Rising Above Lumbar Scars: Thoracic Spinal Anesthesia With Hypobaric Bupivacaine for Hip Replacement

Neuraxial anesthesia is widely practiced for lower limb, abdominal, and pelvic surgeries due to its favorable risk-benefit profile compared with general anesthesia (GA). However, patients with previous lumbar spine surgery and instrumentation present significant challenges for conventional lumbar spinal anesthesia. Altered anatomy, epidural scarring, and the presence of metallic implants often preclude successful needle placement or result in patchy anesthesia. In such patients, GA may be considered, but it carries substantial risks in elderly individuals with significant comorbidities. Thoracic spinal anesthesia (TSA), once regarded with apprehension, has recently re-emerged as a feasible and safe technique, particularly when hypobaric local anesthetics are used to direct drug spread toward the lumbar and pelvic dermatomes. We present two geriatric patients with prior lumbar spine surgeries and multiple comorbidities who underwent total hip replacement under TSA with hypobaric bupivacaine and fentanyl. Both patients had uneventful intraoperative courses and smooth postoperative recovery. These cases highlight the potential of TSA with hypobaric solutions as an effective alternative when conventional neuraxial approaches are not possible and GA poses significant risks.