Ankylosing spondylitis: lateral approach to spinal anaesthesia for lower limb surgery

Combined Fascia Iliaca and Sciatic Nerve Block for Hip Surgery in the Presence of Severe Ankylosing Spondylitis: A Case-Based Literature Review

BACKGROUND AND OBJECTIVES

Selecting an appropriate anesthetic technique for patients with ankylosing spondylitis undergoing hip surgery is challenging because of a potentially difficult airway, the risk of cardiovascular and respiratory complications, and the technical difficulty of performing central neuraxial blocks in patients with ankylosing spondylitis. Our objective was to report a case in which combination neural blockade was used successfully in an elderly patient with ankylosing spondylitis undergoing hip fracture surgery. In addition, a literature review of the anesthetic techniques reported for these patients was conducted.

CASE REPORT

A 70-year-old man with severe ankylosing spondylitis and respiratory dysfunction was scheduled for a closed intertrochanteric fracture reduction and internal fixation. Combined fascia iliaca block and parasacral sciatic nerve block were used successfully for the surgery. Postoperative analgesia was accomplished by continuous fascia iliaca block.

CONCLUSIONS

According to the literature review, general anesthesia is the most commonly performed anesthetic technique for patients with ankylosing spondylitis undergoing hip surgeries. Special intubation techniques and cautious airway management were very important for these patients. Although both general anesthesia and central neuraxial blockade pose considerable risks to the patients, this case report suggests that combined fascia iliaca block and sciatic nerve block might be a promising option.

Fluoroscopy guided transforaminal epidural anesthesia in ankylosing spondylitis

A 48-year-old male patient with a long-standing history of ankylosing spondylitis (AS) presented for ureteroscopic stone removal. On preoperative assessment, tracheal intubation was likely to be difficult due to decreased cervical spine mobility. Traditional neuraxial block was impossible due to the fusion of vertebral bodies. AS patients present the most serious array of intubation, which is secondary to decrease in cervical spine mobility and possible temporomandibular joint disease. Management of a case of AS can be very challenging when the airway and the central neuraxial blockade, both are difficult. Fluoroscopic assisted central neuraxial blockade may lead to predictable success in AS. We present a case report with severe AS where conventional techniques failed and C-arm assisted helped in successful epidural anesthesia for ureteroscopic stone removal.

Spinal anesthesia using Taylor's approach helps avoid general anesthesia in short stature asthmatic patient

The case history of a 35-year-old female patient with short stature is presented. She was posted for rectopexy in view of rectal prolapse. She was a known case of bronchial asthma. She had crowding of intervertebral spaces, which made administration of spinal anesthesia via the normal route very difficult. Taylor's approach for administration of the same was tried and proved successful, thus saving the patient from receiving general anesthesia in the presence of bronchial asthma, for a perineal surgery. The possible cause for the difficulty in administration of spinal anesthesia and the Taylor's approach are discussed, and reports of similar cases reviewed.

Subarachnoid block with Taylor's approach for surgery of lower half of the body and lower limbs: A clinical teaching study

BACKGROUND

Subarachnoid anesthesia is used as the sole anesthetic technique for below umbilical surgeries, but patients with deformed spine represent technical difficulty for its establishment. This study was aimed to find out whether training of Taylor's approach to residents on normal spine is beneficial for establishing subarachnoid block in patients with deformed spine.

MATERIALS AND METHODS

The total of 174 patients of ASA I-III with normal and deformed spine of both genders scheduled for below umbilical surgeries under the subarachnoid block and met the inclusion criteria, were enrolled for this two-phased clinical teaching study. All participating residents have performed more than 100 subarachnoid block with the median and paramedian approach. Residents were randomized into two equal groups. During the first phase program, Group I was taught Taylor's approach by hands on method for the subarachnoid block while Group II kept on observation for the technique. During the second phase of program, Group II was also taught Taylor's approach for establishing the subarachnoid block. Block success was defined according to clinical efficacy.

RESULTS

The results of teaching of Taylor's approach were encouraging. Initially, the residents faced difficulty for establishing the subarachnoid block in deformed spine but after learning by observation and practical hands on, both groups had successfully performed the subarachnoid block by Taylor's approach in one or more attempts in patient with deformed spine with the acceptable failure rate of 15%.

CONCLUSION

Taylor's approach for establishing subarachnoid block in deformed spine should be taught to residents on normal spine.

Respiratory Diseases

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Pulmonary arteriovenous fistulas have congenital and hereditary etiology, and patients are at risk for life-threatening rupture requiring surgery.

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Wegener's granulomatosis can affect any organ system, although renal and pulmonary involvement is most common; men ages 40 to 50 are at increased risk.

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Lymphomatoid granulomatosis affects cardiopulmonary, neurologic, and myeloproliferative systems; may result from opportunistic infection, and frequently progresses to lymphoma; men age 50 to 60 are at increased risk. Spontaneous remission occurs in some cases; mortality is 60% to 90% at 5 years.

