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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 84-86

Repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective cesarean section


Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication1-Nov-2014

Correspondence Address:
Kunal Singh
Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.143879

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  Abstract 

Pregnant patients with kyphoscoliosis present a unique challenge during their anesthetic management due to the physiologic changes of pregnancy and deformity of the spine leading to pulmonary abnormalities. We present a case report of a 29-year-old second gravida with kyphoscoliosis who successfully underwent elective caesarean section under repeat spinal block after failure of first spinal anesthesia.

Keywords: Cesarean section, kyphoscoliosis, pregnancy, spinal anesthesia


How to cite this article:
Kumar R, Singh K, Prasad G, Patel N. Repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective cesarean section . J Obstet Anaesth Crit Care 2014;4:84-6

How to cite this URL:
Kumar R, Singh K, Prasad G, Patel N. Repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective cesarean section . J Obstet Anaesth Crit Care [serial online] 2014 [cited 2020 Nov 29];4:84-6. Available from: https://www.joacc.com/text.asp?2014/4/2/84/143879


  Introduction Top


Kyphoscoliosis involves kyphosis, that refers to anteroposterior spinal angulation and scoliosis (lateral spinal curvature) that begins in childhood. In addition to the lateral curvature of the spine, the vertebrae are rotated, and the rib cage may be markedly deformed. [1] This thoracic deformity may lead to a significant restrictive lung disease, hypoxemia, and cardiovascular compromise. Pregnancy may exacerbate both the severity of spinal curvature and cardiopulmonary abnormalities in women with uncorrected scoliosis. [2],[3] We report a case of failed spinal block, followed by successful repeat spinal anesthesia for elective caesarean section in a patient with kyphoscoliosis.


  Case report Top


A 29-year-old 38 weeks pregnant woman, 40 kg, 152 cm with kyphoscoliosis was posted for elective caesarean section in view of cephalopelvic disproportion in labor. She had history of progressive spinal deformity since childhood and lower segment caesarean section done under spinal anesthesia 3 years back which was uneventful. On hospital admission, she had no complaints other than dyspnea on exertion (New York Heart Association functional class II) since 1 year. Preanesthetic examination of the airway revealed Mallampatti grade l, adequate mouth opening and neck movement. On local examination of the lumbar spine, interspinous space was not well felt. X-ray whole spine showed Kyphoscoliosis of cervicodorsal spine with concavity toward left, Cobb angle >60° and magnetic resonance imaging of the spine showed the scoliotic curvature of the cervical and thoracic vertebra with anterior ostephyte at D4 to D6 vertebra. No other intramedullary and vertebral anomalies were seen. Hemogram, renal function, and liver function tests were within normal limits. Pulmonary function test showed severe restrictive lung disease with a forced vital capacity (FVC) of 41%, forced expiratory volume in 1 s (FEV 1 ) of 35% and FEV 1 /FVC ratio of 90%. Echocardiography showed mild mitral valve prolapse and a left ventricular ejection fraction of 63% [Table 1].
Table 1: Pulmonary function tests

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In view of poor lung function a neuraxial anesthesia (single shot spinal block) was planned, and the same was explained to the patient. Half an hour before shifting to the operation room intravenous ranitidine 50 mg and metoclopramide 10 mg were given as a premedication. In the operating room, standard monitoring was instituted, and baseline parameters were recorded. A peripheral line was secured with 20G cannula. Preloading with ringer lactate 20 ml/kg was done.

Under all aseptic conditions, subarachnoid block was given in sitting a position using a 25G Quincke's needle at L3-L4 interspace through left paramedian approach as interspinous space were not felt. The patients received 10 mg of 0.5% hyperbaric bupivacaine with fentanyl 20 μg after free flow of cerebrospinal fluid. The patient was made supine with a left lateral tilt of 15° and the level of the sensory block was tested with the pin prick method in the mid axillary line after 3 min. On the left side, the level of the block was T8, but on the right there was only minimal sensory block until T12. The hemodynamic parameters remained within normal limits. After 20 min of waiting there was no improvement in the level of the sensory block so a repeat spinal block was given in sitting position at L3-L4 level by right paramedian approach with 7.5 mg of 0.5% hyperbaric bupivacaine. The patient was again made supine with a left lateral tilt. Sensory level was then rechecked after 5 min, a block till T4 level on both sides was achieved. Shortly after the second spinal block patient had one episode of hypotension (blood pressure of 85/50 mmHg) with heart rate of 50/min, which was treated with bolus of ephedrine and rapid infusion of 200 ml of lactated Ringer's solution. The surgery was allowed to proceed and the patient delivered a male baby of 2580 g with an APGAR score of 9/10 at 1 st min and 5 th min. Intraoperatively patient's heart rate remained between 60/min and 70/min and mean arterial blood pressure was 75-85 mmHg. She required three more boluses of ephedrine. The total blood loss was 300 ml and the total intravenous fluids given were 1.5 l of Ringer lactate. After surgery, the patient was shifted to postoperative care unit and was closely monitored for 24 h. During the postoperative period, patient's hemodynamics were stable and no spinal anesthesia related complications were observed.


