Breaking the Taboo: Four Cases of Thoracic Segmental Spinal Anesthesia in Modern Surgical Practice.

Thoracic segmental spinal anesthesia (TSSA) is an old neuraxial technique that has recently regained attention as a possible alternative to general anesthesia (GA) in selected surgical patients. Its segmental nature, low-dose local anesthetic requirement, and ability to preserve spontaneous ventilation may be particularly relevant in high-risk patients in whom airway manipulation, endotracheal intubation, positive-pressure ventilation, and systemic anesthetic exposure could represent an additional physiological burden. We report four selected high-risk patients undergoing procedures from different surgical specialties under TSSA: emergency videolaparoscopic adnexal detorsion in early pregnancy; retrograde intrarenal surgery (RIRS) in a patient with arthrogryposis multiplex congenita and restrictive ventilatory impairment; laparoscopic appendectomy in a patient with severe chronic obstructive pulmonary disease (COPD) and chronic cor pulmonale; and laparoscopic cholecystectomy in a morbidly obese patient with obstructive sleep apnea. In all cases, TSSA was tailored according to patient characteristics and surgical requirements through individualized selection of puncture level, local anesthetic baricity, adjuvants, sedation strategy, and respiratory support. All procedures were completed without conversion to GA, airway rescue, clinically relevant respiratory deterioration, or postoperative neurological complications. Quality of recovery was high in all patients. These cases suggest that TSSA may represent a versatile, physiology-preserving anesthetic strategy in carefully selected high-risk patients, provided that it is performed by experienced practitioners within a multidisciplinary plan and with a clear backup strategy.