Navigating the high-risk airway: Thoracic segmental spinal anesthesia and ESP block for breast surgery, a case report

Background : While general anesthesia remains the standard of care for breast cancer surgery, it poses substantial perioperative risks in elderly patients presenting with complex comorbidities and an anticipated difficult airway. Case Presentation: A 72-year-old female (ASA Class III) with a history of long-standing hypertension, diabetes mellitus, and Class I obesity (BMI 34 kg/m²) presented for a wide local excision of a BIRADS-4 malignant breast lesion. Airway evaluation revealed an anticipated difficult airway (Mallampati Class III, short neck, and thyromental distance <6 cm). To bypass airway manipulation, segmental thoracic spinal anesthesia (STSA) was administered at the T5–T6 interspace using 1 mL of 0.75% isobaric ropivacaine co-administered with 5 mcg dexmedetomidine. For postoperative analgesia, an ultrasound-guided erector spinae plane block (ESPB) was performed at the T5 level using 20 mL of 0.25% bupivacaine. The 45-minute surgical procedure was completed successfully. The patient remained fully conscious and hemodynamically stable throughout, with no need for supplemental sedation or conversion to general anesthesia. Postoperative Visual Analog Scale (VAS) pain scores remained consistently below 3 for the first 12 hours. Conclusion : Combining segmental thoracic spinal anesthesia with an ultrasound-guided erector spinae plane block offers a safe, feasible, and effective regional alternative to general anesthesia for high-risk patients undergoing breast surgery, delivering superior perioperative analgesia while avoiding airway instrumentations.