Anesthesia for ankylosing spondylitis patients undergoing transpedicle vertebrectomy.

Abstract

Ankylosing Spondylitis (AS) patients present specific challenges to the anesthesiologists. Airway management, central venous access, positioning, neuraxial monitoring and protection as well as management of massive blood loss may prove to be difficult. We retrospectively reviewed the anesthetic management of consecutive AS patients who underwent transpedicle vertebrectomy (TPV). To secure airway and administer anesthesia, we used awake fiberoptic endotracheal intubation. The central venous access was attempted through the infraclavicular approach. The positioning was made possible with modification of the operation table and padding. The neuraxial monitoring was done with both somatosensory evoked potentials (SSEPs) and the modified transcranial magnetic evoked potential (tcMMEP). The spinal cord protection was attempted with deliberate hypothermia. To prevent massive blood loss we did controlled hypotension, and autotransfusion. Fiberoptic endotracheal intubation was done smoothly in all cases except two. In one of these two cases, endotracheal intubation was successful only after cricothyroidectomy and retrograde intubation. In the other case antegrade stiff catheter guided intubation was attempted to overcome the acute angulation cause by fixed cervical flexion. Central venous access through infraclavicular approach was agreeable except one case of pneumothorax. Massive rapid blood loss during vertebral osteotomy, occurred in one patient with fall of the mean blood pressure to 20 mmHg and ventricular tachycardia for 10 min, during which all the SSEPs and tcMMEP activities disappeared. The patient recovered without sequelae. Although it is extremely challenging, with proper planning, anticipation of difficulties and meticulous work in airway management, central venous catheterization and positioning as well as prevention of neurological injury and massive bleeding, we successfully accomplished fine job of anesthesia for the AS patients presented for correction of severe kyphosis.