Thoracic Segmental Spinal Anesthesia: Advancing Sustainable Practices in Perioperative Care

Naresh Wamanrao Paliwal¹, Imran Ahmed Khan^2*

¹Department of Anesthesiology, Dr. Panjabrao Deshmukh Memorial Medical College, Amravati, Maharashtra, India

²Department of Community Medicine, KMC Medical College and Hospital, Maharjganj, UP, India

Abstract

The healthcare sector contributes substantially to global greenhouse gas emissions, with anesthetic practices representing a notable source due to the use of volatile anesthetic agents, high fresh gas flows, and disposable medical equipment. As healthcare systems increasingly strive to integrate sustainability into clinical practice, environmentally friendly anesthesia techniques have gained attention. Thoracic Segmental Spinal Anesthesia (TSSA) is an emerging regional anesthesia technique that provides targeted neuraxial blockade at thoracic levels and may serve as a sustainable alternative to general anesthesia (GA) in selected surgical procedures. By avoiding volatile anesthetics, agents with high global warming potential, TSSA has the potential to reduce direct greenhouse gas emissions associated with anesthesia delivery. Clinical literature has demonstrated the safety, feasibility, and effectiveness of TSSA in various surgical settings, with additional benefits including reduced drug requirements, faster recovery, and earlier patient mobilization. These factors suggest lower resource utilization and decreased environmental burden within operating theaters and post-anesthesia care units. However, TSSA is appropriate only for selected patients, requires advanced technical skill, and cannot broadly replace GA. TSSA therefore represents a promising strategy to advance both patient-centered care and environmentally sustainable perioperative practice pending further TSSA-specific environmental data and risk-mitigation validation.

The global healthcare sector is a significant contributor to greenhouse gas emissions, with anesthetic practices accounting for a disproportionate share due to the use of volatile agents, other medications, and single-use biomedical consumables¹. As the medical community increasingly aligns clinical practice with environmental safety, the carbon footprint of anesthetic techniques has gained considerable attention². While recent literature has extensively documented the safety and efficacy of Thoracic Segmental Spinal Anesthesia (TSSA), its potential for providing sustainable healthcare through green anesthesia deserves further exploration. Anesthesiologists should adopt practices that reduce environmental impact without compromising patient safety³. TSSA, a technique that provides targeted neuraxial blockade at thoracic levels, offers a compelling alternative to general anesthesia (GA) in selected surgical populations (e.g., upper abdominal open and laparoscopic procedures, superficial and thoracoscopic procedures, etc.)⁴. While the majority of the evidence with TSSA originates from India, it is now being explored in several parts of the world as evidenced by increasing publications especially post Covid-19. However, currently it lacks a wider adaptation globally.

A considerable portion of the environmental burden of GA is largely driven by volatile anesthetic gases such as desflurane, sevoflurane, and nitrous oxide. In a comparative carbon footprint study, mean carbon dioxide equivalents for GA were found to be 22,707 g versus 63 g for spinal anesthesia⁵. Desflurane has a global warming potential (GWP) of about 2,500 times that of carbon dioxide. Nitrous oxide is known to contribute both to climate change and ozone depletion⁶. High fresh gas flows used during GA further amplify emissions⁷. In addition, GA requires systemic drugs—opioids, sedatives, muscle relaxants, and antiemetics—which contribute to pharmaceutical waste and resource-intensive manufacturing. The cumulative environmental burden of GA underscores the need for greener alternatives.

In contrast, regional techniques such as TSSA generate a lower median footprint per procedure⁸. The transition from GA to TSSA eliminates the need for single-use airway devices, breathing circuits, and heat-moisture exchangers, thereby reducing biomedical waste. Unlike total intravenous anesthesia (TIVA), which requires larger volumes of propofol and opioids, TSSA utilizes minimal dosages of local anesthetics (LAs), reducing the risk of environmental contamination through hospital wastewater⁹. Segmental blockade of TSSA provides effective anesthesia and analgesia with minimal need for systemic opioids or sedatives, translating into lower pharmaceutical waste, decreased risk of drug-related side effects, and diminished environmental impact from drug production and disposal. Unlike GA, which requires mechanical ventilation and high oxygen flows, TSSA allows patients to breathe spontaneously without heavy breathing circuits. This reduces oxygen consumption, energy consumption, and waste production in operating theaters.

