Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia.

The technique of Cervical Epidural Anesthesia (CEA) was first described by Dogliotti in 1933 for upper thoracic procedures. Administration of local anesthetic into cervical epidural space results in anesthesia of the neck, upper extremity, and upper thoracic region. CEA provides high-quality analgesia and anesthesia of above dermatomes and, at the same time, it has favorable effect on hemodynamic variable by blocking sympathetic innervation of the heart. CEA is not practiced routinely because of its potential complications. We selected this technique of CEA for excision of giant cervical lipoma on the back of the neck in an adult patient, as the patient was unwilling for general anesthesia. CEA was induced with 10 ml of 1% lignocaine-adrenaline mixture administered into C7-T1 space through 18G Tuohy needle. Our patient maintained vital parameters throught the procedure. The added advantage of epidural anesthesia was that the patient was awake and comfortable throughout the procedure.

INTRODUCTION

The technique of Cervical Epidural Anesthesia (CEA) can be used successfully for procedures involving the neck and upper thorax. This technique is less commonly practiced due to the concern of potential complications such as dural puncture and paralysis of respiratory muscles. However, in the hands of an expert anesthesiologist, the risks associated with these complications are low. A number of prospective and retrospective studies have compared the frequency of both perioperative and postoperative complications of CEA. Results from some studies suggest that when CEA was used for procedures such as carotid endarterectomy, the morbidity and mortality rates were low and the hemodynamic variables better maintained.[12] This technique offers the advantage of better and early postoperative recovery and reduced incidence of postoperative cardio-respiratory complications. We successfully used technique of CEA for surgical excision of tumor on the back of neck.

CASE REPORT

After obtaining a written informed consent, a 40- year- old American Society of Anaesthesiologists (ASA) grade I male patient was posted for surgical excision of giant cervical lipoma, on the back of neck, measuring 12 × 10 × 4.5 cm. On preanesthetic check-up, all routine investigation results were within normal limit. The patient was kept nil orally after 12 midnight prior to surgery. He was premedicated with tablet alprazolam 0.5 mg half an hour before dinner and at 6 o’clock in the morning of surgery to allay anxiety.

On arrival to the operation theater, an intravenous line was secured with 18G cannula and Lactated Ringer's solution was started. All anesthetic equipment were checked and monitors attached to the patient. Electrocardiogram (ECG), Oxygen Saturation (SpO2), Noninvasive Blood Pressure (NIBP), and Heart Rate (HR) were monitored continuously throughout the intraoperative period. The patient was premedicated with injection ondansetron 6 mg and was properly briefed prior to the procedure. CEA was performed with the patient in a sitting position. With all aseptic precautions, the neck was flexed to make the cervical vertebrae prominent. The C7-T1 space was infiltrated with 3 ml of 2% lignocaine with adrenaline to provide local anesthesia. Thereafter, a wide-bore needle was inserted at the C7-T1 level to create a passage for epidural needle. An 18G Tuohy needle was inserted in the epidural space, which was identified using the ‘hanging drop’ technique. An 18G epidural catheter was then inserted in the space up to the depth of 3 cm [Figure 1]. The direction of catheter tip was kept cephalad. The catheter was fixed in position. Correct placement of the catheter was verified by negative aspiration for blood and CSF, followed by administration of a test dose of 3 ml of 2% lignocaine with adrenaline. The patient was positioned supine on the operating table and vital parameters were monitored with 5-lead ECG, SPO2, NIBP, and HR. After about 5 minutes, 10 ml of 1% lignocaine with adrenaline with 1 mg of butorphanol injected via epidural catheter. After assessing the level of sensory block, the patient's position was changed to prone. A soft pillow was kept under his chest to make the surgical area prominent and one head ring under the forehead to keep the head in a fixed position. Oxygen was given by nasal cannula at the rate of 2 L/min. All emergency equipment were kept ready to handle any emergency. The surgery lasted for one hour and intraoperative period was uneventful. The patient's vitals were maintained during the intraoperative period [Table 1]. The patient was awake and comfortable during the entire intraoperative and postoperative period [Figure 2.]

Figure 1

Cervical epidural catheter placement at the C7-T1 level

Table 1

Intraoperative vital parameters of the patient

Figure 2

Patient sitting comfortably in postoperative ward

No significant decrease was observed in systolic and diastolic blood pressure from the baseline values. Although there was a slight decrease in systolic blood pressure, diastolic blood pressure, and heart rate, none of the patients required therapeutic intervention. The lowest mean blood pressure was 82 mm Hg at 5 minutes and the lowest heart was 62/ min at 60 minutes, which was acceptable. Oxygen saturation remained in the range of 95-99%.

DISCUSSION

The study found that CEA is a safe and effective alternative to general anesthesia during excision of tumors in the region of neck. Although we chose this technique due to the patient's refusal to general anesthesia, our experience with this technique was encouraging. The patient not only remained awake and comfortable throughout the procedure, but also maintained vital parameters. There was no significant fall in systolic and diastolic blood pressure and heart rate so as to require therapeutic intervention. Our findings were comparable to those by Singh-- et al.,[3] who evaluated the safety and efficacy of CEA in 55 patients undergoing modified radical mastectomy. They found no clinically significant variations in per-operative pulse and respiratory rate; there was no fall in mean arterial blood pressure during the procedure. The authors concluded that CEA is a safe alternative to general anesthesia.

However, contradicting results were seen in the study of Domínguez et al.,[4] who reported three patients scheduled for shoulder surgery under CEA with 0.75% ropivacaine. They found that the extent of blockade to the upper thoracic sensory segments causes a total or partial sympathetic block with decreased HR, blood pressure, and cardiac output.

Bonnet et al.[5] reported carotid surgery under CEA in 394 patients by using 15 ml of 0.5 per cent bupivacaine or 0.37-0.40 per cent bupivacaine plus fentanyl (50-100 μg).They found an effective sensory blockade from C2 to T4-T8. Patients were awake during the surgical procedure in comfortable condition. In their study, hypotension and bradycardia were the most frequent side effects of CEA. They concluded that carotid artery surgery may be performed under CEA, but hemodynamic variables should be monitored and managed closely during the procedure.

In a retrospective study, Hakl et al.[6] compared the Cervical Plexus Block (CPB) and Cervical Epidural (CE) for carotid endarterectomy in 1,455 patients. They administered 20 ml drug consisting of 16 ml of bupivacaine 0.5% and 4 ml (20 μg) of sufentanil. They encountered 13 cases of accidental subarachnoid injection with CEA, but did not find any clinically significant respiratory distress.

From our study and other documentary evidences, we conclude that CEA is a safe and effective alternative to general anesthesia for neck surgery. The advantage of this technique is that it provides all benefits of regional anesthesia. Although in our study we did not encounter any episode of significant bradycardia or hypotension, caution must be maintained while performing such block. We strongly recommend that the vitals of patients should be closely and continuously monitored throughout the intraoperative and postoperative period.