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CASE REPORT |
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Year : 2016 | Volume
: 9
| Issue : 6 | Page : 765-767 |
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Management of a case of ankylosing spondylitis for percutaneous nephrolithotomy in prone position under combined spinal epidural anesthesia
Preeti Rustagi, Geeta A Patkar, Bharati A Tendolkar
Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra, India
Date of Web Publication | 16-Nov-2016 |
Correspondence Address: Preeti Rustagi 602, Narayan Niwas CHS, Twinkle Star Society, Chembur, Mumbai - 400 071, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.194228
Management of a case of ankylosing spondylitis (AS) can be very challenging where airway and central neuraxial blockade, both are difficult. Surgical positioning under anesthesia in these patients is also demanding due to risk of iatrogenic fractures and spinal cord trauma. We present a case of AS for percutaneous nephrolithotomy in prone position performed under combined spinal epidural anesthesia successfully. Regional anesthesia gave us the advantage of having an awake patient who could maintain his head and neck posture thereby minimizing the risk of any neurological deterioration while positioning.
Keywords: Ankylosing spondylitis, central neuraxial blockade, percutaneous nephrolithotomy, prone position
How to cite this article: Rustagi P, Patkar GA, Tendolkar BA. Management of a case of ankylosing spondylitis for percutaneous nephrolithotomy in prone position under combined spinal epidural anesthesia. Med J DY Patil Univ 2016;9:765-7 |
Introduction | | |
Ankylosing spondylitis (AS), chronic inflammatory disease of the axial skeleton and peripheral joints, has always been a challenge to the anesthesiologist. [1] The fused spine leads to difficult airway and technical difficulties for establishing regional anesthesia. [2]
Surgeries like percutaneous nephrolithotomy (PCNL) that are usually done in prone position require special concerns in AS, due to the risk of iatrogenic fractures and spinal cord trauma during positioning. [3] Although most centers conduct PCNL under general anesthesia, regional anesthesia has been reported to be a safe alternative. [4]
We report a case of PCNL in a patient with thoracic kyphosis and fixed cervical spine due to AS performed under combined spinal epidural anesthesia highlighting the ease and safety of positioning with a conscious patient.
Case Report | | |
A 64-year-old male, known case of AS for last 30 years was listed for PCNL. He had severe thoracic kyphosis and immobile cervical spine with fixed right tilt [Figure 1]. The patient gave a history of using three pillows while lying down supine. | Figure 1: Patient with ankylosing spondylitis having thoracic, fixed cervical spine with right tilt
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The cardiac and respiratory systems were normal on examination. Pulmonary function tests were suggestive of mild restriction. Serum creatinine was 2 mg/dl. Rest hematological and biochemical parameters including coagulation profile were within normal limits. Although the mouth opening was >2.5 cm, the airway was anticipated to be difficult because of lack of any extension of the cervical spine.
A difficult airway cart was kept ready along with a flexible fibreoptic bronchoscope. Written informed consent was obtained for both general and regional anesthesia, and the patient was fasted adequately. The plan was to first attempt a combined epidural and spinal block and in the case of difficulty or failure, the alternative was a fibreoptic bronchoscope assisted awake intubation followed by general anesthesia.
After arrival in the operation theater, standard monitoring including electrocardiogram, SPO 2 , and blood pressure was done. A 18 G peripheral line was established and normal saline infusion started.
In sitting position, combined spinal epidural technique in L3-L4 vertebral interspace using midline approach was attempted. With single attempt epidural space could be identified and there was free flow of cerebrospinal fluid with insertion of spinal needle. Intrathecal injection of 2.5 ml of 0.5% heavy bupivacaine with 15 µg of fentanyl was given. Then, epidural catheter was inserted 5 cm cephalic and fixed. After making the patient supine, sensory block level was checked to be T6.
