany MH, Abdelhamid SA. Segmental thoracic spinal has advantages over general anesthesia for breast cancer surgery. Anesth Essays Res. 2013 Sep-Dec;7(3):390-5. doi: 10.4103/0259-1162.123263. PMID: 25885990; PMCID: PMC4173558. Aljuba YM, Alkadi AT, Hamamdh MG. Segmental Thoracic Spinal Anesthesia for Critical Patients Undergoing Abdominal Surgeries: A Case Series and Literature Review. Cureus. 2024 Nov 24;16(11):e74348. doi: 10.7759/cureus.74348. PMID: 39723320; PMCID: PMC11669299. Paliwal N, Maurya N, Suthar OP, Janweja S. Segmental thoracic spinal anesthesia versus general anesthesia for breast cancer surgery: A prospective randomized-controlled open-label trial. J Anaesthesiol Clin Pharmacol. 2022 Oct-Dec;38(4):560-565. doi: 10.4103/joacp.JOACP_679_20. Epub 2022 Feb 4. PMID: 36778795; PMCID: PMC9912863. Yousef GT, Lasheen AE. General anesthesia versus segmental thoracic or conventional lumbar spinal anesthesia for patients undergoing laparoscopic cholecystectomy. Anesth Essays Res. 2012 Jul-Dec;6(2):167-73. doi: 10.4103/0259-1162.108302. Retraction in: Anesth Essays Res. 2013 Sep-Dec;7(3):293. PMID: 25885611; PMCID: PMC4173461. Visavakul O, Leurcharusmee P, Pipanmekaporn T, Khorana J, Patumanond J, Phinyo P. Effective Dose Range of Intrathecal Isobaric Bupivacaine to Achieve T5-T10 Sensory Block Heights for Elderly and Overweight Patients: An Observational Study. 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Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Indian J Anaesth. 2011 Jul;55(4):347-51. doi: 10.4103/0019-5049.84841. PMID: 22013249; PMCID: PMC3190507. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6448669","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":448983918,"identity":"143963ae-ee29-48ce-a11d-968b992e2f36","order_by":0,"name":"Alhareth M. Amro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACdh4wlQDhVQAxM3MDfi3MYC0GUC1nQCKMpGhhbAOT+LXwN/Me/FxR8SePgf102oeP82qj+duBWn5UbMOpReIwX7LkmTMGxQw8uZtnztx2PHfGYcYGxp4zt3Fbc5jHQLKxzSCxgSF3MzPvtmO5DUAtzIxtuLXIH+Yx/tn4D6iF/y1Qy5xjufMJaTE4zGMm2dgA1CIBsqWhJncDIS2GQC2WDceME9sk3m5mnHHsQO5GoJaD+Pwid7zH+GZDjVxiP3/uZoYPNXW5884fPvjgRwUe78MAGzQ0wOQBwuoRoI4UxaNgFIyCUTBCAAA5OFkBvm3CfQAAAABJRU5ErkJggg==","orcid":"","institution":"Al-Quds University","correspondingAuthor":true,"prefix":"","firstName":"Alhareth","middleName":"M.","lastName":"Amro","suffix":""},{"id":448983920,"identity":"134c9047-8494-4d82-8b28-fb44f508892a","order_by":1,"name":"Tasneem S. Herbawi","email":"","orcid":"","institution":"Al Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tasneem","middleName":"S.","lastName":"Herbawi","suffix":""},{"id":448983921,"identity":"ce789402-c09d-423b-88e3-d63e3d910e2a","order_by":2,"name":"Islam Frijat","email":"","orcid":"","institution":"Al Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Islam","middleName":"","lastName":"Frijat","suffix":""},{"id":448983922,"identity":"2ff12dfc-796b-4570-9974-b415585e8516","order_by":3,"name":"Sufian M. Alrajabi","email":"","orcid":"","institution":"Al Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sufian","middleName":"M.","lastName":"Alrajabi","suffix":""},{"id":448983923,"identity":"5008d0c4-fc20-4ab2-a3da-711a74aff38d","order_by":4,"name":"Mohammad A. Abudayyeh","email":"","orcid":"","institution":"Al Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"A.","lastName":"Abudayyeh","suffix":""},{"id":448983924,"identity":"e9c31c12-c13a-4755-ae1e-77483d670de8","order_by":5,"name":"Yahya M. Aljuba","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"prefix":"","firstName":"Yahya","middleName":"M.","lastName":"Aljuba","suffix":""},{"id":448983925,"identity":"8ee168a9-9d9d-4fff-87ff-100600288694","order_by":6,"name":"Majde G. Hamamdh","email":"","orcid":"","institution":"Al Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Majde","middleName":"G.","lastName":"Hamamdh","suffix":""}],"badges":[],"createdAt":"2025-04-14 19:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6448669/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6448669/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82125087,"identity":"509301b8-75c0-4f87-b1e0-694840331b15","added_by":"auto","created_at":"2025-05-07 03:44:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":323929,"visible":true,"origin":"","legend":"\u003cp\u003eDermatomal Spread of Sensory Block in Case 1.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6448669/v1/6420694378c1b7b6a21a3d55.png"},{"id":82123852,"identity":"b1833463-5be3-4b27-b5ca-1f8bffbcf7ff","added_by":"auto","created_at":"2025-05-07 03:36:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":227966,"visible":true,"origin":"","legend":"\u003cp\u003eDermatomal Spread of Sensory Block in Case 2.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6448669/v1/de5d9a0640f72ed5bf574f87.png"},{"id":82125442,"identity":"b5c3289d-fd82-4cdd-b2cb-3367b3eac6ab","added_by":"auto","created_at":"2025-05-07 03:52:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":305132,"visible":true,"origin":"","legend":"\u003cp\u003eDermatomal Spread of Sensory Block in Case 2.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6448669/v1/720e5d16f0466e5e411bbb69.png"},{"id":89818368,"identity":"b8d394c0-c58b-474e-92ac-3c08e507a0c2","added_by":"auto","created_at":"2025-08-25 10:54:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1487980,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6448669/v1/fc409dee-891b-4262-beb9-53fbe97d2e24.