CASE REPORT |
https://doi.org/10.5005/jp-journals-10045-00209 |
A Case of a Dwarf Patient with Kyphoscoliosis with Severe Restrictive Airway Disease for Bilateral Tibia Nailing under Ultrasound-guided Spinal Anesthesia
Department of Anesthesiology, K.E.M. Hospital Research Centre, Pune, Maharashtra, India
Corresponding Author: Rashmi Laxman Deshmukh, Department of Anesthesiology, K.E.M. Hospital Research Centre, Pune, Maharashtra, India, Phone: +91 9764440563, e-mail: walimberashmi@yahoo.com
Received on: 23 May 2022; Accepted on: 08 September 2022; Published on: 16 December 2022
ABSTRACT
Thoracolumbar kyphoscoliosis provides a very challenging situation for anesthesiologists because of the changed anatomy and related cardiopulmonary changes in the patient. The spread of drugs and the action of neuraxial anesthesia are erratic in these patients. If short stature is added with a history of failed spinal anesthesia in a different setup, planning anesthesia becomes even more difficult. At such times ultrasonography comes as a boon for visualizing the spine and assists in deciding the site for puncture for spinal anesthesia for a successful intrathecal tap and placement of drug.
How to cite this article: Deshmukh RL. A Case of a Dwarf Patient with Kyphoscoliosis with Severe Restrictive Airway Disease for Bilateral Tibia Nailing under Ultrasound-guided Spinal Anesthesia. J Med Sci 2021;7(4):50-52.
Source of support: Nil
Conflict of interest: None
Keywords: Anesthesia, Dwarf, Kyphoscoliosis, Ultrasound guidance
INTRODUCTION
Kyphoscoliosis is defined as a deviation of the normal curvature of the spine in the sagittal and coronal planes and can include a rotation of the spinal axis.1 Moderate kyphoscoliosis is a Cobb angle ranging from 25 to 100°, whereas severe kyphoscoliosis is a Cobb angle >100°. Etiology includes idiopathic, secondary (degenerative, inflammatory, post-traumatic, and neuromuscular disorders or connective tissue disorders) congenital causes.
Ultrasonography has emerged as a reliable guide for regional and neuraxial anesthesia in the last decade for preprocedural as well as real-time use.
CASE DESCRIPTION
Our patient is an 18-year-old female with a known case of fibrous dysplasia and kyphoscoliosis since childhood. She has walked using crutches for 8–10 years. She has a history of a fall 1 week back with a bilateral tibia midshaft fracture for which surgery was contemplated at a small hospital in a nearby town. Spinal anesthesia failed even after trying for 1 hour, and the surgery was canceled. The patient shifted to our hospital, which is a tertiary care center. Femur nailing was done 8 years back under spinal anesthesia, no details are available.
On examination, the patient was conscious, oriented, afebrile, height 104 cm, weight 21 kg, no pallor, icterus, clubbing, and cyanosis. The airway was malampatti classification (MPC) grade I, mouth opening adequate, breath holding time 10 seconds, single breath count was around 8–10, oxygen saturation of the arterial blood (SaO2) 93% on air. Pulmonary function tests were not done as the patient was admitted during the second wave of COVID-19. The patient is assumed to be having severe restrictive airway disease. Her spine had thoracolumbar kyphoscoliosis, so she could not lie flat. Multiple puncture marks were seen in the lumbar region.
Respiratory system: Air entry bilaterally equal, no adventitious sounds.
Cardiovascular system: S1 and S2 normal, no murmurs.
Central nervous system: Higher functions normal. The patient cannot walk due to her fracture, no obvious sensory deficit.
Investigations: Blood investigations are normal.
Electrocardiogram (ECG) and two-dimensional echocardiogram were normal.
Chest X-ray showed kyphoscoliosis with Cobb’s angle of 65°, right hypoplastic lung.
Challenges for Anesthesia
-
Difficult spine.
-
Short stature.
-
The patient cannot lie in a supine position.
-
Severe restrictive lung disease.
Anesthesia Management
A 20 G intravenous (IV) line was taken in the operation theater as the veins were very thin and Ringer’s lactate was started. All emergency resuscitation equipment and accessories for administering general anesthesia were kept ready if required.
