Technical Case Report: Continuous ultrasound guided spinal placement in a patient with severe scoliosis

Abstract Number: F-58
Abstract Type: Case Report/Case Series

Ultrasound guidance (USG) may increase accuracy of neuraxial anesthesia (NA) placement in patients with anatomical challenges such as morbid obesity and scoliosis. In scoliosis, vertebral bodies rotate toward the convex side of the curve resulting in deviation of the epidural space toward the convexity and larger interlaminar spaces on that side. Failed or inadequate blocks are more common and visualization is difficult. A direct path to the epidural space exists on the convex side using a paramedian approach. Capturing bony and soft tissue landmarks using continuous US facilitates accurate paramedian needle trajectory. Where static USG may give information on depth of structures and confirm vertebral levels, continuous real-time US imaging may enhance accuracy.

We used continuous real-time USG in a parturient with a severe 63˚ thoracic dextroscoliotic curve (compensatory lumbar levocurvature) to place a spinal for C/S. Basic US techniques, landmarks, and pitfalls are described for transverse midline, paramedian oblique and paramedian longitudinal approaches. We explain these US views and highlight the differences between our severely scoliotic parturient and a normal spine. These views can complement each other, allowing identification of the optimal level, angle of placement, and distance from skin to epidural space. Despite significant anatomical variations in our patient, many landmarks were still obtainable.

Continuous real-time imaging of anatomy during placement of NA may be a practical way to increase success rates in parturients with scoliosis. This population has a higher incidence of operative delivery and compromised pulmonary function, placing them at further risk of morbidity if GA becomes necessary.

References

1. Hawkins JL, Arens JF, Bucklin BA, et al. Anesthesiology 2007; 106:843-63

2. Bowens C, Dobie KH, Devin CJ, Corey JM. Br J Anaesth2013;111(5):807-11.

3. Sprung J, Bourke DL, Grass J, et al. Anesth Analg 1999;89:384-9.

4. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. J Clin Anesth 2002;14:169-75.

5. Carvalho JC. Anesthesiology Clin 2008;26:145-158.

6. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Euro J Anaesth 2004;21:25-31.

7. Arzola C, Davies S, Rofaeel A, et al. Anesth Analg 2007;104:1188-92.

8. Huang J. Paramedian approach for neuroaxial anesthesia in parturients with scoliosis. Anesth Analg 2010;111:8

SOAP 2014