Modified Taylor’s approach: An archaic technique or aider in adversity?

Dear Editor,

Spinal anesthesia or subarachnoid block (SAB) is a safe, effective, and widely performed technique for lower limb orthopedic procedures. Taylor’s approach, described more than seven decades ago, is a modified lateral or paramedian SAB technique used when the traditional midline approach is challenging.[1] The reason for writing this letter is to reinforce the importance of the modified Taylor’s approach in the current practice of trauma anesthesia.

A 65-year-old lady (body mass index of 25.5 kg/m²) of American Society of Anesthesiologists (ASA) physical grade II was admitted with an alleged history of fall from height over concrete floor and sustained an injury to left lower back and left leg. She was on regular medications for hypertension and type 2 diabetes mellitus. In pre-anesthetic evaluation, an abrasion over the skin and a swelling were noted near the left lumbar region, crossing the midline and extending towards the right side [Figure 1a]. Radiological investigations revealed comminuted fractures of the distal third of the tibia and fibula without any evidence of lumbosacral (LS) spine or abdominal organ injury [Figure 1b–d]. Laboratory investigations were also unremarkable. She was scheduled for open reduction and internal fixation with intramedullary nailing of the left tibia [Figure 1e]. Considering her age, comorbidities, refusal of general anesthesia (GA), and the extent of hematoma, we decided to perform a right-sided modified Taylor’s approach of SAB. The procedure was explained, and written informed consent was obtained for anesthesia and publication of this letter.

Figure 1.

(a) Abrasion over left lower back and hematoma (yellow arrow) extending towards the right side. (b) X-ray leg (lateral view) showing lower one-third of both bone fractures. (c) X-ray pelvis and LS spine (anteroposterior view). (d) X-ray LS spine (lateral view). (e) Postoperative X-ray of the left leg (lateral view) with tibia intramedullary nail in situ. (f) Landmarks corresponds to the modified Taylor’s approach. (g) Free flow of cerebrospinal fluid (CSF). (h) Administration of local anesthetic

Standard monitors were attached in the operating room, and intravenous access was secured. The patient was placed in a sitting position with the back straight. The needle entry point was determined using the preoperative LS spine skiagram [Figure 1c and 1d] and preprocedural ultrasound scan. Local infiltration with 2 ml of 2% lignocaine was administered at 1.5 cm caudal and 1.5 cm medial to the right posterior superior iliac spine (PSIS) [Figure 1f]. A 25-G Quincke’s spinal needle (Spinocan, B. Braun Medical Industries Sdn. Bhd., Malaysia) was inserted and advanced in the cephalomedial and anterior direction, targeting the L5–S1 interlaminar space. The stylet was withdrawn on a feeling of loss of resistance, and free flow of clear CSF was observed at the needle hub [Figure 1g]. After positive aspiration of CSF into the syringe, 2.5 ml of 0.5% hyperbaric bupivacaine (Anawin heavy, Neon Laboratories Ltd., Mumbai) was injected intrathecally [Figure 1h]. The patient was placed in supine position immediately after the procedure. Surgery was commenced once the sensory level was up to T10 and the motor block was complete (grade 3 on the modified Bromage scale, i.e. unable to move the feet or knee). The rest of the intraoperative and postoperative course was uneventful.

Taylor’s approach has been reported as an alternative to standard midline SAB or GA in patients with achondroplasia, ankylosing spondylitis, kyphoscoliosis, and prior spine instrumentation surgery.[2–5] Anatomical landmarks, LS spine skiagram, fluoroscopy, and ultrasound have also been used in various clinical settings for guidance while performing the modified Taylor’s approach. Although there was no obvious deformity or injury to the LS spine, the lumbar spinous process was barely palpable because of the hematoma. It was probably superficial to the posterior layer of the thoracolumbar fascia as it was extended beyond the midline. Hence, access to the interspinous area and, subsequently, the subarachnoid space was challenging. Even though we could identify the midline with ultrasound, passing the spinal needle through the hematoma could spread the infection to the epidural or subarachnoid spaces. The success of Taylor’s approach was aided by easily palpable PSIS and the absence of spinal deformity. Thus, we could avoid polypharmacy and possible complications associated with GA. Ultrasound helped us to identify the soft tissue window into the vertebral canal and to determine the needle trajectory. Thus, it reduced the number of attempts and increased the probability of success of SAB.

To conclude, the modified Taylor’s approach can be an excellent technique for lower limb surgeries in trauma patients with involvement of soft tissue structures close to the midline in the lumbar area, even without any anatomically or technically challenging spines.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.