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Experience with Thoracic Segmental Spinal Anesthesia in High-Risk Surgical Patients: A Case Series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe choice of anesthetic procedure is critical in improving outcomes, especially for patients with numerous comorbidities undergoing surgical procedures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While general anesthesia (GA) is widely used, it presents significant risks in the elderly and high-risk patients, particularly those with compromised cardiovascular, renal, or pulmonary function. The consequences include increased intensive care unit (ICU) hospitalizations, postoperative mental disorders, hemodynamic instability, and longer recovery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThoracic segmental spinal anesthesia (TSSA) has developed as a specialized regional approach that has multiple benefits over general anesthesia in certain clinical settings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Other advantages include better pain control than opioids and an overall decrease in opioid need before or after a procedure, which reduces the potential side effects of these drugs. Furthermore, bowel function recovers more quickly and problems are reduced, resulting in a shorter in-hospital stay and higher patient satisfaction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite its benefits, TSSA is underutilized, mainly due to safety concerns when injecting at thoracic levels. However, expanding evidence supports its feasibility and safety when performed by expert hands using appropriate technique [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case series presents three high-risk patients who successfully underwent laparoscopic and endourological procedures under TSSA, demonstrating its value as a safe, effective, and patient-centered alternative to general anesthesia.\u003c/p\u003e"},{"header":"Case Presentation 1","content":"\u003cp\u003eWe report the case of an 84-year-old obese male (body mass index (BMI): 30.9; weight: 89 kg; height: 170 cm) with a history of type 2 diabetes mellitus (T2DM) complicated by retinopathy (total blindness), hypertension (HTN), stage 4 chronic kidney disease (CKD) with baseline creatinine 4–4.5 mg/dL, and coronary artery disease medically managed without percutaneous intervention due to high risk of contrast-induced nephropathy and patient refusal. The patient was classified as American Society of Anesthesiologists (ASA) Physical Status IV.\u003c/p\u003e \u003cp\u003e The patient presented with generalized weakness, cough, and decreased oral intake for several days. He had received IV fluids at a governmental hospital and was referred to our ICU as a suspected case of sepsis. On examination, he appeared ill and dehydrated, conscious and oriented (GCS 12). Chest auscultation revealed an irregular heart rhythm and decreased air entry bilaterally. Vital signs were stable: BP 128/79 mmHg, HR 94 bpm, SpO₂ 95% on room air, RR 18 breaths/min, and temperature 37.2°C. ECG confirmed atrial fibrillation.\u003c/p\u003e \u003cp\u003eInitial laboratory investigations revealed leukocytosis with neutrophilia, macrocytic anemia, acute kidney injury on top of chronic kidney disease, and severe electrolyte disturbances, including hyperkalemia and hyponatremia. Inflammatory markers were significantly elevated, and arterial blood gases were consistent with high anion gap metabolic acidosis. The full panel is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative Laboratory Findings for Case 1.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference Range\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite Blood Cell Count (WBC)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 K/uL (↑)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0–10.0 K/uL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeukocytosis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (Hb)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.7g/dL (↓)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5–17.5 g/dL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMacrocytic Anemia\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet Count\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150–400 K/uL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood Urea Nitrogen (BUN)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 mg/dL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7–20 mg/dL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLikely Elevated (CKD, Sepsis)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.57 mg/dL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7–1.3 mg/dL\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStage 4 CKD\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130 mEq/L (↓)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135–145 mEq/L\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHyponatremia\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 mEq/L (↑)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5–5.0 mEq/L\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHyperkalemia\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epH / ABG\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh Anion Gap Metabolic Acidosis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.35–7.