Continuous posterior lumbar plexus and continuous parasacral and intubation with lighted stylet for ankylosing spondylitis.

Ankylosing spondylitis is characterized by progressive ossification of the spinal column with resultant stiffness. Ankylosing spondylitis can present significant challenges to the anaesthetist as a consequence of the potential difficult airway and performing neuraxial blockade. We describe a case of intubation with lighted stylet, and use of the continuous lumbosacral plexus for THA and postoperative analgesia with an elastomeric pump. Key words: Airways difficult anticipated, anesthesia, ankoylosing spondylitis, arthroplasty, conduction, continuous lumbosacral plexus, hip, infusion pumps, intubation awake, replacement.

INTRODUCTION

Recently; the preoperative use of ultrasound in the anesthetic management of a patient with ankylosing spondylitis and the intubation was achieved with the aid of a fiberoptic bronchoscope after.[12] In the hospitals and countries, where it is not possible to use ultrasound and fiberoptic bronchoscope, an option would be to use the peripheral blocks and awake intubation. We describe the use of continuous posterior lumbar and parasacral plexus block and the intubation was achieved with the aid of the lighted stylet for management of a patient with ankylosing spondylitis and arthrosis of the hip joint.

CASE REPORT

A 28-year-old man (height 158 cm, 45 kg) presented to the preanesthetic assessment clinic before an elective right total hip replacement. He had ankylosing spondylitis that severely restricted the range of motion in his cervical, thoracic and lumbar spine. There was no cardiopulmonary involvement, and his hematological and biochemical parameters were within normal limits. Radiological studies done 1 month previously, revealed solid ankylosis of the facet joints between all lumbar vertebrae [Figure 1].

Figure 1

Ankylosing spondylitis: sacroiliitis (roentgenogram)

Airway was anticipated to be difficult because of the lack of any extension of the cervical spine, fixed cervical flexion resulting in chin on chest deformity leads to difficulty with forward vision and severe cervical kyphosis. Awake intubation with lighted stylet was planned.

The patient was evaluated and signed the informed consent to undergo total hip arthroplasty (THA) under posterior lumbar plexus continuous plexus nerve block (CPNB). Prolonged analgesia and potential risks of using both catheters were discussed with the patient and family members.

On the day of surgery, the patient was brought to the block room, where intravenous access was secured, and standard monitors were applied. After administration of 100 μg of fentanyl and 0.25 mg of atropine blockade of the bilateral superior laryngeal nerve with 2 mL 2% lidocaine each side and translaryngeal block with 1.5 mL 6% lidocaine (1.5 mL of 2% lidocaine + 1.5 mL 10% lidocaine) was performed. Immediately, after was performed awake tracheal intubation with the aid of a lighted stylet. Induction of anesthesia with propofol, sevoflurane and controlled ventilation.

The patient was placed in the right lateral decubitus being conducted continuous blockade of the lumbosacral plexus (psoas compartment and parasacral) with Tuohy continuous nerve block set, with the help of the neurostimulator. The stimulating current delivered was 0.5 mA, with a stimulation of 0.3 ms at 2 Hz. Quadriceps contraction and plantar flexion of the foot were detected in all patients. Injected 40 mL of 2% lidocaine solution with epinephrine plus bupivacaine 0.5% (50:50) in the lumbar plexus, and 20 mL of the same solution in parasacral. The contiplex catheter was advanced to a depth of 5 cm past the needle tip in both plexus. Approximately, 5 mL of contrast (iohexol with 300 mg/mL Ominipaque®) were injected in both catheters to study the dispersion of a local anesthetic [Figure 2].

Figure 2

Catheters inside the psoas compartment and parasacral space

During the procedure, 1500 mL of crystalloids and 500 mL of Voluven® (6% hydroxyethyl starch 130/0.4 in 0.9% saline) were administered. The urinary catheter was not used during the procedure. The sensory and motor blocks were adequate, and the patient remained hemodynamically stable intraoperatively. The surgery lasted 2:15 h.

At the end of the procedure, the patient was placed in the supine position. He recovered from the general anesthesia and was extubated. Before his discharge, a disposable elastomeric pump (Easypump®, B. Braun, Germany) containing 400 mL of 0.1% bupivacaine was connected to the both catheters. The pump was programmed for infusion at a rate of 10 mL/h, patient was transferred to ward.

During the 40 postoperative hours, boluses were not necessary. Both catheters were removed without intercurrences. After catheter removal, pain was controlled with oral ketoprofen and dypirone.

DISCUSSION

The neurostimulator to assist the performance, the deep peripheral nerve blockade (lumbar and parasacral) remains an excellent option for both the simple and continuous blockade.[3] The use of both lumbar and parasacral catheters for THA has not been reported. Since, it administers the local anesthetic close to the lumbosacral plexus, analgesia can be prolonged especially in patients undergoing THA. The results of this case demonstrate that the elastomeric pump for CPNB with infusion of local anesthetic in adult patients is an effective and safe analgesia method after some large orthopedic procedures. The use of rescue analgesia was not necessary.

Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton with variable involvement of peripheral joints and nonarticular structures. Ankylosing spondylitis is a form of spondyloarthritis, a chronic, inflammatory arthritis, where immune mechanisms are thought to have a key role.[4] It mainly affects the joints in the spine and the sacroiliac joint in the pelvis, and can cause eventual fusion of the spine.

General anesthesia in a patient with ankylosing spondylitis carries the risk of failed intubation and cervical spine injury, and awake fiberoptic intubation is recommended.[5] The authors also suggest the use of intubation through the laryngeal mask or even the use of the Glidescope®. The authors do not report on any item the possibility of using the lighted stylet. Lighted stylet guided intubation can be a useful technique for oral and nasal intubations in both asleep and awake patients.[678] This type of intubation technique has a reported success rate as high as 99% in experienced hands.[8] In the present case after bilateral blockade upper laryngeal nerve block and translaryngeal block the patient was intubated in the first attempt with 7.5 tube. Patient was maintained with controlled ventilation with oxygen and sevoflurane 1%.

Regional anesthesia offers many advantages over general anesthesia in these patients, but central neuraxial blocks are known to be difficult, though not impossible, depending upon the severity of the disease. Spinal and epidural anesthesia is technically difficult and may result in an increased risk of complications.

Both continuous psoas compartment block and parasacral block were performed with a peripheral nerve stimulator, and we also observed the distribution of contrast in both paths. The use of elastomeric pump in bilateral CPNB for postoperative analgesia has several advantages. This report demonstrated that the patient received adequate analgesia in both catheters. The rate of the flow of anesthetics is dictated by the elastomeric reservoir and the gauge of the tube, which prevents the infusion of a large bolus and over-dose. Although the pump has its own bacterial filter, a second filter was used to increase patient safety. The elastomeric pump has several advantages over the electronic pump, including: Portability, ease of use, and few technical problems, such as undesirable alarms.[9]

Peripheral nerve block is a simple, safe, and effective technique for perioperative anesthesia and with the use of CPNB and a pump, it provides excellent postoperative pain control. The extension of use of local anesthetics to control of postoperative pain has been reported in several countries, with several advantages over commonly used methods, including ease to manage, safe, low cost, and effective. We concluded that the use of the continuous blockade of the posterior lumbar plexus and parasacral, is an excellent option for both anesthesia and for postoperative analgesia in patients with ankylosing spondylitis undergoing THA after intubation agreed with lighted stylet, where there is no routinely use of ultrasound and fiberoptic bronchoscope.