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 Table of Contents  
CASE REPORT
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 81-84

Parturient with severe kyphoscoliosis: An anesthetic challenge


Department of Anaesthesiology, MOSC Medical College, Kolenchery, Kerala, India

Date of Web Publication17-Mar-2012

Correspondence Address:
Sara Korula
Department of Anaesthesiology, MOSC Medical College, Kolenchery Kerala - 682 311
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.93992

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  Abstract 

We present a case of a primigravida with kyphoscoliosis and pneumonia posted for emergency cesarean section. She had a Cobb's angle of 120° and exertional dyspnea. Epidural anesthesia was successfully used for anesthesia and postoperative analgesia. This report highlights the anesthetic challenges and the importance of early planning of anesthetic technique for successful intraoperative management of a kyphoscoliosis patient.

Keywords: Cobb′s angle, epidural, kyphoscoliosis, pregnancy


How to cite this article:
Korula S, Ipe S, Abraham SP. Parturient with severe kyphoscoliosis: An anesthetic challenge. J Obstet Anaesth Crit Care 2011;1:81-4

How to cite this URL:
Korula S, Ipe S, Abraham SP. Parturient with severe kyphoscoliosis: An anesthetic challenge. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2018 Aug 20];1:81-4. Available from: http://www.joacc.com/text.asp?2011/1/2/81/93992


  Introduction Top


Pregnancy along with deformities of the costovertebral skeletal structures challenges our techniques of anesthesia. Kyphoscoliosis is characterized by progressive deformity of the spine consisting of lateral and posterior curvatures. About 80% of the cases are idiopathic in nature. Secondary kyphoscoliosis occurs as a result of various neuromuscular, vertebral or connective tissue disorders. [1] The rates of inadequate or failed neuraxial anesthesia in patients with scoliosis are higher than in general parturient population. [2] Cases with a Cobb's angle of more than 100 0 are quite rare, [3] and we report a case of successful epidural anesthesia in a patient with severe kyphoscoliosis.


  Case Report Top


A 33-year-old primigravida with severe kyphoscoliosis, married for 1 year with a period of gestation of 32 weeks and 3 days, was admitted as a referred case with fever, cough and breathlessness of 4 days duration. She had a productive cough with mucoid expectoration. There was no hemoptysis or chest pain. She was not in labor and the fetal heart rate was within normal limits. She gave history of having suffered from poliomyelitis in childhood. There was no history of trauma or tuberculosis. She had decreased effort tolerance with exertional dyspnoea (NYHA class II) for the past 3-4 years.

On examination, she was short statured with a height of 130 cm and weight of 34.5 kg. She was conscious and oriented but tachypnoeic. Pulse rate was 138/min, BP 130/70 mmHg, RR 38/min and SpO 2 83% on room air and 93% on 10L Oxygen (O 2 ) via poly mask. There was no cyanosis or pedal edema. Systemic examination revealed thoraco-lumbar kyphoscoliosis with mediastinal shift to right. There was bilateral wheeze and few crepitations. Cardiovascular system was normal. Lab investigations showed hemoglobin of 10.9 g%, TLC 12700/mm 3 , ESR 45 mm. Liver function tests, renal function tests and electrolytes were normal. Arterial blood gas (ABG) analysis on admission showed pH 7.30, PO 2 56, PCO 2 -76, HCO 3 28 and SpO 2 90. Chest X-ray showed severe kyphoscoliosis with a Cobb's angle of 120 0 [Figure 1] and patchy infiltrates. ECG was normal and the echocardiography showed normal chambers, absence of regional wall motion abnormalities, normal systolic function and no valvular abnormalities; however, the echocardiography window was poor due to the deformity. Throat swab was negative for H1N1. Pulmonary function test was not done at this time due to her respiratory distress.
Figure 1: Cobbs angle 1200

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The patient was transferred to the intensive care unit (ICU) and started on bronchodilators and intravenous antibiotics (Ceftriaxone 1 g and Azithromycin 500 mg). Her hypoxia improved and she was kept on 40% O 2 via venturi mask. Serial ABGs were done to monitor her respiratory parameters. ABG showed pH 7.34, PO 2 66, PCO 2 -64, HCO 3 29 and SpO 2 92. She remained conscious and oriented. Fetal well being was continuously monitored using cardiotocogram (CTG).