  Discussion Top


Kyphoscoliosis is usually an idiopathic disorder. By measuring Cobb angle, we can determine the severity of scoliosis and spinal deformity, which correlates well with the functional lung impairment. In the case of thoracic involvement, the development of lung and alveoli is compromised, which leads to the development of restrictive lung disease and pulmonary artery hypertension. [4] There is also a decrease in total lung capacity, vital capacity, functional residual capacity, and tidal volume. Perioperative morbidity and mortality increases if PaCO 2 levels are increased or if pulmonary hypertension is present during pregnancy. [5] In kyphoscoliotic patients the diaphragm is entirely responsible for all increments in minute ventilation but in pregnancy as the uterus becomes an abdominal organ this diaphragmatic activity is constrained and leads to decrease in functional residual capacity and closing capacity. During pregnancy, the cardiac output is increased by up to 50% at the end of the third trimester which is due to both increases in stroke volume and heart rate. In kyphoscoliotic patients, the peripheral vascular resistance is increased so increase in cardiac output is not tolerated during pregnancy. [6] In our patient the cardiovascular condition was not compromised, electrocardiography (and the echocardiography study was normal. Operative delivery is increased in such patients due to skeletal deformities and cephalopelvic disproportion as in our case. Cesarean section is also difficult due to acute anteflexion of uterus.

Both general anesthesia and central neuraxial anesthesia are described for caesarean sections in patient with kyphoscoliosis and scoliosis. [7],[8] Neuraxial anesthesia in this type of patient is technically challenging to the anesthesiologist. Due to angulation and rotation of vertebral body epidural space is deviated toward the convexity of angulation. One method of administering spinal or epidural block is by directing the needle toward the convexity of the curve with significant angulation of the needle. Huang have described a modified paramedian approach of spinal anesthesia in such patients. [9] In this approach, the skin is entered just lateral to the dorsal spine perpendicular to the skin and it is advanced toward and onto the lamina. Then the needle is "walked" cephalad over the lamina until the interlaminar space is entered. Ko and Leffert reported in their neuraxial anesthesia review on anesthesia in scoliosis patients that in uncorrected scoliosis patient 8% have an asymmetric patchy block or unilateral block. [10] Advantages of a neuraxial block in this type of parturients is avoidance of airway manipulation in a setting of the difficult airway and a full stomach (pregnancy), but the main disadvantage is the possibility of partial or incomplete block if the subarachnoid space can be reached which itself is difficult. Our patient had not developed adequate level of sensory block even after 20 min so a repeat spinal anesthesia was administered in order to avoid airway manipulation. The causes of failed or incomplete spinal block in such parturients could be the anatomical defect itself or improper placement of the local anesthetic, drug incompatibility, drug density and drug defects. In our patient since the level of block was adequate on the left side, that is, toward the concavity side we decided to repeat the spinal block through right paramedian towards convexity side. Such an approach has been reported earlier. [11] However, it is possible that a partial block in such patients may be because of some anatomical reason, preventing the spread of the local anesthetic solution in the spinal space, and this may hold true for the repeat injection also. In our view, a repeat injection should always be kept as an option specially in patients like the present one - With a full stomach and difficult airway. A repeat spinal block after a partial spinal block can lead to a high block due to the increased spread of the second dose of the local anesthetic. It is but natural to decrease the dose of the repeat injection; the same was done in the present case also.

General anesthesia is only indicated if the parturient refuses for a neuraxial block, or if the same is contraindicated.


  Conclusion Top


If maternal and fetal condition allow, then, repeat spinal anesthesia appears to be safe with a reduced dose and after waiting for about 15-20 min in kyphoscoliotic patients. It can avoid the need of general anesthesia in parturient with kyphoscoliosis needing cesarean sections.

 
  References Top

1.
Liljenqvist UR, Allkemper T, Hackenberg L, Link TM, Steinbeck J, Halm HF. Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am 2002;84-A:359-68.  Back to cited text no. 1
    
2.
Berman AT, Cohen DL, Schwentker EP. The effects of pregnancy on idiopathic scoliosis. A preliminary report on eight cases and a review of the literature. Spine (Phila Pa 1976) 1982;7:76-7.  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.
Kafer ER. Respiratory and cardiovascular functions in scoliosis and the principles of anesthetic management. Anesthesiology 1980;52:339-51.  Back to cited text no. 4
    
5.
Hung CT, Pelosi M, Langer A, Harrigan JT. Blood gas measurements in the kyphoscoliotic gravida and her fetus: Report of a case. Am J Obstet Gynecol 1975;121:287-9.  Back to cited text no. 5
    
6.
Katsuragi S, Yamanaka K, Neki R, Kamiya C, Sasaki Y, Osato K, et al. Maternal outcome in pregnancy complicated with pulmonary arterial hypertension. Circ J 2012;76:2249-54.  Back to cited text no. 6
    
7.
Gupta S, Singaria G. Kyphoscoliosis and pregnancy. Indian J Anaesth 2004;48:215-20.  Back to cited text no. 7
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8.
Veliath DG, Sharma R, Ranjan R, Kumar CR, Ramachandran T. Parturient with kyphoscoliosis (operated) for cesarean section. J Anaesthesiol Clin Pharmacol 2012;28:124-6.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Huang J. Paramedian approach for neuroaxial anesthesia in parturients with scoliosis. Anesth Analg 2010;111:821-2.  Back to cited text no. 9
    
10.
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. 10
    
11.
Fettes PD, Jansson JR, Wildsmith JA. Failed spinal anaesthesia: Mechanisms, management, and prevention. Br J Anaesth 2009;102:739-48.  Back to cited text no. 11
    



 
 
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