Thoracic segmental spinal anaesthesia for scapular fracture: Facts versus exaggerations!!

Dear Editor,

We read with interest the case report by Dharamkhele et al.[1] The literature on appropriate anaesthetic management plans for scapular surgeries is sparse.[2] While most of the undisplaced injuries are managed conservatively, the displaced fractures, like “floating shoulders”, need surgical correction, requiring significant tissue exploration. The scapula, as a part of the shoulder girdle, is well supported and protected by muscles and ligaments, which, along with their extensive innervation, make perioperative pain management extremely challenging.

We congratulate the authors on the successful management of the surgical correction of a case of floating shoulder under thoracic segmental spinal anaesthesia (TSSA); however, several concerns warrant discussion. First, the authors should mention the extent of surgical incision as it included correction of clavicle as well as scapular fractures. The complex innervation of the scapula needed to be briefly mentioned.[3] The dermatomal supply of scapula is from superficial cervical plexus (C3, C4), brachial plexus (C5, C6), and medial branches of dorsal rami of spinal nerves (C4–T6). The muscles and joints of this region are innervated mainly by brachial plexus (C5–C8) with trapezius being supplied by spinal accessory nerve (Cranial nerve XI). So, to provide surgical plane anaesthesia, C3–T6 dermatomes need to be covered. There is an inconsistency in the reported sensory block levels as the authors mentioned the sensory coverage was from C5 to T7, which is unlikely to cover for both clavicle and scapula. Third, the authors described a sensory block from C5 to T7 following injection at T4–T5, yet they attributed the procedure’s success to “appropriate dermatomal coverage (C3–T6)”. It remains unclear how coverage extended cephalad to C3–C4 as isobaric solutions typically exhibit limited and unpredictable spread in the thoracic region, particularly in the seated position. Even if that is the case, achieving such a cranial level of C3 till T7 by TSSA alone would increase the possibility of hypotension and bradycardia. Fourth, drug dosing lacks critical specificity. The report mentions 1.4 mL of isobaric levobupivacaine without indicating concentration. This omission hinders reproducibility and evaluation of dose adequacy. Fifth, safety concerns in TSSA for non-high-risk cases are usually understated. While the report cites an MRI study on dura-to-cord distances to mitigate puncture risks,[4] thoracic injections above the cord termination carry inherent dangers of direct spinal cord trauma, transient or permanent neurological deficits, and other complications like epidural hematoma or anterior spinal artery syndrome. Further, the remarkable 48-hour analgesia without any analgesic request was attributed to dexmedetomidine, which should have been substantiated by quantitative scoring (e.g., VAS), as typical extensions in analgesia mentioned are ≤24 hours.[5]

Presentation at conferences/CMEs and abstract publication

None.

Study data availability

Not applicable.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.

Authors contributions

R was involved in concept, literature search, preparation of original draft and editing of final draft AR was involved in literature search and editing of final draft.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.