Retrograde pyelography performed in lithotomy position and patient was made comfortable with 2 pillows and one head ring [Figure 2]. The position of the patient was then changed to prone. Due to the arched spine, the cavity thus formed in the region starting from neck until the knees of the patient was filled soft pillows and cotton pads while communicating with the patient and ensuring his comfort [Figure 3]. | Figure 3: In prone position, patient could maintain his head and neck posture. The cavity in the region from neck to knees was filled with soft pillows and cotton pads
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After prone position, spinal block level was still T6. Procedure lasted for 1 h 30 min. Epidural supplementation of local anesthetic was not required. The patient was comfortable and vitally stable throughout. Surgeons were satisfied and there was a complete clearance of stone.
Discussion | | |
AS is classified as autoimmune spondyloarthropathy disorder, which affects joints and adjacent structures. The inflammatory process begins at sacroiliac joint, spreads cephalad to involve spine up to cervical level and costovertebral joints also. The fusion of vertebra leads to the appearance called as bamboo spine. [1] Resulting kyphosis, spinal rigidity, and secondary osteoporosis lead to changes in biomechanics of the spine.
It is indicated that stone disease has a higher incidence rate in AS patients. [5] PCNL is the treatment of choice for large renal calculi. It is usually performed in prone position under general anesthesia. However, studies have reported regional anesthesia to be a safe and equally effective alternative. [4],[6] There are only a few reports of PCNL in AS.
Skeletal changes of AS make administration of both general and regional anesthesia difficult. For general anesthesia, awake intubation with fibreoptic bronchoscope has been used successfully to secure the airway. [2]
Along with administration of anesthesia, giving prone position for surgery was our concern. The pathological posture along with the altered biomechanics puts the patients of AS at increased risk for iatrogenic fractures of the spine and neurological deterioration. Due to the rigid yet brittle spine, such risks are potentially increased not only during surgical manipulation but also during positioning within the operating room, especially while under sedation and anesthesia. [3] The cervicothoracic region of the spine being most vulnerable. [7]
Due to these concerns, we opted for regional anesthesia. Establishing regional anesthesia in ankylosed spine is challenging due to reduced articular mobility, obliteration of the inter-spinal spaces and impossibility to position the patient adequately. The use of ultrasound-guided central and peripheral nerve blocks has helped in achieving predictable success in these cases. [8]
A paramedian approach may be easier because of the midline ossification of the interspinous ligaments. Taylor's approach, a paramedian approach to L5-S1 interspace, may lead to better access in some cases, but both median and paramedian approach can be attempted with success. [9],[10] In our patient, we were able to give epidural and intrathecal block through median approach in the first attempt only.
Intrathecal spread of local anesthetic is unpredictable in cases with skeletal deformities. An epidural catheter was inserted with the purpose of supplementing the block in the case of insufficient spinal block or in the case of prolonged surgery, but it was not required.
With regional anesthesia we had the advantage of having an awake patient, who could maintain head and neck posture in prone position. With the help of soft pillows and cotton pads the pathological posture of ankylosed spine was maintained intraoperatively also thereby minimizing the chances of iatrogenic fractures and spinal cord trauma while positioning.
This case shows that in patients with chronic skeletal disease, regional anesthesia in the form of combined epidural spinal with an awake patient can be considered for surgeries requiring special positions, however, a case specific strategy should be formed.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References | | |
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8. | Goyal R, Singh S, Shukla RN, Singhal A. Management of a case of ankylosing spondylitis for total hip replacement surgery with the use of ultrasound-assisted central neuraxial blockade. Indian J Anaesth 2013;57:69-71. [ PUBMED] |
9. | Yoganarasimha.N, Shivaramu.BT. Management of ankylosing spondylitis case for ankle surgery under spinal anaesthesia by Taylor's approach. ISOR J Dent Med Sci 2014;13:60-2. |
10. | Schelew BL, Vaghadia H. Ankylosing spondylitis and neuraxial anaesthesia - A 10 year review. Can J Anaesth 1996;43:65-8. |
[Figure 1], [Figure 2], [Figure 3]
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