Thoracic Segmental Spinal Anesthesia for Bullectomy in a Patient With Severe Pulmonary Compromise: A Case Report.

Background: Thoracic surgery is conventionally performed under general anesthesia with one-lung ventilation. However, this approach may pose considerable perioperative risks in selected patients with advanced pulmonary disease and significant medical comorbidities. Thoracic segmental spinal anesthesia (TSSA), combined with adjunctive regional techniques, has emerged as a potential alternative in carefully selected high-risk patients undergoing nonintubated thoracic surgery [1-3]. Presentation: A 76-year-old man with spontaneous left-sided pneumothorax, persistent air leak despite chest tube drainage and two autologous blood patch pleurodesis attempts, resolving pneumonia, cerebellar atrophy, parkinsonian tremor, and anterior fascicular block was referred for surgical management. His respiratory reserve was severely compromised, with oxygen saturation decreasing to 72% before admission and persistent oxygen dependence despite chest drainage [1,2]. Pulmonary function testing could not be performed because of his clinical condition. Following multidisciplinary discussion, conventional general anesthesia with one-lung ventilation was considered to carry a substantial perioperative respiratory risk. The patient subsequently underwent awake video-assisted thoracoscopic surgery (VATS) under low-dose TSSA at the T5-T6 interspace using 6 mg isobaric bupivacaine, combined with an ultrasound-guided cervical vagus nerve block using 4 mL of 1% lidocaine to suppress the intraoperative cough reflex. The patient remained awake, maintained spontaneous ventilation throughout surgery, demonstrated stable hemodynamics, and required no conversion to general anesthesia. Wedge resection of a giant pulmonary bulla and mechanical pleurodesis were completed successfully without intraoperative complications. Postoperatively, lung re-expansion was achieved, the persistent air leak resolved, and the patient recovered without neurological complications, postdural puncture headache, urinary retention, dysphagia, hoarseness, or respiratory deterioration. He was discharged home on postoperative day two in stable condition. Conclusion: This case illustrates that TSSA combined with ultrasound-guided vagus nerve block may represent a feasible anesthetic option for carefully selected high-risk patients undergoing awake thoracoscopic surgery when conventional general anesthesia is considered undesirable. Larger prospective studies are required to further evaluate the safety, efficacy, and patient selection criteria for this approach [2,3].