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSevere Acidosis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP / Inflammatory Markers\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElevated (↑)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistent with Sepsis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt; 7% (T2DM target)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood Glucose (Random)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt; 140 mg/dL (non-fasting)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eChest CT revealed bilateral atypical pneumonia, and abdominal ultrasound demonstrated a distended gallbladder measuring 8.5 × 3.5 cm with stones impacted at the neck. Echocardiography showed preserved systolic function (EF 60%) and mild aortic, tricuspid, and mitral regurgitations. A diagnosis of sepsis secondary to pneumonia and acute cholecystitis was made. Following intensive supportive care, including fluid correction, electrolyte stabilization, and antibiotic therapy, the patient’s condition gradually improved. After several days, repeat investigations confirmed clinical and laboratory improvement, and the patient was cleared for laparoscopic cholecystectomy\u003c/p\u003e \u003cp\u003eGiven his advanced age, cardiac history, and renal dysfunction, general anesthesia posed a significant risk. A thoracic segmental spinal anesthesia (TSSA) technique was chosen after multidisciplinary discussion and informed consent from the patient and family.\u003c/p\u003e \u003cp\u003eIn the operating room, standard ASA monitoring was initiated. Initial vitals were stable: BP 142/90 mmHg, HR 95 bpm, SpO₂ 95%. In the sitting position, the T8–T9 interspace was accessed using the median approach with a 25-gauge pinpoint spinal needle under sterile technique. After confirmation of CSF flow, the subarachnoid block was administered using 7.5 mL of isobaric bupivacaine, along with 5 mcg dexmedetomidine. The patient was then placed supine. The sensory block level achieved was T4–T6 up and L2–L3 down, confirmed by pinprick and cold sensation testing within 5–10 minutes of injection (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo sedation was required intraoperatively. The patient remained fully awake, hemodynamically stable, and cooperative throughout the procedure. Pneumoperitoneum was created with CO₂ after Veress needle insertion, and a standard four-port laparoscopic cholecystectomy was performed. The critical view of safety was achieved, and the gallbladder was dissected retrogradely from the liver bed. The procedure lasted 45 minutes, with no intraoperative complications.\u003c/p\u003e \u003cp\u003eIntraoperative fluid management included a total of 500 mL crystalloid infusion, with no need for blood transfusion or vasopressors. The patient breathed spontaneously with 6 L/min oxygen via a face mask. Vital signs remained stable: SBP ranged between 110–142 mmHg, DBP 63–90 mmHg, HR 70–110 bpm, and SpO₂ improved to 99%.\u003c/p\u003e \u003cp\u003eMotor and sensory block persisted for approximately two hours, after which the patient gradually regained full lower limb function. Postoperative pain was minimal (VAS score \u0026lt; 2/10), and no nausea, hypotension, urinary retention, or neurological symptoms were observed. The patient ambulated the same evening and was monitored in the surgical ward without the need for ICU care. At discharge, the patient was alert, mobile, and satisfied with his anesthetic and surgical experience. This case demonstrates that thoracic segmental spinal anesthesia can be a safe and effective anesthetic alternative in elderly, high-risk patients undergoing laparoscopic cholecystectomy.\u003c/p\u003e "},{"header":"Case Presentation 2","content":"\u003cp\u003eA 57-year-old female, chronic smoker with a BMI of 34.4 (weight: 85 kg; height: 157 cm), presented to our hospital with abdominal distention and right flank pain. She had a history of type 2 diabetes mellitus, paroxysmal atrial fibrillation, and chronic kidney disease with a baseline creatinine of 1.8 mg/dL. Three months prior to admission, she was diagnosed with metastatic ovarian cancer after presenting with progressive abdominal distention and daily discomfort. A CT scan at that time revealed a 9.5 \u0026times; 9.2 cm right adnexal mass, moderate ascites, multiple pathologically enlarged intra-abdominal lymph nodes, two uterine fibroids, and three hepatic hemangiomas. A core biopsy confirmed the diagnosis of ovarian adenocarcinoma, and she began chemotherapy, with her first cycle administered 10 days prior to this admission. Her ASA physical status was classified as class IV.\u003c/p\u003e\n\u003cp\u003eShe was not on any medications other than metformin and had no known drug allergies. On physical examination, she appeared ill and pale, though conscious and oriented. Her abdomen was tense and distended with shifting dullness, and she exhibited\u0026thinsp;+\u0026thinsp;2 bilateral lower limb edema. Cardiopulmonary examination revealed no abnormalities. Vital signs were stable: BP 113/67 mmHg, HR 86 bpm, SpO₂ 95% on room air, RR 16 breaths per minute, and temperature 38.0\u0026deg;C. Laboratory investigations on admission revealed leukopenia (WBC 0.78 K/uL), anemia (Hb 8.9 g/dL), platelet count of 228 K/uL, markedly elevated BUN (106 mg/dL), and a creatinine level of 4.5 mg/dL\u0026mdash;significantly above her baseline. Hemoglobin A1c was 6.8%. ECG showed a regular rhythm with no acute changes, and chest radiography was unremarkable (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cp\u003eTable 2. Preoperative Laboratory Findings for Case 2.