In a sitting position, a lumbar spine preprocedural scan was performed with ultrasonography. Paramedian sagittal view and transverse interlaminar view were used. A linear probe was used as the patient was very thin built. Best space found was L2-L3 and the point of insertion of the spinal needle was marked.
Under aseptic precautions, spinal anesthesia was given using a paramedian approach. A 26 G Quincke spinal needle was used. Cerebrospinal fluid was aspirated in the first attempt at 2 cm from the skin. A total of 0.5% bupivacaine heavy 2.6 mL + clonidine 10 µg (0.5 µg/kg) was given. The patient was made semi-recumbent, and the spine was supported with pillows. T10 level was achieved.
Pulse, SaO2, noninvasive blood pressure, and ECG were monitored. Foley’s catheterization was done. Surgery was done using a tourniquet. Vital parameters were stable throughout. Blood loss was minimal. IV fluids total of 1200 mL of Ringer’s lactate was given. The duration of the surgery was 3 hours. Urine output was 300 mL.
For postoperative analgesia, bilateral adductor canal and popliteal blocks were given using bupivacaine 0.125% 7 mL and 12 mL volume, respectively, and dexamethasone 4 mg as an additive, under ultrasonography guidance. Total bupivacaine administered was 47.5 mg in blocks and 13 mg in intrathecal space, which is well below the toxic dose. A linear probe and 50 mm nerve stimulator needle was used.
Postoperatively, the patient was conscious, cooperative, and had stable vitals. She was monitored in recovery for 3 hours. The spinal level receded by more than four segments. The visual analog scale score was 0/10 (Figs 1A to C and 2).
Figs 1A to C: Ultrasound imaging of the spine of the patient
Fig. 2: X-ray spine Cobb’s angle
CONCLUSION
Hence, to conclude, neuraxial anesthesia can be successfully administered in kyphoscoliotic patients with short stature using ultrasonography guidance.
CLINICAL SIGNIFICANCE
It was decided to anesthetize this patient with spinal anesthesia, considering the higher risk for general anesthesia in view of her severe restrictive airway disease and the COVID-19 pandemic. Misra et al.2 have discussed the efficacy of spinal anesthesia in kyphoscoliosis. Ultrasound proved to be a boon for our patient in localizing the subarachnoid space.3 The paramedian approach was preferred.4 Kim et al. have discussed the doses of intrathecal bupivacaine.5 General anesthesia6 was always a backup plan, and ventilation with lung protective strategy and postoperative ventilation, if required, were readily accessible.
ACKNOWLEDGMENT
I would like to thank my postgraduate residents and operating room staff for helping me with anesthesia care and ultrasound imaging.
ORCID
Rashmi Laxman Deshmukh https://orcid.org/0000-0003-2230-1499
REFERENCES
1. Papaliodis DN, Bonanni PG, Roberts TT, et al. Computer assisted Cobb angle measurements: a novel algorithm. Int J Spine Surg 2017;11(3):21. DOI: 10.14444/4021
2. Misra S, Shukla A, Rao KG. Subarachnoid block in kyphoscoliosis: a reliable technique? Med J DY Patil Univ 2016;9(6):761–764. DOI: 10.4103/0975-2870.194226
3. Ravi PR, Naik S, Joshi MC, et al. Real-time ultrasound-guided spinal anaesthesia vs pre-procedural ultrasound-guided spinal anaesthesia in obese patients. Indian J Anaesth 2021;65(5):356–361. DOI: 10.4103/ija.IJA_446_20
4. Kumari BG, Samantaray A, Kumar VA, et al. Spinal anaesthesia in poliomyelitis patients with scoliotic spine: a case control study. Indian J Anaesth 2013:57(2):145–149. DOI: 10.4103/0019-5049.111839
5. Kim J, Woodruff BC, Girshin M. Anesthetic considerations in patients with achondroplasia. Cureus 2021;13(6):e15832. DOI: 10.7759/cureus.15832
6. Mayhew JF, Katz J, Miner M, et al. Anaesthesia for the achondroplastic dwarf. Can Anaesth Soc J 1986;33(2):216–216. DOI: 10.1007/BF03010834
________________________
© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.