Anaesthetic Management of Hemiparesis Patient with Severe Thoracolumbar Scoliosis for Orthopaedic Surgery by Taylor's Approach of Lumbar Subarachnoid Block in the era of COVID 19 Pandemic

Veena P,Geethakumari P,Mohankumar R,Arun R

doi:10.33582/anesthesia/1015

Abstract

Background: Subarachnoid block in patients with scoliosis always present a unique challenge to the anesthesiologist owing to the deformity of spine. Difficulty in performing neuraxial anaesthesia may result in neural injury, spinal haematoma, post-dural puncture headache In addition, it may decrease procedure efficiency and increase patient discomfort and dissatisfaction. The most commonly practiced technique is the midline approach. This approach is technically difficult in the geriatric patients because of degenerative changes in the spine. Calcification of supraspinous and interspinous ligaments in the geriatric age group makes midline approach difficult. Paramedian approach and its modification Taylor’s approach is not routinely practiced and is definitely a game changer when midline approach of lumbar subarachnoid block has failed or is not possible due to anatomical variations like ankylosing spondylitis, thoracolumbar kyphoscoliosis. We report a case of unilateral hemiparesis patient with severe thoracolumbar scoliosis anaesthetically managed by Taylor’s approach of lumbar Subarachnoid block for Proximal Femur Nailing (PFN) of intertrochanteric fracture thus avoiding general anaesthesia and associated aerosol generation in the era of COVID19 pandemic.

Highlights

Subarachnoid blockade is widely used due to its procedural simplicity, low cost and better physiological benefits and reduced complications than that of general anaesthesia
We report a case of unilateral hemiparesis patient with severe thoracolumbar scoliosis anaesthetically managed by Taylor’s approach of lumbar Subarachnoid block for Proximal Femur Nailing (PFN) of intertrochanteric fracture avoiding general anaesthesia and associated aerosol generation in the era of COVID19 pandemic
Severe thoracolumbar scoliosis with hemiparesis following a cerebrovascular accident in a geriatric age group holds array of challenges for both general anaesthesia and regional anaesthesia

Summary

Introduction

Subarachnoid blockade is widely used due to its procedural simplicity, low cost and better physiological benefits and reduced complications than that of general anaesthesia. Subarachnoid block can be safely administered via Taylor’s approach for anticipated as well as unanticipated difficult spine cases when general anaesthesia has to be avoided as far as possible to prevent aerosol generation during era of COVID19 Pandemic. Considering the prevailing COVID19 Pandemic and thoracolumbar scoliosis with hemiparesis its always safe to proceed with regional anaesthesia as far as possible. After arranging adequate blood products, a detailed written informed high risk consent was obtained for the planned anaesthesia procedure along with a backup plan for general anaesthesia in view of anticipated difficult regional anaesthesia access. Considering the prevailing covid pandemic and to avoid general anaesthesia for the patient we reassured the patient and reverted the patient to sitting position for a modified paramedian approach “Taylor’s Approach” of subarachnoid blockade.

Discussion

Conclusion