\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"560\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eWhite Blood Cell Count (WBC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.78 K/uL (\u0026darr;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4.0 \u0026ndash; 10.0 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eSevere Leukopenia (post-chemo)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHemoglobin (Hb)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e8.9 g/dL (\u0026darr;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e12.0 \u0026ndash; 15.5 g/dL (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eAnemia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePlatelet Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e228 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e150 \u0026ndash; 400 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eBlood Urea Nitrogen (BUN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e106 mg/dL (\u0026uarr;\u0026uarr;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7 \u0026ndash; 20 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eSevere Renal Impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCreatinine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.5 mg/dL (\u0026uarr;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.6 \u0026ndash; 1.1 mg/dL (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eAcute on CKD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eSodium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e135 \u0026ndash; 145 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003ePotassium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3.5 \u0026ndash; 5.0 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003epH / ABG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7.35 \u0026ndash; 7.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eCRP / Inflammatory Markers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eHbA1c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt; 7% (T2DM target)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003eControlled\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eBlood Glucose (Random)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt; 140 mg/dL (non-fasting)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eA contrast-enhanced abdominal CT scan was performed and showed moderate ascites and severe right-sided hydronephrosis, for which urological intervention was indicated. A right-sided double J stent insertion was scheduled for the following day.\u003c/p\u003e\n\u003cp\u003eIn the operating room, full ASA monitoring was applied. Pre-anesthesia vitals remained stable: BP 105/60 mmHg, HR 86 bpm, and SpO₂ 95%. With the patient in the sitting position, the T11\u0026ndash;T12 interspace was identified and disinfected using a full sterile technique. Local infiltration with 2% lidocaine was administered. Using the median approach, a 25-gauge spinal needle was inserted, and cerebrospinal fluid was obtained on the first attempt. Intrathecal injection of 7.5 mg isobaric bupivacaine and 5 mcg dexmedetomidine was performed slowly and without complications (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSensory block to the T8\u0026ndash;L4 dermatomes was achieved within five minutes, assessed by cold sensation and pinprick testing. No sedation was needed, and the patient reported comfort throughout the procedure. Motor block was mild and appropriate for the surgical area. The patient was placed in the lithotomy position, and cystoscopy was performed. A 6 French double J stent was inserted into the right ureter under fluoroscopic guidance without difficulty. The surgery lasted approximately 45 minutes, during which the patient remained fully awake, breathing spontaneously with stable vitals, and without the need for supplemental oxygen or vasoactive medications. Estimated blood loss was negligible, and 500 mL of crystalloid was administered intravenously.\u003c/p\u003e\n\u003cp\u003ePostoperatively, the patient was transferred to the surgical department for observation. She regained full motor function within two hours, experienced minimal pain (VAS score 1\u0026ndash;2), and ambulated on the same day. No nausea, hypotension, headache, or neurologic complications were observed. She remained hemodynamically stable and satisfied with the anesthetic experience.\u003c/p\u003e\n\u003cp\u003eThis case highlights the effective use of thoracic segmental spinal anesthesia in a high-risk, immunocompromised patient undergoing endourological intervention. Regional anesthesia techniques such as this offer a safer alternative to general anesthesia in select populations, particularly in the setting of renal impairment and active oncologic treatment.\u003c/p\u003e"},{"header":"Case Presentation 3","content":"\u003cp\u003eA 67-year-old male patient with a BMI of 36.3 (weight: 105 kg; height: 170 cm) presented with a two-month history of intermittent, colicky right upper quadrant abdominal pain exacerbated by fatty meals and alleviated by fasting and analgesics. His medical history included T2DM, HTN, ischemic heart disease (IHD) with three percutaneous coronary interventions (PCIs), the most recent in 2019, coronary artery bypass grafting (CABG) in 1996, benign prostatic hyperplasia (BPH), and L4-L5 discectomy in 2022. His medication regimen comprised metformin 850 mg, bisoprolol 5 mg, atorvastatin 40 mg, aspirin 100 mg, tamsulosin 0.4 mg, furosemide 40 mg, and dapagliflozin 10 mg. He reported an allergy to sulfa drugs.\u003c/p\u003e\n\u003cp\u003eOn examination, the patient appeared ill and pale but was conscious and oriented. His abdomen was tense and distended, with bilateral + 2 pitting edema in the lower limbs. Cardiopulmonary examination revealed no additional sounds or murmurs. Vital signs were: blood pressure (BP) 110/60 mmHg, heart rate (HR) 65 bpm, respiratory rate (RR) 14 breaths per minute, oxygen saturation (SpO₂) 97% on room air, and temperature 38.0°C.