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LETTER TO THE EDITOR
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 36-37

Response to "repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective caesarean section"


Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Date of Web Publication15-Apr-2015

Correspondence Address:
Dr. K S Sushma
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, 206, Hubli, Dharwar - 580 021, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.155199

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How to cite this article:
Sushma K S, Shaikh S, Nagamani K R. Response to "repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective caesarean section". J Obstet Anaesth Crit Care 2015;5:36-7

How to cite this URL:
Sushma K S, Shaikh S, Nagamani K R. Response to "repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective caesarean section". J Obstet Anaesth Crit Care [serial online] 2015 [cited 2019 Dec 7];5:36-7. Available from: http://www.joacc.com/text.asp?2015/5/1/36/155199

Sir,

We read with interest the case report "repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective caesarean section" in volume 4 (2). We would like to share our experience of anesthetizing a similar case of kyphoscoliotic parturient posted for an emergency caesarean section.

We encountered a short statured (138 cm) primigravida at 38 weeks of gestation with severe thoracolumbar kyphoscoliosis posted for emergency caesarean section, indication being severe oligohydramnios [Figure 1] and [Figure 2]. She didn't have any prior imaging reports as she was never hospitalized before. She had good exercise tolerance and even during pregnancy she was able to do the routine household work (New York Heart Association grade 2). She had a short neck and mallampatti grade 3. Her systemic examination was normal, blood investigations were within normal limits. We didn't have time either to get an X-ray chest and spine done to calculate the Cobb's angle or to get pulmonary function testing done. In view of type of surgery and anticipating difficult airway, we decided to go ahead with spinal anesthesia. With the patient in sitting position, on the second attempt at L3-L4 space, with 25 G quincke's needle, cerebrospinal fluid was tapped and 1.6 cc of hyperbaric bupivacaine 0.5% was injected. Speed of onset was slow, but the level of analgesia was adequate. A 2.8 kg baby was extracted, and APGAR score was 8 and 10 at 1 and 5 min respectively. Perioperative course was uneventful.
Figure 1: Lateral view of the patient

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Figure 2: Posterior view of the patient

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Kyphoscoliosis, whether idiopathic or due to other causes, has increased incidence in females, hence anesthetizing such patients in emergency obstetric scenario can be challenging for anesthesiologist. Ideally a kyphoscoliotic parturient needs a multidisciplinary approach and many investigations to understand the severity of disease. In an emergency situation like ours, anesthetist is left with only clinical assessment of the patient to decide with the type of anesthesia. Even though Cobb's angle is definitive indicator of severity of pulmonary impairment, we couldn't assess it due to the emergency situation. Absence of history of frequent respiratory infections and good effort tolerance were positive indicators of fairly good pulmonary reserve. [1] Even though regional anesthesia is the preferred technique, there is a high incidence of failed or inadequate anesthesia as happened with the authors. Even though neuraxial techniques need more time than usual in kyphoscoliotic patients, [2] we could achieve the block in the second attempt. Level of blockade was adequate in our patient in spite of slow onset of blockade. For successful neuraxial anesthesia in uncorrected scoliotic patients, it is recommended that the needle to be oriented toward the convexity of the curve where the interlaminar spaces are usually larger. [3] Augmentation of an asymmetric block by placing an epidural catheter has been described, but its technically difficult. General anesthesia has a role if the regional block is technically difficult to achieve or if there is cardiopulmonary decompensation. Hence, an unevaluated kyphoscoliotic parturient in an emergency surgery can be a challenge to the anesthetist.

 
  References Top

1.
Menon B, Aggarwal B. Influence of spinal deformity on pulmonary function, arterial blood gas values, and exercise capacity in thoracic kyphoscoliosis. Neurosciences (Riyadh) 2007;12:293-8.  Back to cited text no. 1
    
2.
Korula S, Ipe S, Saramma SP. Parturients with severe kyphoscoliosis: An anesthetic challenge. J Obstet Anesth Cri Care 2011;1:81-4.  Back to cited text no. 2
    
3.
Ko JY, Leffert LR. Clinical implications of neuraxial anesthesia in the parturient with scoliosis. Anesth Analg 2009;109:1930-4.  Back to cited text no. 3
    


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  [Figure 1], [Figure 2]



 

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