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Successful Use of an Intrathecal Catheter for Labor Analgesia in a Patient with Advanced Ankylosing Spondylitis
Abstract Number: T-69
Abstract Type: Case Report/Case Series
Introduction: Ankylosing spondylitis (AS) is a chronic, progressive form of spondyloarthropathy. Majority of patients manifest before age 30, thus many affected women remain at a reproductive age. AS patients pose a specific set of anesthesia-related challenges. This report is our experience with a parturient with advanced AS, in whom we used an intrathecal catheter for labor analgesia. This clinical scenario has not yet been described in the medical literature.
Case: We present a 36-year-old G1P0 parturient, with a history of severe AS. She was noted to have an extremely difficult airway (no c-spine mobility, Mallampati class III, limited mouth opening). Her lumbar spine also had zero mobility and her intervertebral spaces were narrow. The obstetrical plan for this patient was a trial of labor at term. Two attempts at L3/4 epidural placement were performed. Although we had no technical difficulty in catheter placement, the patient never developed a sensory level above L3, despite adequate dosing of local anesthesia. Thus, an intrathecal catheter was subsequently performed. An 18G Tuohy needle was advanced in the L3/4 interspace and the dura mater was purposely punctured. A 20G B-Braun Perifix® epidural catheter was threaded 4 cm into the intrathecal space. A bolus of bupivacaine 0.25% 3.75mg and fentanyl 20 µg was given. Thirty minutes later, the patient had a T6 sensory level and reported no pain. The patient subsequently delivered a healthy baby, pain free, without development of post dural puncture headache.
Discussion: The manifestations of AS pose a unique set of challenges to the anesthesiologist. Neuraxial anesthesia is complicated by severe abnormalities of the spinal column. Epidural catheter placement may be technically difficult due to restricted flexion of the lumbar spine. Epidural catheter placement may also be associated with higher rate of complications, including spinal hematoma (1). This may be due to abnormal contiguity of the epidural space, which may explain our patient’s lack of rostral spread of local anesthetics. General anesthesia is complicated by abnormal posture, difficult airway, and extra-articular manifestations. The parturient with AS presents unique challenges. Epidural catheter placement would be the ideal choice to avoid the AS airway, however its unreliability for labor analgesia and eventual Cesarean delivery makes it less than ideal. We recommend considering continuous spinal analgesia in these patients. Although the use of spinal catheters in obstetric anesthesia practice has been tarnished by reports of neurologic complications, recent studies suggest when large gauge catheters are used, with infusion of dilute local anesthetics, complications are minimized (2). This report adds to the growing body of literature supporting the safety and efficacy of intrathecal catheters for labor analgesia in specific situations.
(1)Wulf H. Can J Anesth, 1996;43(12):1260
(2)Palmer C.M. Anesth Analg,2010;111(6):1476