Ultrasound-guided subarachnoid block in kyphoscoliotic parturient posted for urgent caesarean section

Richa Jain; Kamya Bansal; Kanupriya Jain; Mirley Rupinder Singh; Anju Grewal

doi:10.4103/JOACC.JOACC_42_22

CASE REPORT

Year : 2023 | Volume : 13 | Issue : 1 | Page : 112-115

Ultrasound-guided subarachnoid block in kyphoscoliotic parturient posted for urgent caesarean section

Richa Jain¹, Kamya Bansal¹, Kanupriya Jain², Mirley Rupinder Singh¹, Anju Grewal¹
¹ Department of Anaesthesia, DMCH, Ludhiana, Punjab, India
² Department of Obstetrics and Gynaecology, DMCH, Ludhiana, Punjab, India

Date of Submission	07-Jul-2022
Date of Acceptance	28-Aug-2022
Date of Web Publication	09-Mar-2023

Correspondence Address:
Dr. Kamya Bansal
Department of Anaesthesia, DMCH Ludhiana, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JOACC.JOACC_42_22

Abstract

Parturient with kyphoscoliosis poses a major challenge in the administration of spinal anaesthesia owing to changes in the anatomy of the spine and physiological changes associated with pregnancy. Recently, ultrasound guidance has proved to be a boon for regional anaesthesia techniques. We report the successful anaesthetic management of a 43 year-old primigravida with kyphoscoliosis who was posted for emergency caesarean section using an ultrasound-guided subarachnoid block.

Keywords: Caesarean section, kyphoscoliosis, spinal anaesthesia, ultrasound

How to cite this article:
Jain R, Bansal K, Jain K, Singh MR, Grewal A. Ultrasound-guided subarachnoid block in kyphoscoliotic parturient posted for urgent caesarean section. J Obstet Anaesth Crit Care 2023;13:112-5

How to cite this URL:
Jain R, Bansal K, Jain K, Singh MR, Grewal A. Ultrasound-guided subarachnoid block in kyphoscoliotic parturient posted for urgent caesarean section. J Obstet Anaesth Crit Care [serial online] 2023 [cited 2023 Mar 25];13:112-5. Available from: https://www.joacc.com/text.asp?2023/13/1/112/371316

Introduction

Kyphoscoliosis is a deformity of the spine, characterised by anteroposterior spinal angulation and lateral spinal curvature.^[1] The anatomic anomalies of scoliosis can cause challenges in the performance of central neuraxial block (CNB). Moreover, pregnancy may exacerbate both the severity of spinal curvature and cardiorespiratory complications in these patients. The use of a preprocedural scan and/or ultrasound-assisted CNB improves the technical efficiency of the block by facilitating precise identification of underlying anatomical structures. We report successful administration of subarachnoid block using ultrasound guidance to a parturient with uncorrected kyphoscoliosis posted for emergency lower segment caesarean section (LSCS).

Case History

A 43-year-old G2A1 female at 33 weeks period of gestation with in vitro fertilisation (IVF) conceived triplets, with twin live foetuses and one macerated intrauterine demise, with a history of decreased foetal movements, presented for category 2 LSCS. She gave a history of hypothyroidism and gestational hypertension for which she was taking thyroxine 50 mcg Once a Day (OD) and labetalol 100 mg bis in die (twice a day) (BD). She gave a history of fall from height at age of 5 years which according to her led to severe thoracolumbar kyphoscoliosis for which she underwent conservative management till 15 years of age with the use of braces. History of previous exposures to general anaesthesia for dilatation and curettage and hysteroscopy was present and was uneventful. She had good exercise tolerance without any symptoms suggestive of respiratory or cardiovascular compromise.