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Churg-Strauss syndrome is usually associated with long-standing asthma, with men and women affected equally, and can affect any organ system; major cause of death is cardiac related.

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Primary pulmonary hypertension is a diagnosis of exclusion; women are affected twice as likely as men; right-to-left shunt may occur in 30%, secondary to patent foramen ovale; hypoxia with resultant heart failure is typical cause of death.

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Cystic fibrosis is an autosomal recessive disease, eventually fatal, with increased risk for airway obstruction, fluctuating pulmonary function, and chronic hypoxia; risk for spontaneous pneumothorax is 20%.

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Bronchiolitis obliterans organizing pneumonia is a pulmonary obstructive disease that may be reversible and usually resolves spontaneously.

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Idiopathic pulmonary hemosiderosis is associated with autoimmune disorders; patients have recurrent hemorrhage, pulmonary fibrosis, restrictive lung disease, and pulmonary hypertension, with some cases of spontaneous remission.

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Chronic eosinophilic pneumonia may be preceded by adult-onset asthma; women are at increased risk; prognosis is good.

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Goodpasture's syndrome is a genetic autoimmune disorder involving the pulmonary and renal systems.

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Pulmonary alveolar proteinosis, a lipoprotein-rich accumulation in alveoli, has three forms: congenital, decreased alveolar macrophage activity, and idiopathic; some cases of spontaneous remission occur.

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Sarcoidosis may affect any organ system; African American, northern European, and females are at greater risk; many patients are asymptomatic.

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Systemic lupus erythematosus may affect any organ system; women of childbearing age are at increased risk.

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Idiopathic pulmonary fibrosis is a rare interstitial lung disease, with smokers at increased risk for pulmonary malignancy; survival is usually 2 to 3 years from diagnosis; no effective treatment exists, with lung transplant the only therapeutic option.

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Acute respiratory distress syndrome (ARDS) is associated with underlying critical illness or injury, developing acutely in 1 to 2 days; mortality is 25% to 35%.

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Pulmonary histiocytosis X is an interstitial lung disease associated with cigarette smoking and an unpredictable course; some spontaneous remission occurs.

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Lymphangioleiomyomatosis involves progressive deterioration of lung function, associated with tuberous sclerosis and exacerbated by pregnancy, with women at increased risk; possible spontaneous pneumothorax and chylothorax; death usually results from respiratory failure.

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Ankylosing spondylitis is a genetic inflammatory process resulting in fusion of axial skeleton and spinal deformities, with men at increased risk; radiologic bamboo spine, sacral to cervical progression, and restrictive lung disease with high reliance on diaphragm; extraskeletal manifestations may occur.

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Kyphosis (exaggerated anterior flexion) and scoliosis (lateral rotational deformity) are spinal/rib cage deformities with idiopathic, congenital, or neuromuscular etiology; corrective surgery done if Cobb thoracic angle >50% lumbar angle >40%.

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Bleomycin is an antineoplastic antibiotic used in combination chemotherapy, with no myelosuppressive effect; toxicity can cause life-threatening pulmonary fibrosis.

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Influenza A is highly infectious, presenting with flulike symptoms and possible progression to ARDS; human-to-human exposure is through droplets or contaminated surfaces, with high risk for infants, children, pregnancy, chronically ill, or renal replacement therapy patients. No prophylactic treatment exists; treat patients with high index of suspicion without definitive testing; rRT-PCR and viral cultures are sensitive for pandemic H1N1 strain.

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Severe acute respiratory syndrome (SARS) is highly infectious, transmitted by coronavirus with human-to-human exposure via droplets or surfaces, and may progress to ARDS.

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Echinococcal disease of lung is from canine tapeworm, transmitted by eggs from feces; rupture of cyst may result in anaphylactic reaction or spread of disease to other organs; children are at increased risk. No transthoracic needle aspiration is done; surgery is only option.

Taylor's approach in an ankylosing spondylitis patient posted for percutaneous nephrolithotomy: A challenge for anesthesiologists

We describe a patient with long-standing ankylosing spondylitis who underwent percutaneous nephrolithotomy under spinal anesthesia. At preoperative assessment, it was considered that intubation of the trachea was likely to be difficult. Fiberoptic bronchoscopy was attempted, but without success. As the standard technique for spinal anesthesia failed, a variation of the paramedian approach in the lumbosacral approach, also known as Taylor's approach was successfully attempted. This resulted in adequate sensory and motor blockade for the surgical procedure. The patient did not require airway interventions, but equipment and aids to secure airway were available.

Anaesthetic management of a vaginal hysterectomy case with an unanticipated failure of epidural injection due to fused lumbar spine

Epidural anesthesia is one of the easier and safer techniques for lower abdominal surgery. It has a very high success rate in the experienced hands, and failure rates are minimal when it is administered by the experienced anesthesiologists. As it is a blind technique, failures can be encountered even by a senior anesthesiologist in many situations and one must analyze retrospectively the various causes responsible for such failures. We report a case of 45-year-old female, weighing 60 kg, who was scheduled for elective vaginal hysterectomy under regional anesthesia. Initial four to five attempts were unsuccessful in establishing the epidural block as the epidural injection encountered bony resistance each time, but subarachnoid block could be achieved with a 23 G spinal needle in the paramedian site of entry in the third attempt. Postoperatively, lumbar and cervical spine X-rays were done which revealed an isolated lumbar spine bony fusion. She was diagnosed as a rare case of isolated lumbar spine fusion without any involvement of cervical spine, other articular joints or any systemic manifestations of diseases like ankylosing spondylitis.