\u003c/p\u003e\n\u003cp\u003eLaboratory investigations revealed a white blood cell (WBC) count of 8.4 K/uL, hemoglobin level of 17.05 g/dL, hematocrit at 52.5%, and platelet count of 156.1 K/uL. Renal function tests showed a blood urea nitrogen (BUN) of 22 mg/dL and creatinine at 0.9 mg/dL. Glycemic assessment indicated an HbA1c of 5.4% and a random blood sugar of 121 mg/dL. Electrolyte analysis revealed sodium at 140 mEq/L and potassium at 4.4 mEq/L. These findings suggest stable renal function and adequate glycemic control (Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3. Preoperative Laboratory Findings for Case 3.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"531\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWhite Blood Cell Count (WBC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.4 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0 – 10.0 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHemoglobin (Hb)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.05 g/dL (↑)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.5 – 17.5 g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElevated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlatelet Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e156.1 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e150 – 400 K/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood Urea Nitrogen (BUN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 mg/dL (↑)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 – 20 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMildly Elevated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCreatinine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7 – 1.3 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSodium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e140 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e135 – 145 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePotassium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.4 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5 – 5.0 mEq/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003epH / ABG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.35 – 7.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e—\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCRP / Inflammatory Markers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e—\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e—\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHbA1c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 7% (T2DM target)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExcellent Control\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood Glucose (Random)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e121 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 140 mg/dL (non-fasting)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003eTable 4: Comparison of Anesthetic Techniques and Outcomes in All Three Cases.\u003c/div\u003e\n \u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase No.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge / Gender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eASA Class\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgery Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLevel of LA Injection\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLA and Adjuvants Injected\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSensory Block Level\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgery Duration (min)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSedation Used\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAirway Support\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHemodynamic Stability\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-op Recovery\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84 / M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic cholecystectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8–T9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5 mL isobaric bupivacaine\u003c/p\u003e\n \u003cp\u003e+ 5 mcg dexmedetomidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4–T10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpontaneous (O₂ mask)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMobilized same day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 / F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUreteric stent insertion (endourological)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT11–T12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5 mL isobaric bupivacaine\u003c/p\u003e\n \u003cp\u003e+ 5 mcg dexmedetomidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8–S2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRoom air\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMobilized same day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 / M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic cholecystectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8–T9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5 mg isobaric bupivacaine + 5 mcg dexmedetomidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT6–T12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRoom air\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMobilized same day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eElectrocardiography (ECG) demonstrated a right bundle branch block (RSR pattern) with Q waves in anteroseptal leads. Chest X-ray was unremarkable. Abdominal ultrasound revealed multiple gallbladder stones without signs of cholecystitis and an enlarged prostate. Transthoracic echocardiography indicated an ejection fraction (EF) of 40%, with septal, anterior, and apical hypokinesia, mild mitral and tricuspid regurgitation, and a pulmonary artery pressure (PAP) of 27 mmHg at rest.