Avoiding General Anesthesia in Achilles Lengthening

Spinal anesthesia has good results and avoids potential adverse effects of general anesthesia in infants undergoing TAL.

After concerns about potential neurotoxic risks of general anesthesia for young patients, surgeons and anesthesiologists at Nationwide Children’s Hospital developed a spinal anesthesia program in 2016. Early, proven success in urological surgeries suggested spinal anesthesia would be useful in other procedures performed below the umbilicus.   

A new case series from the Departments of Orthopaedics and Anesthesiology & Pain Medicine at Nationwide Children’s shows an expansion of the program has worked: spinal anesthesia is safe and effective for infants undergoing tendon Achilles lengthening – and perhaps other lower extremity orthopedic procedures.

“There are many reasons to consider spinal anesthesia for these children, even before you discuss neurotoxicity risks of general anesthesia,” says David P. Martin, MD, an anesthesiologist at Nationwide Children’s, coauthor of the case series and cofounder of the spinal anesthesia program. “There is a multifold decrease in operating room side effects with spinal, like hemodynamic instability and laryngospasm. We don’t have to intubate these children, and almost never even have to supply supplemental oxygen like we do in general.”   

The case series, published in Local and Regional Anesthesia, considered six infants: four were 2 months old, one was 10 weeks old, and one was 7 weeks old. The patients were typically injected with 1 mL of isobaric 0.5% bupivacaine with epinephrine 1:200,000 and 5µg of clonidine. The two youngest infants did not receive clonidine. Motor and sensory blocks were achieved within 60 seconds in all cases.

Each tendon Achilles lengthening procedure lasted between 30 and 35 minutes. There were no noted changes of vital signs during the procedure, no supplemental analgesic medications or sedations were needed during the procedures, and no patient needed postoperative analgesia during the immediate postoperative period.

“Except for patients with a bleeding disorder or a congenital spinal abnormality, I cannot think of a reason not to do use spinal anesthesia in this procedure,” says Dr. Martin.

Parents also like hearing from a surgeon that their child does not need to be fully put to sleep for such a short surgery, says Walter Samora, MD, an orthopedic surgeon at Nationwide Children’s and coauthor of the case series.

“While a TAL can be done as an office procedure without general anesthesia, it can be challenging for a surgeon when a child becomes upset,” he says. “Performing a TAL in an operating room under spinal anesthesia allows us to have the control of the OR while avoiding some of the possible problems of general anesthesia.”

Reference:
AlSuhebani M, Martin DP, Relland LM, Bhalla T, Beebe AC, Whitaker AT, Samora W, Tobias JD.  Spinal anesthesia instead of general anesthesia for infants undergoing tendon Achilles lengthening.Local and Regional Anesthesia. 2018 May 3; 11:25-29.