Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: a novel explanation

Abstract

Purpose Ankylosing spondylitis (AS) is a chronic progressive multisystemic disease. Patients with AS present a specific set of anesthesia-related challenges, and the parturient with AS presents particular anesthetic considerations. We report our experience with a parturient with advanced AS and offer a novel explanation for the high incidence of epidural failures in this patient population. Clinical features We present the case of a 36-yr-old primigravida parturient with a very difficult airway and a history of severe AS. The initial treatment plan was to use a continuous epidural for labour analgesia. Despite two successful placements of lumbar epidural catheters, adequate rostral spread of local anesthesia to control her labour pain was never achieved via the epidural route. Thus, continuous spinal anesthesia was used, which provided effective labour analgesia in this patient. Conclusion We hypothesize that this patient's advanced calcified posterior longitudinal ligament caused a physical barrier to rostral spread of local anesthesia solution within her epidural space. This hypothesis is supported by a recent study highlighting the importance of this ligament in allowing adequate distribution of solution within the epidural space. In addition, the successful use of continuous spinal analgesia adds to the growing body of literature supporting the safety and efficacy of intrathecal catheters for labour analgesia in specific situations. RésuméObjectif La spondylarthrite ankylosante (SpA) est une maladie chronique e´volutive affectant plusieurs syste`mes. Les patients souffrant de SpA posent une se´rie de de´fis spe´cifiques lie´s à l'anesthe´sie et les proble`mes d'une parturiente souffrant de SpA ne´cessitent une approche encore plus e´labore´e. Nous de´crivons notre expe´rience avec une parturiente atteinte de SpA avance´e et proposons une nouvelle explication pour l'incidence e´leve´e d'e´checs de la pe´ridurale dans cette population de patientes. Caractéristiques cliniques Nous pre´sentons le cas d'une parturiente de 36 ans, primipare, ayant des ante´ce´dents de SpA se´ve`re et des voies ae´riennes difficiles. Le plan the´rapeutique initial consistait a`utiliser une pe´ridurale continue pour l'analge´sie au cours du travail. Malgre´la mise en place re´ussie de deux cathe´ters pe´riduraux par voie lombaire, une diffusion rostrale approprie´e de l'anesthe´sie locale pour atte´nuer sa douleur n'a jamais e´teó btenue par voie pe´ridurale. En conse´quence, une

Anticipated difficult airway during obstetric general anaesthesia: narrative literature review and management recommendations.

“…We have included 136 reports, both full publications and abstracts, covering 158 cases (see also Supporting Information, Appendices S1–S6) . Case reports largely fall into two groups: those describing equipment, or a technique, for provision of general anaesthesia; or those identifying a woman who had predicted airway difficulty, who was managed with regional analgesia or anaesthesia with the aim of avoiding of general anaesthesia.…”

“…Of note, 22 women with fixed or chronic conditions that involved airway risks were only identified by the anaesthetic service at short notice before surgery, rendering advanced planning impossible .…”

Management of pregnancy complicated by ankylosing spondylitis: A case report and literature review

“…When labor pain control or CS is needed, challenges may remain. Stiffness of the axial joints and calcified spinal ligament may cause extreme difficulty in placing the epidural catheter or in inserting the spinal needle . Narrow intervertebral spaces also make it difficult to perform epidural or spinal anesthesia.…”

“…Stiffness of the axial joints and calcified spinal ligament may cause extreme difficulty in placing the epidural catheter or in inserting the spinal needle. 13,14 Narrow intervertebral spaces also make it difficult to perform epidural or spinal anesthesia. When regional anesthesia fails or an emergency CS is required, general anesthesia should be the first choice, but intubation may be difficult due to limited neck mobility.…”

Epidural analgesia in parturients with ankylosing spondylitis: A role for ultrasound surveillance and ultrasound-guided placement

“…1 An extensive review of neuraxial blockade in non-parturient AS patients [mean age 44 standard deviation (15) yr, mean duration of AS 19 (9) yr] at Vancouver General Hospital showed that epidural placement had a very poor success rate. 2 On the other hand, spinal anesthesia (using either a midline or a paramedian approach) was successful in 76% of cases.…”