She was brought in for emergency cesarean section after 20 h in view of her poor respiratory status. There was no fetal distress and she was not in labor. To avoid postoperative hypoventilation and prolonged mechanical ventilation, we decided to give her epidural anesthesia. All the facilities for general anesthesia (GA) and difficult intubation were kept ready. The patient was preloaded with 250 mL of Ringer Lactate. An 18G epidural needle was introduced in the lumbar area using a loss of resistance technique in sitting position. Successful insertion was possible in the second attempt with the needle oriented toward the convexity of the curve and epidural catheter was inserted and fixed with 2 cm of the catheter in the space. She was placed in a 30 o head up position with a wedge under the right buttock. Test dose of 3 mL 1.5% lignocaine with adrenaline was given. Two percent lignocaine 6 mL and 0.5% bupivacaine 4 mL was given as graded doses over 10 min. Adequate anesthesia up to the T6 level was achieved 12 min after the total dose was administered. There was no significant hypotension or bradycardia. SpO 2 was maintained at 93% on venturi mask with 40% oxygen. Cesarean section using a Kerr's incision was done and a male baby with weight 1.39 kg was delivered. APGAR was 7 at 1 min and the baby was transferred to the neonatal ICU.

The patient was conscious and oriented and interacting with the anesthesiologist throughout the procedure. ABG done intraoperatively showed pH 7.33, PO 2 64, PCO 2 -67, HCO 3 29.5 and SpO 2 92. Postoperatively, the patient was transferred to the ICU and kept in a head up position. Continuous epidural analgesia with 0.125% Bupivacaine was used for postoperative pain relief. Noninvasive BIPAP was instituted at night. Her respiratory status gradually improved and she was transferred from the ICU after 1 week and discharged with the baby after 2 weeks.


  Discussion Top


Kyphoscoliosis is the result of the disruption of balance between structural and dynamic components or the neuromuscular elements of the spine. The severity of the deformity is best determined by measuring Cobb's angle. Numerous studies have documented that the more severe the thoracic curve (greater Cobb's angle), the more profound the disturbances in pulmonary function. [1],[4] Most patients with curves >90 0 develop marked ventilatory abnormalities. [4] In this case, the Cobb's angle was 120 0 . The incidence of kyphoscoliosis reaching an angle of 35 0 is 1 in 1000 and that more than 70 0 is 1 in 10,000. [5] Severe scoliosis is rare in parturients, which varies from 1 in 1500 to 1 in 12,000 pregnancies. [3],[6] The major pathophysiological effects of severe kyphoscoliosis in pregnancy are mentioned in [Table 1]. Pregnancy may exacerbate both the severity of spinal curvature and the cardiorespiratory compromise in kyphoscoliotic patients. [7] The risks to the fetus are of intrauterine growth restriction caused by maternal hypoxemia and preterm delivery.
Table 1: Differences in physiological changes during pregnancy in normal parturient and in a parturient with kyphoscoliosis

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Preoperative assessment should focus on any cardiovascular, respiratory or neurological impairment related to the deformity. In patients with curves >60 0 , cardiologic evaluation to assess ventricular size and evidence of pulmonary hypertension are required. [6] Any preexisting neurological deficits should be documented. Pulmonary function tests (PFT) and ABG are crucial and will guide decisions regarding mode and time of delivery and requirement of ventilatory support. Early admission in the third trimester for supplementary oxygen therapy may be beneficial to both mother and fetus. Noninvasive positive-pressure ventilation may help in patients with impending respiratory failure. [7],[8] The incidence of operative delivery is higher in these parturients, and neuraxial anesthesia is currently the technique of choice for operative deliveries as the risk of maternal mortality during GA is higher. [9],[10] GA along with all the difficulties of pregnancy has the additional risk factor of a distorted airway anatomy. As seen in our patient, there can be tracheal shift, which can make intubation difficult [Figure 2]. The risk of hypoventilation leading to prolonged requirement of mechanical ventilation is high in the postoperative period. The distortion of the spinous process and rotation of the vertebral column makes identification of the intervertebral space difficult in these patients. [2] The rate of failed or inadequate anesthesia is also higher. [11] Therefore, the timing of anesthesia for labor and delivery is important and we should be ready to convert to GA if required. Because the neuraxial techniques may take longer, ample time should be allowed for the procedure. Their utility in an urgent situation may be limited, and therein lies the importance of early hospitalization of these patients. Some studies recommend that the epidural catheter should be placed early in the course of labor and delivery so that the patient is more cooperative. [2] This also gains us time to confirm that the epidural catheter is correctly placed and reposition the catheter if required and increases the chances of a successful epidural block. We preferred epidural anesthesia over spinal anesthesia as the dose of the local anesthetic can be titrated in small doses minimizing the risk of sudden hemodynamic changes. It has the added advantage of providing excellent postoperative analgesia.
Figure 2: Tracheal deviation

