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Anesthetic Management of Cesarean Section in Patient with Klippel-Feil Syndrome
Abstract Number: F5C-4
Abstract Type: Case Report/Case Series
Klippel-Feil Syndrome (KFS) is a congenital disorder characterized by anomalous fusion of two or more cervical, and sometimes thoracic or lumbar, vertebrae. The combination of possible difficult airway and likely difficulty in placement of neuraxial anesthetics present an interesting clinical scenario for obstetric anesthesiologists. Case reports and literature pertaining to anesthetic management for cesarean section in KFS are limited.
Our patient was a 28y.o. G1P0 female with known diagnosis of KFS, associated scoliosis, severe, persistent asthma, and bicuspid aorta scheduled for cesarean delivery secondary to breech presentation. The patient had an MRI from years prior, which revealed fusion abnormality of each of her cervical vertebrae extending into her thoracic spine with scoliosis of her cervicothoracic spine. No images of her lumbar spine were available and spinous processes were unable to be palpated. In addition to KPS, she had severe asthma, requiring use of nebulized albuterol four times daily. We elected to use ultrasound for location of midline and interspaces. Scoliosis was noted on ultrasound examination. We elected to proceed with combined spinal-epidural (CSE) due to uncertainty in proper dose given her short stature. We obtained loss of resistance at 7cm on the second needle pass and gave 10mg of 0.5% bupivacaine, 15mcg of fentanyl, and 150mcg of morphine intrathecally. An epidural catheter was placed and she received no additional epidural medications with the exception of the epidural test dose. Her surgery and hospital stay were uneventful.
This patient provided an interesting clinical scenario given that she was not a good candidate for general anesthetic due to airway concerns and significant asthma history. For this reason, the use of neuraxial anesthetics were particularly beneficial in her case. The use of ultrasound for facilitating placement of neuraxial anesthetics can be particularly helpful in patients with abnormalities of their spine. We found that we were able to identify that the patient had some degree of scoliosis and were able to use the ultrasound to approximate the appropriate angle of insertion of our epidural needle, and we were able to accurately identify specific lumbar interspaces, which given her short stature and abnormal anatomy, was particularly useful over landmark techniques. We attribute the use of ultrasound to successful placement the anesthetic with few needle passes. We felt that a CSE provided an advantage in that it provided the tactile feedback and ability to titrate provided by epidurals, as well as the benefit of a fast-acting, reliable anesthesia provided by spinal anesthetics. We found that combining the use of ultrasound with a CSE was particularly advantageous in our patient with KFS.