On general physical examination, she had a heart rate of 90 beats/min, non-invasive blood pressure (NIBP) 136/84 mmHg, respiratory rate 32/min, O₂ saturation (SpO₂) 94–95% on room air and BMI 36.6 kg/m². Airway examination revealed Mallampati class 2 with normal dentition, adequate mouth opening and neck movements in the optimal range. Gait was normal. On examination of the spine, marked thoracolumbar kyphoscoliosis was present with the spine curved towards the right side and the spine could not be demarcated beyond T6. No motor or sensory deficit was present. Examination of the respiratory and cardiovascular systems was unremarkable. Her blood investigations were within normal limits. In view of the category 2 caesarean section, tests for assessment of cardiopulmonary reserve were not performed.

After a thorough discussion with the patient and the obstetrician regarding the risks and benefits of general and regional anaesthesia techniques, spinal anaesthesia was planned (Plan A) considering these parturients to have low respiratory reserve with an anticipated difficult airway. General anaesthesia was kept as Plan B in case of failed or inadequate subarachnoid block. Continuous NIBP, pulse oximetry and Electrocardiogram (ECG) monitoring were established. She was co-loaded with Ringer's lactate at 20 ml/kg via an 18G intravenous cannula. For spinal anaesthesia, the patient was put in a sitting position with the spine flexed. Since the midline of the lower spine could not be palpated. An ultrasound scan (curved array probe 2–5 mHz, FUJIFILM SonoSite Edge II) of the whole spine was performed, in both longitudinal and transverse planes at different intervertebral levels. Scanning in the longitudinal parasagittal plane revealed the spine to be curved to the right at the thoracolumbar level. In the parasagittal oblique view, the spinous process of L5 was identified. The probe was turned 90° transversely and moved in a cephalad direction and then rotated anti-clockwise to enable us to visualise L4–L5 interspace with its structures [Figure 1]. Once the best possible image of the interspace structures was captured, the transducer tip was stabilised and a horizontal line across the points joining the midpoints of the right and left lateral surfaces of the probe was drawn. A vertical line was then drawn from the midline of the probe. Accordingly, the puncture site was marked at the intersection of these two lines [Figure 2]. The needle insertion depth was estimated by measuring the distance from the skin to the anterior complex (5.69 cm) [Figure 3].

Figure 1: Transverse interlaminar view of L4–L5 interspace using ultrasound

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Figure 2: Placement of preprocedural USG probe with markings

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Figure 3: Depth of intrathecal space from skin estimated on ultrasound image

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After a preprocedural scan and marking, under all aseptic precautions, a 26G Quincke's spinal needle was inserted at the L4–L5 interspace (as marked with the help of USG). After two redirections, subarachnoid space was confirmed with free flow of clear Cerebro-Spinal Fluid (CSF). Hyperbaric bupivacaine 10 mg with fentanyl 25 μg was injected intrathecally. Within 10 min, a sensory block to the T4 dermatomal level was achieved bilaterally, as assessed by cold touch and pinprick sensations. There was no significant hypotension throughout the procedure and vasopressors were not required. Twin female babies delivered at 10 min after skin incision, both with satisfactory Apgar scores. The motor block regressed 3 h after the administration of the spinal anaesthetic, and the sensory block regressed by 4 h. The patient recovered uneventfully without any postoperative complications.

On the second postoperative day, an X-ray chest was done which showed overcrowding of ribs with reduced lung span on the right side. The patient refused to get an X-ray spine so Cobb's angle could not be determined. The patient was discharged on postoperative day 6 in satisfactory condition.

Discussion

Kyphoscoliotic patients pose a major anaesthetic challenge for both regional and general anaesthesia techniques due to many reasons. Difficulty in the identification of spinal landmarks results in the technical challenge in the administration of CNB. The presence of a restrictive ventilatory defect, ventilation-perfusion mismatch, hypoxemia and cardiovascular compromise may result in complications during general anaesthesia.^[1] We preferred regional anaesthesia because of: i. availability of USG and technical expertise to use it for the neuraxial block; ii. better postoperative analgesia; iii. the least effect on cardiopulmonary reserve; iv. no foetal compromise and v. no risk of malignant hyperthermia.