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Although our patient had tachypnea, she was able to lie down with a 30 0 head tilt. ABG showed improvement in her respiratory status with conservative therapy. The near-normal pH suggests a chronic adaptation to the hypercarbia. Additionally, we expected a postoperative improvement in her vital capacity because of the removal diaphragmatic splinting by the enlarged uterus. Therefore, we decided to use epidural anesthesia for cesarean section. Facilities for managing a difficult airway and experienced personnel were available.

Anesthesia poses a significant risk to a parturient with kyphoscoliosis and there is no single regimen that can be recommended for anesthetic management. The anesthesiologist should be involved early in the antenatal period for multidisciplinary planning, review of imaging and preoperative counseling of these patients. Epidural anesthesia offers a good quality pain relief without further respiratory embarrassment and can be successfully used in a parturient with kyphoscoliosis for anesthesia and analgesia. Patient co-operation and adequate time for the neuraxial techniques ensures better chances of success for the procedure.

 
  References Top

1.Kearon C, Viviani GR, Kirkley A, Killian KJ. Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis. Am Respir Dis 1993;148:288-94.  Back to cited text no. 1
    
2.Ko JY, Leffert LR. Clinical implications of neuraxial anaesthesia in the parturient with scoliosis. Anesth Analg 2009;109:1930-4.  Back to cited text no. 2
    
3.Chopra S, Adhikari K, Agarwal N, Suri V, Sikka P. Kyphoscoliosis complicating pregnancy: Maternal and neonatal outcome. Arch Gynecol Obstet 2011;284:295-7.  Back to cited text no. 3
    
4.Levine DB. Scoliosis. Curr Opin Rheumatol 1990;2:190-5.  Back to cited text no. 4
    
5.Bergofsky EH. Respiratory failure in disorders of the thoracic cage. Am Rev Respir Dis 1979;119:643-69.  Back to cited text no. 5
    
6.Gupta S, Singaria G. Kyphoscoliosis and pregnancy. Indian J Anaesth 2004;48:215-20.  Back to cited text no. 6
  Medknow Journal  
7.Kähler C M, Högl B, Habeler R, Brezinka C, Hamacher J, Dienstl A, et al. Management of respiratory deterioration in a pregnant patient with severe kyphoscoliosis by non-invasive positive pressure ventilation. Wien Klin Wochenshr 2002;114:874-7.  Back to cited text no. 7
    
8.Buyse B, Meersseman W, Demedts M. Treatment of chronic respiratory failure in kyphoscoliosis: Oxygen or ventilation? Eur Respir J 2003;22:525-8.  Back to cited text no. 8
    
9.American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anaesthesia: An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anaesthesia. Anesthesiology 2007;106:843-63.  Back to cited text no. 9
    
10.Hawkins JL, Chang J, Palmer SK, Callaghan WM, Gibbs CP. Anesthesia related maternal mortality in the United States 1997 - 2002. Anesthesiology 2008;109:206.  Back to cited text no. 10
    
11.Preston R, Crosby ET. Musculoskeletal disorders. In: Chestnut DH, Polley LS, Tsen LC, Wong CA, editors. Obstetric anaesthesia: Principles and practice. 4 th ed. Philadelphia: Mosby-Elsevier; 2009. p. 1035-52.  Back to cited text no. 11
    


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    Tables

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