Thoracic spinal anaesthesia for breast surgeries: Addressing concerns and highlighting benefits

Dear Editor, We appreciate the concerns raised by Karim et al.[1] in their comments published on article by Karthik GS et al.[2] While we acknowledge the importance of critical appraisal, we believe that TSA remains a viable and safe anaesthetic technique when appropriately implemented. Firstly, we agree with Karim et al.’s notion of multimodal analgesia during GA. TSA provides superior analgesia by directly targeting the surgical site, reducing systemic opioid requirements, thus minimising their side effects.[3] Regarding fentanyl use, all patients in the TSA group were given 25 μg intrathecally and in the GA group were given 1–2 μg/kg intravenously. The interpretation that the analgesic advantage of TSA is solely attributable to an inadequate GA regimen overlooks the fundamental pharmacodynamic benefits of neuraxial blockade in terms of pain control and patient recovery. Secondly, concerns regarding haemodynamic instability with TSA have been overstated. Hypotension and bradycardia are dose dependent and easily manageable. TSA offers haemodynamic stability by preserving sympathetic tone in non-anaesthetised segments, and individualised titration of medications mitigates the risks effectively. Another argument raised by the authors pertains to diathermy-induced twitches and their impact on surgical conditions. The majority of breast surgeries do not necessitate profound neuromuscular blockade. The avoidance of neuromuscular blocking agents under TSA contributes to faster postoperative recovery.[4] The critique regarding the open-label design of the referenced study is acknowledged, but it is important to recognise that double blinding cannot be applied here. The outcomes assessed, particularly pain scores and patient satisfaction, are clinically significant endpoints that support the effectiveness of TSA. Moreover, anaesthesia cost was about half of the GA cost, which is also an important consideration, particularly in resource-limited settings. While ongoing research should refine patient selection and dosing strategies, the concerns raised by Karim et al. do not outweigh the benefits of TSA. We encourage continued exploration and adoption of TSA, particularly in resource-limited settings where its advantages over GA can have profound implications for perioperative care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.