CNB may be especially challenging in cases where anatomical landmarks are abnormal or poorly palpable, and thus ultrasound is of a particular advantage here. There is consistent evidence to suggest that neuraxial ultrasound can be used to identify vertebral levels more accurately than palpation of surface anatomical landmarks.^[2] Thus, we performed a preprocedure scan and marked the needle insertion point using a paramedian transverse ultrasound approach. A recent systematic review highlighted the poor correlation between vertebral levels determined by ultrasound and palpation, with rates of agreement varying from 14% to 64%.^[3] It has been observed that there is an excellent correlation between ultrasound-measured depth and actual needle insertion depth using either transverse, sagittal or Para-Saggital Oblique (PSO) views.^[3] Thus, we also estimated the needle depth before insertion to guide us in the dural puncture.

In a randomised study of 120 orthopaedic patients with obesity (BMI >35 kg/m²), lumbar scoliosis or previous lumbar spinal surgery, who received spinal anaesthesia by the conventional landmark-guided technique or by an ultrasound-assisted approach, Chin and colleagues^[4] reported that preprocedural ultrasound significantly increased first-attempt success rates and reduced both the median number of needle insertions and additional needle passes. We were also able to successfully insert the needle in the first attempt with two redirections. Two meta-analyses showed that neuraxial ultrasound can improve the technical performance of CNB. Shaikh and colleagues found a significant reduction in both skin punctures and needle redirection attempts with the use of ultrasound, while Perlas and colleagues noted a reduction in overall needle passes. Also, a significant reduction in the overall procedure failure rate was pragmatic in two meta-analysis done by Perlas et al. and Shaikh et al. when ultrasound guidance was used for the neuraxial technique.^[3],[5] Systemic review and meta-analysis by Shaikh et al. encompassed epidural, spinal and lumbar puncture procedures, and included both adult and paediatric populations, and both preprocedural and real-time ultrasound scans.

Severe kyphoscoliosis can be associated with decreased volume of cerebrospinal fluid and even lower doses of local anaesthetics may achieve a higher than expected level of the block with the higher incidence of hypotension.^[6],[7] Moreover, due to the increased intraabdominal pressure and engorged veins in the epidural space during pregnancy, the subarachnoid space is decreased. Hence, usual anaesthetic doses intrathecally may lead to the higher block.^[6] In our case, only 2.0 ml of 0.5% bupivacaine (10 mg) with 25 mcg fentanyl was used which produced the sensory block level up to T4 dermatome without any significant hypotension.

An improvement in the clinical efficacy of obstetric epidural analgesia with the use of ultrasound as compared to surface-landmark-guided techniques has also been suggested by data from various randomised controlled trials.^[3],[5] There are limited reports of successful USG-guided spinal in obstetric patients with the scoliotic spine. We found one report involving the real-time use of USG assistance for spinal anaesthesia for LSCS in a patient with scoliosis where the dural puncture was achieved in a paramedian approach, by real-time ultrasound-guided-in-plane technique in a single attempt.^[8] In another scenario, Majeed A et al.^[9] demonstrated insertion of the continuous spinal catheter in L3–L4 interspace in the parturient with scoliosis, using ultrasound for prepuncture marking of skin and measurement of the distance to dorsal dura from the skin. In our case also, we achieved success in the administration of spinal anaesthesia in a single attempt in a kyphoscoliotic parturient with an impalpable thoracolumbar spine with the use of preprocedural ultrasound for prepuncture marking of skin and measurement of the depth of intrathecal space from the skin.

Conclusion

Though not designed to replace landmark technique, ultrasound assistance for regional anaesthesia can be used as an advanced tool in obstetric patients and those with kyphoscoliosis to improve efficacy and safety of neuraxial block with higher success rates. We, therefore, recommend that anaesthesiologists should acquire skills to use ultrasound for neuraxial anaesthesia technique and incorporate them into their clinical practice whenever possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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