Case report: Spinal anesthesia by mini-laminotomy for a patient with ankylosing spondylitis who was difficult to anesthetize

BACKGROUND

Orthopaedic surgeons frequently encounter patients with ankylosing spondylitis who would benefit from various types of lower limb operations; however, some of these patients present challenges for anesthesiologists.

CASE DESCRIPTION

We report the case of a 65-year-old patient with a fractured femoral component 30 years after a cemented THA. The patient had severe tracheal stenosis and ankylosing spondylitis making general endotracheal and conventional neuraxial anesthesia nearly impossible.

LITERATURE REVIEW

Possible alternative anesthetic approaches described in the literature include awake fiberoptic bronchoscopic guided intubation, laryngeal mask airway, and caudal anesthesia.

PURPOSES AND CLINICAL RELEVANCE

We achieved successful anesthesia using spinal laminotomy with the patient under local anesthesia followed by insertion of a spinal catheter and injection of an anesthetic agent. The loosened component was revised to a cementless THA.

LATERAL APPROACH : A BETTER TECHNIQUE FOR SPINAL ANAESTHESIA IN THE MODERN ERA

The most commonly used technique in routine spinal anaesthesia practice is the midline approach, compared to the lateral or paramedian approach. With the better understanding of the technique and introduction of fine gauge spinal needles, this practice needs a rethinking. Lateral approach was used in 60 patients undergoing different surgical procedures below the umbilicus, using 24 or 25 gauge, Quincke spinal needle without an introducer. The result was gratifying. In 77% of the cases the subarachnoid space could be entered in the first attempt. There was no failure. No patient complained of postdural puncture headache or post operative backache. Only one patient reported paraesthesia during needle placement without any residual effect. Various other advantages of the technique are discussed. Thus with due practice, lateral approach is found to be superior in modern day spinal anaesthesia.

Massive bleeding during spine surgery in a patient with ankylosing spondylitis

PURPOSE

Ankylosing spondylitis is associated with pathophysiology that has important anaesthetic implications. We report a case where the sequelae of ankylosing spondylitis may have been responsible for massive bleeding during emergency spine surgery.

CLINICAL FEATURES

A 69 yr old man with long standing ankylosing spondylitis sustained a complex fracture of the lumbar spine in a fall, and was scheduled for stabilization of the spine. Under general anaesthesia, prone positioning was difficult because of the extreme spinal deformity. During exploration, dilatation of epidural veins was encountered and sustained haemorrhage was encountered throughout the surgical procedure. Estimated blood loss was 17,000 ml which was replaced with 31 units of packed red blood cells, 3200 ml of salvaged blood, 18 units of fresh frozen plasma, 26 units of platelets, 1,000 ml of albumin and 9,000 ml of crystalloid.

CONCLUSIONS

Extreme deformity of the spine led to positioning difficulties that may have contributed to massive blood loss during complex spine surgery. Difficulties with placement in the prone position in-patients with advanced ankylosing spondylitis should be anticipated.

Ankylosing spondylitis and neuraxial anaesthesia--a 10 year review

PURPOSE

Ankylosing Spondylitis (AS) patients present specific challenges to the anaesthetist. Both airway management and neuraxial access may prove to be difficult. The trend has been to deal with the airway challenge, and avoid neuraxial anaesthesia. In many cases this may lead to unnecessarily denying the patient neuraxial anesthesia (NA). We retrospectively reviewed the operative anaesthetic management of 51 consecutive AS patients who underwent 82 perineal or lower limb procedures and concurrent anaesthetic management at the Vancouver Hospital and Health Sciences Center from 1984 through 1994 (inclusive).

SOURCE

Anaesthetic records were used to document the type of anaesthetic used, i.e., general or regional, and the degree of difficulty experienced with each.

PRINCIPAL FINDINGS

Of the 82 procedures performed on AS patients 16 (19.5%) were planned as NA. General anaesthesia (GA) was planned for 65 (79.3%) of the procedures. One procedure involved monitored anaesthetic care (MAC). Neuraxial access consisted of 13 spinal and three epidural attempts. Spinal anaesthesia was possible in 10 (76.2%) of cases and failed in 3 (23.8%). Epidural anaesthesia was unsuccessful in each attempt. There was no difference in demographics or duration of disease between the successes and failures.

CONCLUSIONS

These data suggest that spinal anaesthesia can be used as an alternative to general anaesthesia in AS patients undergoing perineal or lower limb surgery. There were no factors identified in this review that were predictive of success or failure in gaining neuraxial access.