Pragmatic view of the segmental thoracic spinal as an alternative to general anaesthesia for breast surgeries

Dear Editor, Karthik et al.[1] recently published an article on segmental thoracic spinal anaesthesia (STSA) for breast surgeries and concluded it is an effective alternative to general anaesthesia (GA). We applaud the authors’ hypothesis and randomised design; however, the authors’ interpretation needs further scrutiny. Firstly, multimodal analgesia is considered ‘the’ technique of analgesia, the current minimum standard for postoperative pain management, and regional analgesia techniques play a crucial role as a component whenever possible.[2,3] Intraoperative analgesia should be tailored to extend its effects into the postoperative period, providing pain relief with minimal complications.[2] While it is evident that the authors have considered fentanyl as an adjuvant to levobupivacaine in the STSA group, the GA group did not receive any such consideration. Although both groups received paracetamol as the maintenance analgesia, GA group lacked the planning and benefit of multimodal analgesia. Notably, the regional analgesia technique is recommended in breast cancer surgeries.[4] This crucial deficit left the GA group at the mercy of the rescue dose, resulting in all the differences in pain, analgesia request time and rescue analgesic dose. It also suggests that poor satisfaction might result from suboptimal pain management and the experience of postoperative nausea and vomiting. The second aspect that needs attention is highlighting what is known and hiding the devil in the room. Recent systematic reviews and meta-analyses indicate that STSA leads to significant haemodynamic compromise.[5] The authors also noticed bradycardia and hypotension in 20% of participants of STSA requiring treatment when monitored at 15-min intervals. While heart rate is continuously monitored, blood pressure is typically checked intermittently, raising concerns that significant hypotension may go unnoticed. The literature indicates that hypotension, even for 5 min, leads to end organ damage.[6] Studies also suggest that diathermy-induced twitches are very bothering, especially in breast cancer surgeries requiring axillary clearance, which provide less satisfactory surgical conditions to the surgical team.[5] Lastly, a non-blinded design, especially the data collection, may have influenced the outcomes in such cases. The fact that the patients in the GA group had visual analogue scale (VAS) scores above 5 almost throughout the postoperative period also indicates that their pain management was inadequate. Furthermore, there is also a need for more clarity regarding the GA maintenance protocol. Nevertheless, the authors’ study strengthens the thrust of STSA, and future studies considering the above facts will enlighten us on whether STSA can serve as a safer alternative to GA. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.