///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Challenges Associated With Ankylosing Spondylitis in the Obstetric Patient: A Case Report

Abstract Number: 38
Abstract Type: Case Report/Case Series

Lindsey M Atkinson MD1 ; Steven S Lipman MD2; Sheila E Cohen MB.Ch.B, FRCA3

Patients with ankylosing spondylitis (AS) present a particular challenge in obstetric anesthesia due to their potential for a difficult airway and a difficult neuraxial block. We present a case of a patient with AS who underwent two cesarean sections (CS).

Case Report:

A 39 year old G4P1 with a 6 year history of AS and who was 148 cm and 52 kg presented for elective CS. Her prior cesarean was remarkable for difficult airway management during an emergent general anesthetic for placental abruption. Rapid sequence induction, external laryngeal manipulation and 3 attempts at laryngoscopy - including changes in blades, positioning and operator - produced a Grade 3 view. Intubation was achieved with a bougie, resulting in a suspected tracheal laceration (later excluded), and disposition to the ICU for continued intubation and mechanical ventilation. She recovered without complications.

For this elective CS, the initial plan was for spinal anesthesia. 24 and 22g pencil-point spinal needles were utilized attempting midline and paramedian approaches in both sitting and lateral positions. However, significant peri-vertebral ossification of the tissues precluded access to the intrathecal (IT) space. The secondary plan was for combined spinal-epidural hoping that a rigid 17g Touhy needle would breach the ossified tissue. An Episure syringe filled with 3 ml of saline was utilized so that the operator could use both hands on the needle flanges for better control. The needle was slowly advanced and a crisp loss of resistance was achieved, but when the Episure syringe was removed CSF flowed from the Touhy needle. An IT catheter was placed and initially dosed with 12 mg 0.75% bupivacaine with dextrose plus 10 mcg fentanyl and 0.15 mg morphine, which achieved adequate surgical anesthesia. An additional 2.25 mg of hyperbaric 0.75% bupivacaine was required during the case due to intraoperative pain, but otherwise her course was unremarkable. After recession of the neuraxial block, the IT catheter was bolused with 15 ml sterile preservative-free saline and then removed. The patient did well postoperatively and did not develop a post dural puncture headache.

Discussion:

AS is associated with difficult neuraxial block placement, higher block failure, and increased complications. Fusion and calcification in peri-vertebral tissues may lead to difficulty finding the space with a spinal needle. Furthermore, scarring or partial obliteration of the epidural space may result in difficulty threading the epidural catheter or dural puncture, as occurred this case. In light of the potential airway difficulties and associated morbidity, a reliable neuraxial technique is critical. An IT catheter may be a good option in these high-risk patients especially after accidental dural puncture.

References:

Can J Anaesth 1996;43:65-8

Eur J Anaesthesiol 2008;25:767-9

Eur J Anaesthesiol 2006;23:897-8

SOAP 2009