Caudal Anesthesia through Drilling Hole on Sacral Hiatus: A Case Report

Abstract

A 40 (forty) year old male patient with Ankylosing Spondylitis was admitted for total replacement of left hip joint. Fusion of the axial skeleton, immobility of cervical spines and restricted movement of temporo- mandibular joint lead to anticipate difficulty in intubation and failure of central neuraxial blockade for total hip replacement. Above factors also compelled to discard the attempts for spinal or epidural or general anesthesia (G.A.) in the conventional way. Last of all, it was decided to operate under caudal anesthesia. But it was difficult to administer caudal anesthesia through calcified sacral hiatus. After through discussion with surgeons, decision was taken to drill the calcified membrane over the sacral hiatus. Through the drilling hole, nerve stimulator needle was introduced and 30 ml of local anesthetic was injected in sacral epidural space after electing dorsiflexion moment of great toe. Satisfied anesthesia developed within 5 minutes. At last, an epidural catheter was inserted within sacral epidural space and kept it left in the sacral epidural space. Operation was completed smoothly without any disturbance from patient's side. No hemodynamic instability was noted. Keywords: axial skeleton, cervical spines, blind nasal intubation, awake fiber optic intubation, peripheral nerve block, psoas compartment, nerve stimulator I. Introduction Airway management is the essential and topmost important component of general anesthesia and major responsibility of anesthesiologist during and after operation. For maintaining an intact functional airway and also for ventilating the anaesthetized patient, several techniques are advocated. Among those, endotracheal intubation achieved top most priority in airway management and also in ventilating the patient either for short term or long term procedure. Awake nasal intubation or fiber optic intubation is useful at the time of failed intubation or anticipated difficult intubation or at the time of failure of maintaining airway integrity and restoration of functional airway patency with mask ventilation. Laryngeal mask airway or intubating laryngeal mask airway is also useful to establish an airway patency of the patient in above purposes and also to avoid the pulmonary aspiration and pressure damage of the eye. But in emergency, this device (L.M.A.) is very much important life saving procedure for patent airway management to ventilate the anaesthetized patient. Ankylosing Spondylitis is always problematic and challenging case to anesthesiologist to anaesthetize the patient for their surgeries. In advanced form of Ankylosing Spondylitis, involvement of axial skeleton provides impracticability of central neuraxial procedure. The involvement of temporo-mandibular joint and fusion of cervical spine make the condition worst for intubation and general anesthesia become impossible without awake nasal or fiberoptic intubation. But both are troublesome, injurious and painful procedure without acceptance of patient. The Psoas compartment block with sciatic nerve block may form an alternative option to anesthetize. But its' reliability for major operation is doubtful. The sacral spinal anesthesia 1 or sacral epidural anesthesia 2 through its foramen is anticipated to be impossible due to obliteration of dorsal foramen of sacrum. For the above causes, decision was taken to anesthetize the patient with caudal anesthesia through the drilling hole on the sacral hiatus.