\u003c/p\u003e\n\u003cp\u003eHe was classified as ASA Physical Status Class III. Given his significant cardiac history and multiple comorbidities, the decision was made to perform laparoscopic cholecystectomy under segmental thoracic spinal anesthesia (STSA) to minimize the risks associated with general anesthesia.\u003c/p\u003e\n\u003cp\u003eIn the operating room, standard monitoring was applied, revealing BP 105/57 mmHg, HR 67 bpm, and SpO₂ 96%. With the patient in the sitting position, the T8-T9 interspace was identified and prepared under sterile conditions. Local infiltration with 2% lidocaine was administered. Using the paramedian approach, a 25-gauge spinal needle was inserted, and clear cerebrospinal fluid (CSF) was obtained on the first attempt. Intrathecal injection of 7.5 mg isobaric bupivacaine combined with 5 mcg dexmedetomidine was performed slowly (Fig.\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eA sensory block from T6 to L3 was achieved within five minutes, confirmed by cold sensation and pinprick testing. No significant hemodynamic changes occurred post-anesthesia. The patient was positioned with a head-up tilt toward the surgeon's side. Pneumoperitoneum was established, and laparoscopic cholecystectomy was completed uneventfully over 40 minutes. The patient remained awake, breathing spontaneously, and hemodynamically stable throughout the procedure without complications.\u003c/p\u003e\n\u003cp\u003ePostoperatively, the patient was transferred to the surgical department for observation. He reported minimal pain (Visual Analog Scale score 1–2) and regained full motor function within two hours. No postoperative nausea, vomiting, or neurologic complications were observed. He was mobilized on the same day and discharged in stable condition after an uneventful recovery.\u003c/p\u003e\n\u003cp\u003eThis case illustrates the successful use of STSA in a high-risk patient undergoing laparoscopic cholecystectomy. STSA offers advantages such as stable hemodynamics, effective analgesia, and reduced postoperative complications compared to general anesthesia, particularly in patients with significant cardiopulmonary comorbidities. STSA is a viable and effective anesthetic technique for laparoscopic cholecystectomy in patients with multiple comorbidities, providing stable intraoperative conditions and favorable postoperative outcomes.\u003c/p\u003e\n\u003cp\u003eThe three patients in this series were classified as American Society of Anesthesiologists (ASA) Physical Status Class III and IV and presented with significant comorbidities, including cardiovascular disease, chronic kidney disease, and/or active malignancy. In each case, thoracic segmental spinal anesthesia (TSSA) was selected over general anesthesia to minimize systemic impact, reduce perioperative risk, and promote rapid postoperative recovery.\u003c/p\u003e\n\u003cp\u003eDespite differences in surgical indication and individual comorbidity profiles, the anesthetic approach was similarly structured: a thoracic or thoracolumbar spinal block using hyperbaric bupivacaine with intrathecal or intravenous adjuvants. All patients remained awake, spontaneously breathing, and hemodynamically stable throughout the procedures. None required sedation, vasopressors, airway management, or ICU-level care postoperatively. Pain control was excellent, and all patients ambulated on the same day of surgery. A comparative summary of the anesthetic details and outcomes is provided in Table\u0026nbsp;4.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThoracic segmental spinal anesthesia (TSSA) has emerged as a valuable alternative to general anesthesia (GA) in select high-risk surgical patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This case series demonstrates the successful use of TSSA in three individuals with significant comorbidities, including chronic kidney disease, ischemic heart disease, diabetes, and malignancy. In each case, TSSA was chosen to mitigate the systemic impact of GA, reduce perioperative risk, and facilitate faster postoperative recovery. The outcomes were consistently favorable: all patients remained awake, spontaneously breathing, and hemodynamically stable during surgery, with no need for sedation, vasopressor support, or airway intervention. Pain control was excellent, and early ambulation was achieved, contributing to an efficient and uncomplicated recovery process.\u003c/p\u003e \u003cp\u003eIn TSSA, the anesthetic drug used is critical to provide a controlled, segmental sensory block while maintaining hemodynamic stability and decreasing motor injury [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Isobaric bupivacaine is commonly preferred for TSSA due to its predictable spread, slower onset, and prolonged duration of action compared to other local anesthetics [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Unlike hyperbaric solutions, isobaric formulations tend to remain localized around the site of injection, allowing for more precise control of dermatomal spread, which is essential for thoracic applications where excessive cephalad or caudal distribution could result in high spinal block or unnecessary motor block [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Adjuvants such as dexmedetomidine, fentanyl, or clonidine