Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia

Background Spinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA), we developed a SA program to provide an alternative option. We present our initial experience with this program. Objective To implement a SA program at a large tertiary care pediatric center and assess the safety and efficacy of the technique as an alternative to GA for urologic surgery. Study design/methods We prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications. Results SA was attempted in 105 consecutive children (104 boys, 1 girl) with a mean age of 7.4 +/- 4.3 months (range 19 days -24 months) and mean weight of 8.3 +/- 1.7 kg (range 3.5-13.7). Placement of the SA was successful in 93/ 105 children (89%). Inability to achieve lumbar puncture (cerebrospinal fluid was not obtained) meant that SA was abandoned in seven (7%) patients and GA was administered. In five patients in whom SA was successful and surgery was begun, 5/ 93 (5%) required conversion to GA: two because of evisceration of intestine through large hernia defects related to coughing and abdominal irritation, two because of lack of motor blockade despite an adequate sensory block, and one because of an inability to place an intravenous catheter in the lower extremities (required per SA protocol). If necessary, an intravenous catheter can be placed in the upper extremity, but this must be weighed against the fact that the block has already been placed and is of limited duration. Overall, SA was successful (SA was placed and surgery was completed without conversion to GA) in 88/ 105 children (84%). No additional sedation and no systemic anesthetic agents were required in 75/ 88 children (85%). The average time required to place the SA was 3.8 +/- 2.7 min (range 1-12). The average time for the surgical procedure was 38.3 +/- 23.1 min (range 10-122). No patient required conversion to GA because of recession of block. There were no surgical complications. Discussion/conclusions SA is a safe and efficacious technique for routine pediatric urological procedures. SA should be considered for cases such as neonatal torsion or patients with significant cardiac or pulmonary comorbidities when the risks of GA are often weighed against the risks of non-intervention.