Anesthesia considerations for Ankyslosing Spondylitis

R. Nagesh*, Hemanth Kamath, M. Ashok

Department of Anaesthesia and Intensive care, Kauvery Hospital, Electronic City, Bengaluru

*Correspondence: [email protected]

Abstract

We report the anaesthetic management of a patient with progressive ankylosing spondylitis with severe deformity at cervical, thoracic and lumbar spines. She was admitted for restorative surgery of thoracic and lumbar spines, to improve her functional, immobility and quality of life and to treat the gastro esophageal reflux disease (GERD. We offered her surgery. In view of the presence of difficult airway, and failure of a traditional approach to intubation, we chose to Spray As You Go (SAGO) technique by Awake Fibreoptic Intubation. A ‘difficult intubation’ cart, that had a selection of oropharyngeal and nasopharyngeal airways, gum elastic bougie, fiberoptic bronchoscope, intubating laryngeal mask (ILMA), and cricothyroidotomy set was kept ready. Patient was breathing spontaneously and tolerating the tube well, with no tachypnea, tachycardia or hypoxia. Anesthesia was induced with IV injection propofol 2 mg/kg, IV fentanyl 2 μg/kg and IV Atracurium 0.5 mg/kg. Right femoral vein was cannulated with a triple lumen central venous catheter by modified Seldinger’s technique. Our case highlights that, in some cases of ankylosing spondylitis, one can be successful in using the fibre optic bronchoscope to manage the airway, which is considered to be technically more difficult.

Keywords: Ankylosing Spondylitis, Gastro Esophageal Reflux Disease (GERD), SAGO and ILMA.

Background

Ankylosing spondylitis is a chronic inflammatory disease, most commonly observed in joints and spine, and results in reduction of the physiological functions of spine and surrounding tissues [1]. Inflammation in cervical, thoracic and lumbar spine causes damage and results in stiffness and kyphosis from ankylosing spondylitis. In this condition, maintaining airway and access to the neuroaxis can be difficult for the anesthesiologist [2]. There is a very high risk of pre-operative and post-operative complications due to possible spinal cord compression during the surgery. Also, the patient unable to lie down in supine position [3]. Under such conditions most of the anaesthesiologists prefer to give general anaesthesia. This study reports that airway management with awake fibreoptic intubation is the best way and that maintaining appropriate spinal position in these patients is a challenge to the anaesthesiologist [4].

Case Presentation

A 65-year-old female, of weight 60 kg and height 155 cm, was admitted to our hospital with a 30-year-old history of progressive ankylosing spondylitis, with severe deformity to cervical, thoracic and lumbar spines. She was admitted for corrective surgery of thoracic and lumbar spines to improve her functional immobility and quality of life, and also for treatment of GERD.

Patient was admitted two days prior to surgery. Respiratory exercise training was given with incentive respirometer. During preanesthetic assessment her history revealed that she required three pillows to support her head due to the disease process and the involvement of the cervical spines. A physical examination suggested that there was severe cervical spondylitis involving thoracolumbar vertebral column, without lower limb neurological involvement. No cardiovascular system abnormality was detected. The airway examination could not be done effectively

due to fixed flexion deformity of cervical spine. Mouth opening was only two fingers and neck mobility was restricted; Mallampati class was III. Thyromental distance could not be assessed as chin was touching the manubrium sternum. Front of neck was not visualised; neck mobility was restricted zero degree. A preoperative assessment for difficult intubation was done and an awake fibreoptic intubation was planned. Radiographs of the vertebral column revealed ankylosis of the cervical, thoracic, and lumbar spinous processes showing posterior joint involvement, resorption of the anterior surfaces of the vertebral bodies and calcification and ossification of the posterior ligaments and surrounding soft tissues. Pulmonary function tests showed combined obstructive and restrictive disease, FEV1/FVC ratio was 64.

