|Year : 2020 | Volume
| Issue : 3 | Page : 282-284
Subarachnoid block in a pediatric patient with severe kyphoscoliosis
Alka Chandra1, Sharda Jha1, Megha Agarwal1, Naresh Chandra2
1 Department of Anaesthesia and Critical Care, Hindurao Hospital and NDMC Medical College, New Delhi, India
2 Department of Orthopaedics, Guru Govind Singh Government Hospital, New Delhi, India
|Date of Submission||28-May-2019|
|Date of Decision||24-Sep-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||3-Jun-2020|
802, South Delhi Apt., Sector 4, Dwarka, New Delhi
Source of Support: None, Conflict of Interest: None
Anesthesia in pediatric patients with severe kyphoscoliosis presents a definite challenge to the anesthesiologists. Giving general anesthesia as well as regional anesthesia is quite tricky in such patients. Anesthesiologists must be prepared for general anesthesia even after giving subarachnoid blockade as chances of failure, patchy effect, and unilateral blocks are very high. Here, we report a pediatric case of kyphoscoliosis posted for inguinal hernia repair done successfully under subarachanoid blockade.
Keywords: Kyphosis, scoliosis, subarachnoid block
|How to cite this article:|
Chandra A, Jha S, Agarwal M, Chandra N. Subarachnoid block in a pediatric patient with severe kyphoscoliosis. Med J DY Patil Vidyapeeth 2020;13:282-4
|How to cite this URL:|
Chandra A, Jha S, Agarwal M, Chandra N. Subarachnoid block in a pediatric patient with severe kyphoscoliosis. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 25];13:282-4. Available from: https://www.mjdrdypv.org/text.asp?2020/13/3/282/285755
| Introduction|| |
Kyphoscoliosis is usually an idiopathic disorder characterized by progressive deformity of the spine, which includes kyphosis (anteroposterior spinal angulation) and scoliosis (lateral spinal curvature). In severe cases, displacement with rotation of the trachea and main stem bronchi may also be noted due to distorted airway anatomy, causing difficulty during intubation for general anesthesia. The tracheal tube should not be forced against resistance in these patients. Such patients, especially pediatric age group, are a challenge to anesthesiologists from regional anesthesia as well as general anesthesia point of view.
Idiopathic kyphoscoliosis accounts for 80% of cases which commonly begin in late childhood and may progress in severity during rapid skeletal growth. Spine curvature of >40% is considered severe and is likely to be associated with physiological derangement in cardiac and pulmonary function. Restrictive lung disorder and pulmonary hypertension progressing to cor pulmonale are the principal causes of death in patients with kyphoscoliosis. Secondary kyphoscoliosis occurs as a result of various neuromuscular, vertebral, or musculoskeletal disorders.
| Case Report|| |
A 10-year-old child, weighing 22 kg, was posted for inguinal hernia repair. The patient had a history of kyphoscoliosis being noticed at the age of 5 years. He achieved normal milestone and was fully immunized. The patient used to preferably lie on his sides although lying supine was not an issue for him. There was no significant history of cyanotic spells, respiratory distress, or any motor/sensory disturbances. There was no other significant medical or surgical illness. On general examination, the patient had a cachexic look with poor nourishment. Airway examination revealed Mallampatti Grade II. On respiratory examination, crowding of ribs was present on the right side with concavity toward the left side; breath-holding time was 30 s. Spine examination revealed thoracolumbar kyphoscoliosis with loss of intervertebral space as shown in [Figure 1]. Complete blood analysis revealed hemoglobin of 12 g%, with total white blood cell count of 5400 cells/mm  and platelet count of 3.86 lakh/mm . His blood urea was 18 mg%, creatinine was 0.7 mg%, and random blood sugar was 118 mg%. Spine radiography showed thoracolumbar kyphoscoliosis with Cobb's angle of around 90° as shown in [Figure 2] and severe kyphotic deformity as shown in [Figure 3]. Pulmonary function test revealed moderate restrictive airway pattern. Electrocardiography and echocardiography showed no deviation from normal limits. Pediatric referral showed no evidence of any other congenital anomaly.
The patient was taken for herniotomy after proper consent and high risk explained in view of kyphoscoliosis and restrictive airway disease and need of postoperative ventilator support. After attaching all the standard monitors and taking baseline value of vital signs, a 22G intravenous cannula was secured on the dorsum of the left hand and injection ringer lactate was started. As the Cobb's angle was significantly high, the decision to give regional anesthesia and avoid general anesthesia was made. Under all aseptic precautions, subarachnoid block was given with 2 cc of 0.5% heavy bupivacaine in L2–L3 space in sitting position with a 26G spinal needle. A midline approach with the direction of the needle toward the convexity of the curve was made after giving local anesthetic infiltration. To square the pelvis in supine position after spinal anesthesia, folded sheets were used under the right hip to achieve adequate level of anesthesia. However, a slight tilt on the right side was left uncorrected as it was a right-sided herniotomy. Sensory level of T8 dermatome was achieved. The patient was adequately sedated to keep him still in the position. The surgery lasted for 45 min. Vitals were within normal range during the intra- and postoperative period.
| Discussion|| |
The incidence of kyphoscoliosis reaching an angle of 35° is 1 in 1000 and that >70° is 1 in 10,000.