The safety and feasibility of TSSA in diverse surgical contexts has been demonstrated in various clinical studies. Imbelloni et al. reported on 1,406 patients undergoing TSSA without significant adverse outcomes, including neurological sequelae, highlighting its safety profile¹⁰. Literature supports the reduced drug requirements and faster recovery associated with TSSA¹¹. The segmental nature of TSSA facilitates faster ambulation and earlier discharge. This efficiency reduces the per-patient energy consumption of the Post-Anesthesia Care Unit (PACU), optimizing the hospital's operational carbon footprint. In the absence of direct comparative carbon-footprint analyses specific to TSSA, data from SA versus GA in other settings can be extrapolated to support the hypothesis that the technique could translate into meaningful environmental gains.

Despite these benefits, TSSA is not suitable for all patients or procedures and cannot replace GA broadly in current practice. The theoretical risk of spinal-cord injury may be perceived as unacceptable by patients when weighed against environmental gains. Adoption by anesthesiologists is further hindered by its perceived technical complexity, steep learning curve, need for precision (low-dose local anesthetic, optional imaging guidance), requirement for patient cooperation, and unsuitability for anxious, emergent, or certain comorbid cases (e.g., coagulopathy, spinal pathology)¹². Control of segmental level is not always straightforward and demands meticulous technique. To facilitate safe, wider implementation, a structured risk-evaluation framework such as Healthcare Failure Mode and Effect Analysis (HFMEA) combined with the Risk Assessment Code Matrix should be applied at each stage of the TSSA process. The broader adoption of TSSA be realistically pursued only when both clinicians and patients are confident that risks are controllable and within acceptable limits. Using high-fidelity simulation, ultrasound-guided phantom and cadaver workshops, video-based learning of landmark and imaging-guided techniques, and supervised conduction of cases in high-volume centers may offer a practical solution to overcome hesitation. Standardized credentialing pathways based on these approaches could accelerate safe dissemination¹³.

Healthcare systems worldwide are adopting sustainability frameworks. The World Health Organization has called for climate-resilient health systems, while the UK’s National Health Service has committed to achieving “Net Zero” emissions^14,15. TSSA may align with these initiatives by potentially reducing reliance on high-GWP anesthetics and systemic drugs. Its integration into routine anesthesia practice represents a practical step toward greener operating theaters.

Future Directions

To fully establish TSSA’s role in sustainable anesthesia, future research should quantify the carbon footprint reduction achieved by substituting GA with TSSA where applicable. Conducting life-cycle analyses of drug use, oxygen consumption, and hospital resource utilization and integrating sustainability metrics into electronic medical records allow anesthesiologists to see the real-time carbon footprint of their technique. Exploring surgeon- and patient-reported outcomes in the context of sustainability and developing training and credentialing models to ensure safe and widespread adoption will provide additional solid ground. Such evidence will strengthen the TSSA as both a clinical and ecological innovation. In particular, life-cycle analyses focused explicitly on TSSA rather than extrapolating from SA are urgently needed. We believe that the standardized TSSA training can mitigate the barriers, making green anesthesia a practical reality rather than a theoretical goal.

Conclusion

TSSA can provide clinical precision and potentially impact the environmental stewardship. By reducing systemic drug use, eliminating volatile anesthetics, and optimizing recovery, TSSA offers a promising pathway towards more sustainable perioperative care. Its adoption in suitable cases represents one possible step towards reduced environmental impact. Embracing TSSA is not only a clinical choice but also a commitment to planetary health provided that safety is assured through rigorous risk assessment (e.g., HFMEA), structured training, and TSSA-specific environmental studies. We urge colleagues to consider the environmental impact of their anesthetic choice as one important component of clinical excellence, never at the expense of patient safety.

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