are often added intrathecally to enhance the quality and duration of the block, reduce the required dose of local anesthetic, and provide superior postoperative analgesia without increasing systemic side effects [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our case series, a consistent anesthetic regimen was employed across all three patients: 7.5 mg of isobaric bupivacaine combined with 5 mcg of dexmedetomidine administered at either the T8\u0026ndash;T9 or T11\u0026ndash;T12 interspaces. This combination facilitated rapid onset of an adequate sensory block covering the necessary dermatomes for laparoscopic and endourological procedures, while preserving motor function in the lower limbs. The use of dexmedetomidine as an intrathecal adjuvant enhanced intraoperative analgesia, prolonged block duration, and contributed to the stable hemodynamic profiles observed in all cases. Importantly, none of the patients required supplemental opioids, sedation, or vasopressor support, and all reported minimal postoperative pain, supporting the efficacy and safety of this anesthetic approach in high-risk surgical populations.\u003c/p\u003e \u003cp\u003eTSSA remains underutilized in clinical practice, because of concerns about spinal cord injury when injected at thoracic levels. However, growing evidence indicates it is safe in the hands of professionals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previous studies, such as those by Elakany et al. and Aljuba et al., found equally positive outcomes in patients undergoing breast or abdominal procedures, particularly in high-risk or elderly populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The present series reinforces these findings by extending the application of TSSA to laparoscopic and endourological procedures in patients with ASA Class III status. The hemodynamic stability and minimal postoperative morbidity observed in our cases highlight the physiologic advantages of avoiding GA in patients with compromised cardiac or renal function.\u003c/p\u003e \u003cp\u003eEach case presented unique challenges that illustrate the versatility of TSSA. In the first case, an elderly male with sepsis and stage 4 chronic kidney disease successfully underwent laparoscopic cholecystectomy without deterioration in renal function or cardiovascular status. The second case involved a patient with advanced ovarian cancer, chemotherapy-induced leukopenia, and acute on chronic renal failure TSSA offered a low-risk anesthetic plan that avoided further nephrotoxicity. In the third case, a cardiac patient with reduced ejection fraction and previous coronary interventions underwent surgery safely without myocardial stress, arrhythmia, or hypotensive episodes. These examples demonstrate how TSSA can be adapted to reduce risks in complex clinical situations when GA is potentially harmful.\u003c/p\u003e \u003cp\u003eThis case series demonstrates that thoracic segmental spinal anesthesia, when performed by experienced clinicians with careful patient selection, offers a safe and effective alternative to general anesthesia in high-risk surgical patients. It enables stable intraoperative conditions, rapid postoperative recovery, and reduced systemic complications. As awareness and technical proficiency grow among anesthesiologists, TSSA may assume a more prominent role in perioperative care for vulnerable patient populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case series highlights the feasibility, safety, and effectiveness of thoracic segmental spinal anesthesia in high-risk surgical patients. In all three cases, TSSA provided excellent intraoperative conditions, stable hemodynamics, and rapid postoperative recovery without the need for sedation, airway support, or ICU admission. The absence of complications and early mobilization underscore its potential as a viable alternative to general anesthesia, particularly in patients with significant cardiovascular, renal, or oncologic comorbidities. With growing clinical experience and careful patient selection, TSSA may play an increasingly important role in the anesthetic management of complex surgical patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The data supporting the findings of this study are included within the article. Additional patient information and clinical details are available from the corresponding author upon reasonable request, subject to institutional and ethical guidelines to protect patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding sources are available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was designed and carried out in accordance with the ethical principles established by Al-Quds University. Ethical approval was obtained from the Institutional Review Board (IRB) Committee at Al-Quds University. Written informed consent was obtained from all participants for their participation in this study and for the publication of accompanying images. A copy of the signed consent forms is available for review by the Editor-in-Chief of this journal upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent was obtained from all patients for the publication of this case series and any accompanying images. The patients were informed that their anonymity would be preserved and that no identifying information would be published.