Spinal deformities may cause difficulties with both general anesthesia and regional anesthesia. It has been suggested that hyperbaric solutions can safely produce blocks for many operations under spinal anesthesia in a patient with severe thoracolumbar kyphoscoliosis. However, incomplete blocks with the use of hyperbaric local anesthetic drug in kyphoscoliosis patients has also been reported. Strong clinical evidence regarding the use of isobaric drug in these patients is still lacking.
It has been found that only upper thoracic scoliosis with a Cobb's angle >70° can be correlated with restrictive ventilation disorder and latent hypoxemia demonstrated during the exercise tolerance test. In scoliosis below 60°, postoperative complications are low with no requirement of postoperative ventilator support.
Scoliosis results in restrictive pulmonary disease pattern characterized by increased respiratory rate and decreased tidal volume. The severity of pulmonary impairment is influenced by the scoliosis angle (>70%) and number of vertebrae involved (seven or more).
In our patient, as the Cobb's angle was around 90°, we refrained from giving general anesthesia. Subarachnoid block is controversial and poses a challenge to the anesthetists due to difficulty in the palpation of anatomical landmarks, difficulty in performing dural puncture, and difficulty in predicting the extent of block.
Owing to the anatomical consideration in patients with scoliosis, a modified paramedian approach with needle insertion toward the convexity may offer several advantages. If a midline approach is used, the spinal needle should be angled in the transverse plane toward the convex side of the curve.
In our patient, the midline approach with the direction of the needle toward the convexity of the curve could make a successful dural puncture. The hip was relatively straightened by putting rolled towels under the right hip; however, a slight tilt on the right side was left uncorrected as it was a right-sided herniotomy operated in supine position.
In patients who have scoliotic curves with a Cobb's angle >50° and unclear anatomy, imaging modalities should be used for neuraxial access or a different modality should be used. An ultrasound doesn't use ionizing radiation and is portable. It is the preferred modality for neuraxial access, however fluoroscopy can also be used. Due to lack of these facilities at our institute, the landmark technique was used in a guarded manner keeping all the preparations for general anesthesia and difficult intubation ready.
| Conclusion|| |
The rate of inadequate or failed neuraxial anesthesia in patients with kyphoscoliosis is higher than that in the general population. Adequate level of block can be achieved by meticulous positioning of the patient after giving subarachnoid block with hyperbaric drug. However, the perioperative evaluation of the cardiovascular and respiratory system of these patients is of utmost importance as they might need general anesthesia anytime.
Declaration of patient consent
The authors certify that they have obtained all appropriate consent forms. The patient's father has given the consent for the images and other clinical informations to be reported in the journal. He understands that the name and initials will not be published and due efforts will be made to conceal the identity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dongare HC, Khatib KI, Baviskar AS. Principles of anesthetic management in patients with congenital kyphoscoliosis undergoing laparotomy. Indian J Appl Res 2013;3:444-6.
Kim HJ, Choi YS, Park SH, Jo JH. Difficult endotracheal intubation secondary to tracheal deviation and stenosis in a patient with severe kyphoscoliosis: A case report. Korean J Anesthesiol 2016;69:386-9.
Ramani R. Skin and musculoskeletal diseases. In: Hines RL, Marschall KE. Editors. Stoelting's Anesthesia and Co-existing Disease. 6th
ed. Philadelphia: Elsevier Saunders; 2012. p. 452.
Kearon C, Viviani GR, Kirkley A, Killian KJ. Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis. Am Rev Respir Dis 1993;148:288-94.
Bergofsky EH. Respiratory failure in disorders of the thoracic cage. Am Rev Respir Dis 1979;119:643-69.
Ozyurt G, Basagan-Mogol E, Bilgin H, Tokat O. Spinal anesthesia in a patient with severe thoracolumbar kyphoscoliosis. Tohoku J Exp Med 2005;207:239-42.
Moran DH, Johnson MD. Continuous spinal anesthesia with combined hyperbaric and isobaric bupivacaine in a patient with scoliosis. Anesth Analg 1990;70:445-7.
Sakić K, Pećina M, Pavicić F. Cardiorespiratory function in surgically treated thoracic scoliosis with respect to degree and apex of scoliotic curve. Respiration 1992;59:327-31.
Raw DA, Beattie JK, Hunter JM. Anaesthesia for spinal surgery in adults. Br J Anaesth 2003;91:886-904.
Lambert DA, Giannouli E, Schmidt BJ. Postpolio syndrome and anesthesia. Anesthesiology 2005 S; 103:638-44.
Misra S, Shukla A, Rao KJ. Subarachnoid block in kyphoscoliosis: A reliable technique? Med J D Y Patil Univ 2016;9:761-4.
Ko JY, Leffert LR. Clinical implication of neuraxial anesthesia in the parturient with scoliosis. Anesth Analg 2009;109:1930-4.
Bowens C, Dobie KH, Devin CJ, Corey JM. An approach to neuraxial anaesthesia for the severely scoliotic spine. Br J Anaesth 2013;111:807-11.
[Figure 1], [Figure 2], [Figure 3]