Thoracic Spinal Anesthesia in Awake Breast Surgery
Condition: Breast Cancer
MeSH terms: Breast Neoplasms
Study type: Interventional

Summary: 
      General anesthesia is the conventional technique used for breast surgery. breast surgery is
      associated with a high incidence of postoperative pain, it is estimated that over 50 % of
      women suffer chronic pain following breast cancer surgery. Regional anesthesia is a good
      alternative to general anesthesia for breast cancer surgery, providing superior analgesia and
      fewer side effects related to a standard opiate-based analgesia. there is no evident optimal
      regional techniques for operative procedures on the breast and axilla, like high thoracic
      epidural, cervical epidural, paravertebral block, intrerpleural block, PECs block, serratus
      plane block and segmental thoracic spinal anesthesia. Regional anesthesia decreases operative
      stress, provides beneficial hemodynamic effects especially for critically ill patients and
      decreases postoperative morbidity and mortality. Also it reduces post-operative nausea and
      vomiting and provides prolonged post-operative sensory block, minimizing narcotic
      requirements. Additionally, this application positively affects the early start of feeding
      and mobilization.
    

Detailed description: 
      Thoracic paravertebral block (TPVB) is an alternative method to general anesthesia for
      patients undergoing breast surgery, because it provides a safe anesthesia with balanced
      hemodynamic response with unilateral somatic and sympathetic blockade, allows postoperative
      analgesia lowering narcotic usage , minimal nausea and vomiting rate, early discharge and low
      cost.

      Segmental thoracic spinal anesthesia have introduced for cardiac surgery in adults and
      children in the early 1990's. Kowalewski et al., performed over 10000 cases of spinal
      injections without a single case of spinal/epidural hematoma or any neurological
      complications, also segmental thoracic spinal anesthesia has been used successfully for
      laparoscopic cholecystectomy and abdominal surgeries. It has some advantages when compared
      with general anesthesia and can be a sole anesthetic in breast cancer surgery with axillary
      lymph node clearance especially in critical cases. Among its advantages are the quality of
      postoperative analgesia, lower incidence of nausea and vomiting, and shorter recovery time,
      with the consequent early hospital discharge. The dose of the anesthetic is exceedingly low,
      compared with lumbar spinal anesthesia, given the highly specific block to only certain nerve
      functions along a section of the cord, there is no blockade of the lower extremities. This
      means that a significantly larger portion of the body experiences no venal dilation, and may
      offer a compensatory buffer to adverse changes in blood pressure intra-operatively. there was
      no recorded of neurological complications.The incidence of parasthesia in a study with 300
      patients subjected to thoracic spinal puncture at T10-11 was 4.67% in the cut needle group
      and 8.67% in the pencil point needle group, similar to that reported in lumbar spinal
      anesthesia.The aim of the present study is the comparison between two sole regional
      anesthetic techniques, thoracic para-vertebral block and segmental thoracic spinal anesthesia
      in breast cancer surgery especially for critically ill patients.
    

Intervention name(s): spinal group; paravertebral group
Intervention type(s): Other; Other
Intervention description(s): plain bupivacaine 0.5%,1.5 ml plus dexmedetomidine 5 μg. once injection.; plain bupivacaine 0.5%, 0.3 ml (1.5 mg)/kg plus dexmedetomidine 0.5 μg /kg divided between the T2 and T4 levels.
Other intervention name(s): STSB; TPVB
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: thoracic spinal; awake mastectomy; paravertebral block; analgesia; ultrasound; breast cancer