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlhareth M. Amro and Tasneem S. Herbawi contributed equally to the conception, data collection, clinical analysis, literature review, and writing of the manuscript. Islam Frijat, Mohammad A. Abudayyeh, and Yahya M. Aljuba performed the anesthesia procedures and assisted in clinical case documentation. Majde G. Hamamdh supervised the clinical work and provided critical revisions to the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNordquist D, Halaszynski TM. Perioperative multimodal anesthesia using regional techniques in the aging surgical patient. Pain Res Treat. 2014;2014:902174. doi: 10.1155/2014/902174. Epub 2014 Jan 20. PMID: 24579048; PMCID: PMC3918371.\u003c/li\u003e\n\u003cli\u003eDas S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging. 2010 Apr 1;27(4):265-82. doi: 10.2165/11534990-000000000-00000. PMID: 20359259.\u003c/li\u003e\n\u003cli\u003eElakany MH, Abdelhamid SA. Segmental thoracic spinal has advantages over general anesthesia for breast cancer surgery. Anesth Essays Res. 2013 Sep-Dec;7(3):390-5. doi: 10.4103/0259-1162.123263. PMID: 25885990; PMCID: PMC4173558.\u003c/li\u003e\n\u003cli\u003eAljuba YM, Alkadi AT, Hamamdh MG. Segmental Thoracic Spinal Anesthesia for Critical Patients Undergoing Abdominal Surgeries: A Case Series and Literature Review. Cureus. 2024 Nov 24;16(11):e74348. doi: 10.7759/cureus.74348. PMID: 39723320; PMCID: PMC11669299.\u003c/li\u003e\n\u003cli\u003ePaliwal N, Maurya N, Suthar OP, Janweja S. Segmental thoracic spinal anesthesia versus general anesthesia for breast cancer surgery: A prospective randomized-controlled open-label trial. J Anaesthesiol Clin Pharmacol. 2022 Oct-Dec;38(4):560-565. doi: 10.4103/joacp.JOACP_679_20. Epub 2022 Feb 4. PMID: 36778795; PMCID: PMC9912863.\u003c/li\u003e\n\u003cli\u003eYousef GT, Lasheen AE. General anesthesia versus segmental thoracic or conventional lumbar spinal anesthesia for patients undergoing laparoscopic cholecystectomy. Anesth Essays Res. 2012 Jul-Dec;6(2):167-73. doi: 10.4103/0259-1162.108302. Retraction in: Anesth Essays Res. 2013 Sep-Dec;7(3):293. PMID: 25885611; PMCID: PMC4173461.\u003c/li\u003e\n\u003cli\u003eVisavakul O, Leurcharusmee P, Pipanmekaporn T, Khorana J, Patumanond J, Phinyo P. Effective Dose Range of Intrathecal Isobaric Bupivacaine to Achieve T5-T10 Sensory Block Heights for Elderly and Overweight Patients: An Observational Study. Medicina (Kaunas). 2023 Mar 1;59(3):484. doi: 10.3390/medicina59030484. PMID: 36984485; PMCID: PMC10057130.\u003c/li\u003e\n\u003cli\u003eUppal V, Retter S, Shanthanna H, Prabhakar C, McKeen DM. Hyperbaric Versus Isobaric Bupivacaine for Spinal Anesthesia: Systematic Review and Meta-analysis for Adult Patients Undergoing Noncesarean Delivery Surgery. Anesth Analg. 2017 Nov;125(5):1627-1637. doi: 10.1213/ANE.0000000000002254. PMID: 28708665.\u003c/li\u003e\n\u003cli\u003eSwain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases. 2017 Aug 16;5(8):307-323. doi: 10.12998/wjcc.v5.i8.307. PMID: 28868303; PMCID: PMC5561500.\u003c/li\u003e\n\u003cli\u003eCook TM, Counsell D, Wildsmith JA; Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009 Feb;102(2):179-90. doi: 10.1093/bja/aen360. Epub 2009 Jan 12. PMID: 19139027.\u003c/li\u003e\n\u003cli\u003eGupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Indian J Anaesth. 2011 Jul;55(4):347-51. doi: 10.4103/0019-5049.84841. PMID: 22013249; PMCID: PMC3190507. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Thoracic spinal anesthesia, high-risk surgery, regional anesthesia, general anesthesia alternative, comorbidities, case series","lastPublishedDoi":"10.21203/rs.3.rs-6448669/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6448669/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGeneral anesthesia (GA) can pose significant risks in patients with advanced comorbidities. Thoracic segmental spinal anesthesia (TSSA) is an underutilized alternative that offers hemodynamic stability and enhanced postoperative recovery. This case series highlights the application of TSSA in three high-risk surgical patients with complex cardiovascular, renal, or oncologic conditions.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eWe describe three patients (ASA Class III\u0026ndash;IV) undergoing laparoscopic or endourological procedures who received TSSA instead of GA due to high anesthetic risk. Each patient received isobaric bupivacaine combined with dexmedetomidine via thoracic or thoracolumbar spinal injection. All patients remained awake, hemodynamically stable, and spontaneously breathing throughout their procedures. No sedation, vasopressor support, airway intervention, or ICU admission was required. Postoperative pain was minimal, with early ambulation and no reported complications.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThoracic segmental spinal anesthesia is a safe and effective anesthetic technique for select high-risk patients undergoing abdominal or urological surgery. It provides excellent intraoperative conditions, avoids the systemic effects of GA, and facilitates rapid recovery. With proper technique and patient selection, TSSA offers a valuable alternative to general anesthesia in complex surgical cases.\u003c/p\u003e","manuscriptTitle":"Clinical Experience with Thoracic Segmental Spinal Anesthesia in High-Risk Surgical Patients: A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 03:36:05","doi":"10.21203/rs.3.rs-6448669/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6dca3b5d-f0af-47c5-a4f8-e01cad5c1fbf","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T10:53:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 03:36:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6448669","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6448669","identity":"rs-6448669","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}