Patient’s relatives were explained about the presence of difficult airway, likely failure of traditional approach for intubation, distorted airway anatomy with no access to perform a tracheostomy and the high risks surrounding failure to obtain a definitive airway; consent was obtained. An awake fibreoptic intubation was planned with spray as you go (SAGO) technique. A difficult intubation cart, which had a selection of oropharyngeal, nasopharyngeal airway, gum elastic bougie, fiberoptic bronchoscope, intubating laryngeal mask (ILMA), cricothyroidotomy set, was kept ready. On the day of the surgery, the patient was premedicated with IV Pantoprazole 40 mg, IV Ondansetron 4 mg and IV Glycopyrrolate 30 min before surgery. Preparation for fiberoptic intubation was done. Nasal patency was checked and the nasal cavity prepared with oxymetazoline nasal drops. In the operation room the patient was made to lie supine with the head adequately supported on three pillows and routine monitors, such as, the electrocardiogram, non-invasive blood pressure, and pulse oximeter and capnograph were placed. The IV line, with an 18 Gauge cannula, was started. Patient was nebulised with 4% lignocaine 5ml for about 20 minutes following which patient was asked to gargle 2% viscous solution of Lignocaine. Awake Fibreoptic intubation was done nasally using a SAGO technique and airway secured with size 7 flexometallic endotracheal tube. Air entry was confirmed with auscultation and capnography. Patient was breathing spontaneously and tolerating the tube well with no tachypnea, tachycardia or hypoxia.

Anesthesia was induced with IV injection propofol 2 mg/kg, IV fentanyl 2 μg/kg and IV Atracurium 0.5 mg/kg. Right femoral vein was cannulated with a triple lumen central venous catheter by modified Seldinger’s technique. Right Radial artery was chosen and arterial line secured for IBP monitoring. Anesthesia was maintained with O2, N2O, Isoflurane, Injection Dexmadetomedine and maintenance dose of IV Atracurium. Prone position had to be given carefully, with bolsters confirming to the contours of the patient, to avoid fractures. Procedure was uneventful. The vital signs remained stable. Intraoperative mean blood pressure maintained 65-70 mmhg, Fluid calculations and management of blood pressure were very important in this patient with severe lung disease.

There were no intraoperative problems throughout the procedure, which was completed in 6 h. Hemostasis was adequate; 300 mL blood loss was there. Epidural catheter was placed by surgeon under direct vision before closure of surgical site.

Post operatively, patient was shifted to the ICU for elective ventilation. Pain management was arranged with epidural infusion 0.2% Ropivacain 6 mL/hour, Fentanyl patch 25 mic/h, IV Paracetamol 1G thrice a day and tramadol 50 mg thrice a day. Patient had 800 mL drain collection from wound site leading to drop in Hb to 8.4 mg%; two units of Packed red blood cell transfusion were given, repeat Hb was 11.2 gm%. Patient was weaned off the ventilator and extubated uneventfully within the next 24 h.

Discussion

AS is a group of chronic inflammatory disorders that occurs in the spines and sacroiliac joints, termed as spondyloarthropathies [5]. This disease mostly occurs in women compared to men. It may cause arthritis, uvitis, psoriasis, cardiovascular diseases and cardiomyopathy [6]. The symptoms of AS are chronic pain in joints and spines and reflect the reduction of physiological functions of spines and surrounding tissues [7]. Inflammation in cervical, thoracic, lumbar spines and the consequent damage results in stiffness and kyphosis. The risk factors for AS are gender, age, environmental and genetic factors. In this condition, airway management is difficult for the anesthesiologist due to reduced range of motion and fixed cervical spine [8,9]. Generally, in such circumstances, most anaesthesiologists prefer general anaesthesia to prevent neuroaxial complications. Our study reports that airway management by awake fibreoptic intubation is the best way. Maintaining appropriate spinal position is a challenge in these patients for the anaesthesiologist [10]. In this study preoperative assessment for difficult intubation was done and awake fibreoptic intubation was planned.

Radiographs of the vertebral column of our patient had revealed ankylosis of the cervical, thoracic, and lumbar spinous processes showing posterior joint involvement, resorption of the anterior surfaces of the vertebral bodies and calcification and ossification of the posterior ligaments and surrounding soft tissues [11]. The degree of spine involvement determines how difficult the tracheal intubation can be. Special care was taken to avoid excessive manipulation of the neck, which could cause trauma to the spinal cord. We chose to spray as you go (SAGO) technique by awake fibreoptic intubation [12]. A difficult intubation cart, which had a selection of oropharyngeal, nasopharyngeal airway, gum elastic bougie, fiberoptic bronchoscope, intubating laryngeal mask (ILMA), and cricothyroidotomy set was kept ready.

Conclusion

Patients with chronic diseases of the spine represent specific challenges to the anesthesiologist. Handling of the airways and the access to the neuroaxis can be difficult. Most anesthesiologists prefer to use general anesthesia in these patients, avoiding the neuroaxis. The degree of spine involvement will determine how difficult the tracheal intubation could be. Special care should be taken to avoid excessive manipulation of the neck, which could cause trauma to the spinal cord.

Our case highlights that in some cases of ankylosing spondylitis one can be successful in using the fibre optic bronchoscope to manage the airway, which is considered to be technically more difficult.

References

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