In an era marked by precision and patient-centric perioperative care, Thoracic Segmental Spinal Anaesthesia (TSSA) has emerged as a transformative technique in regional anaesthesia. Once considered unorthodox, thoracic spinal blockade is now being re-evaluated through the lens of modern evidence, anatomy-based practice, and improved technological support. As regional anaesthesiologists navigate increasingly complex patient profiles, TSSA offers a compelling alternative—particularly for high-risk surgical candidates and in resource-limited healthcare systems.
Though the concept of TSSA dates back to the early 20th century, its renaissance in the 21st century—particularly the COVID era—has redefined its utility. Patients with significant cardiopulmonary comorbidities who are unable to tolerate general anaesthesia (GA) or conventional lumbar spinal blocks can benefit significantly from TSSA. By delivering low-volume, segment-targeted anaesthesia, the technique avoids unnecessary spread to lumbosacral roots, thus preserving sympathetic tone and maintaining haemodynamic stability. The precision of TSSA enables adequate surgical anaesthesia without systemic disruption, especially valuable in elderly and frail patients, where even minor perioperative instability may lead to poor outcomes. TSSA is more than an academic curiosity—it presents practical, patient-centred advantages over GA, particularly in select cohorts:
- Avoidance of airway instrumentation eliminates postoperative airway morbidity and aspiration.
- Reduced incidence of postoperative pulmonary complications, especially critical in patients with chronic respiratory disease.
- Stable intraoperative haemodynamics, owing to its segmental nature and minimal sympathetic blockade.
- Faster postoperative recovery, with reduced emergence delirium, nausea, and opioid use.
- Lower ICU and hospital length of stay, translating to reduced perioperative costs.
- Cost-effectiveness, particularly in low-resource settings where availability of ventilators, ICU beds, and trained anaesthesia providers may be limited.
Perhaps the most significant barrier to widespread adoption has been the long-standing concern over neurological injury from spinal puncture at higher levels. However, accumulating clinical evidence, along with MRI-based anatomical studies, has shown that the spinal cord is more anteriorly positioned within the vertebral canal at mid-thoracic levels—offering a safe corridor for needle passage when performed with expertise and fine-gauge needles. In fact, accidental dural punctures during thoracic epidural attempts have not led to disastrous outcomes—prompting a re-evaluation of our collective assumptions.
What sets TSSA apart is its scientific finesse. It’s not a one-size-fits-all solution. It demands a refined understanding of spinal anatomy, segmental dermatomes, and local anaesthetic dynamics. Dosing must be precisely tailored to prevent excessive spread while ensuring sufficient anaesthesia. Factors such as baricity, volume, concentration, and needling level play a critical role. Emerging strategies such as two-drug technique, two-level spinal puncture, continuous segmental spinal, and even prone-position thoracic spinal anaesthesia are being explored, pushing the boundaries of what is possible with segmental techniques. Visionary researchers across the globe are expanding its horizon—applying TSSA in various surgical procedures once thought unsuitable for regional techniques. In recent years, ultrasound-guided approaches have improved needle placement accuracy and safety.
Despite its clear potential, TSSA remains underutilized, with its expansion limited by medicolegal concerns, lack of widespread training, and the absence of large-scale randomized controlled trials. The current evidence base largely consists of case reports and observational studies—though their outcomes are uniformly reassuring. For TSSA to move from niche to norm, it will require formal inclusion in training curricula, standardized protocols, and multicentre collaborations to validate its safety and efficacy across diverse patient populations.
Thoracic Segmental Spinal Anaesthesia represents more than just a technical variation—it embodies the evolution of regional anaesthesia toward minimalism, precision, and patient safety. In the hands of trained anaesthesiologists, TSSA is not only feasible—it is transformative. As we redefine the frontiers of anaesthesia practice, it’s time to recognize TSSA not as an alternative, but as a mainstream technique with game-changing potential.
Dr Suvarna K,
Professor of Anaesthesia,
Government Medical College Manjeri.