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Table of Contents    
BRIEF REPORT
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1756-1758

Perioperative Management of a Patient with Chin-On-Chest Deformity Presenting for Reconstructive Spine Surgery


1 Department of Neuroanaesthesiology and Critical Care, 710, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Physiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
3 Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Submission26-Apr-2020
Date of Decision09-Jun-2020
Date of Acceptance07-Oct-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Keshav Goyal
Department of Neuroanaesthesiology and Critical Care, 710, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333489

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 » Abstract 


Chin-on- chest deformity is not uncommon sequelae of ankylosing spondylitis. Apart from difficult airway, several other considerations might include co-existing cardio-respiratory embarrassment, osteoporotic bones, and neurological perturbations. We describe the successful anesthetic management of a case of chin-on-chest deformity with no access to midline neck structures and extremely difficult airway posted for corrective spine surgery.


Keywords: Ankylosing spondylitis, chin-on-chest deformity, difficult airway, fibreoptic bronchoscopy
Key Message: Fixed flexion neck deformity due to ankylosing spondylitis presenting for corrective spine surgery brings forth tremendous anesthetic challenges. Great Team work at all stages by thorough preoperative assessment, appropriate planning, anticipation of complications and preparedness leads to better outcome.


How to cite this article:
Khandelwal A, Sokhal S, Dube SK, Goyal K, Singh A, Tandon V, Phalak M, Chaturvedi A, Kale SS. Perioperative Management of a Patient with Chin-On-Chest Deformity Presenting for Reconstructive Spine Surgery. Neurol India 2021;69:1756-8

How to cite this URL:
Khandelwal A, Sokhal S, Dube SK, Goyal K, Singh A, Tandon V, Phalak M, Chaturvedi A, Kale SS. Perioperative Management of a Patient with Chin-On-Chest Deformity Presenting for Reconstructive Spine Surgery. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1756-8. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1756/333489




Ankylosing spondylitis (AS) is a painful chronic inflammatory arthritis characterized by exacerbations and quiescent periods.[1] AS can present significant challenges to the anesthetist as a consequence of the potential difficult airway, cardio-respiratory complications, osteoporotic bones, increased predisposition to neurological injury and the side-effect of drugs used to reduce pain and control the disease. We wish to report the successful anesthetic management of a case of chin-on-chest deformity and extremely difficult airway posted for corrective spine surgery. We obtained written consent from the patient's husband for reporting this case for publication.


 » Brief Report Top


A 33 years female (50 kg/152 cm) presented with extreme fixed flexion deformity of neck (chin-brow angle- 103°) as a sequelae of AS (HLA- B27) and was scheduled for corrective spine surgery [Figure 1]a. She had a history of receiving recombinant human parathyroid hormone (20 μg daily subcutaneously) for osteoporosis. Currently, she was on sulfasalazine (1 gram thrice daily orally). She did not have any other co-morbidities. Sensory and motor functions were intact. On airway examination, mouth opening was found to be 3 cm breadth. Evaluation of Mallampati and other airway scorings were not possible. Midline neck structures including trachea were not accessible. Other complicated issues were inability to gargle, lack of landmarks for airway blocks, left-sided deviated nasal septum, no scope for both preoperative or even emergency tracheostomy/cricothyroidotomy, and associated marked kyphoscoliosis. Moreover, it was not possible to conduct pulmonary function test. However, functional status was reasonably fair as revealed by clinical tests (breath holding time of 20 seconds, single breath count of 16 and a 6-minute walk test of 371 meters). As a result of anticipated difficult airway, preoperative mock drills were carried out. We planned awake fibreoptic intubation (FOI) through right nostril. Our patient received ranitidine 150 mg orally and glycopyrrolate 0.2 mg IM as premedication. In the operating room (OR), all emergency drugs including difficult airway cart were kept ready. The patient was propped up on a ramp created with pillows and padding. Thereafter, her airway was prepared using 0.1% xylometazoline nasal drop, 10% lignocaine spray (40 mg, orally) and 4% lignocaine nebulization (80 mg). The nasal passage way was also dilated progressively with a 6.0 mm and 6.5 mm nasal airway which had been lubricated with 2% viscous lidocaine. While standing in front of the patient, awake nasal FOI (flexometallic ETT) was carried out successfully through the right nostril using spray-as-you-go (SAYGO) technique (2% lignocaine, 40 mg). Induction of anesthesia was achieved with fentanyl (150 μg) and propofol (100 mg). A single dose of rocuronium (50 mg) was used during induction. Maintenance of anesthesia was done with oxygen (50%) and air along with continuous infusions of propofol (titrated to maintain bispectral index of 40-50) and fentanyl (2 μg/kg/hour). No muscle relaxant (MR) was administered further in view of motor evoked potential (MEP) monitoring in addition to somatosensory evoked potential (SSEP) monitoring. A mouth gag was also placed to prevent tongue bite due to MEP stimulation. We also administered paracetamol 1 gram every 6 hourly. Ultrasound-guided cannulation of right internal jugular vein was done to guide fluid therapy. Invasive arterial line was secured for beat-to-beat monitoring of blood pressure and blood gas sampling. The patient was positioned in sitting posture with the head stabilized on a Mayfield head clamp. Mechanical DVT pumps were applied to both lower limbs. All the pressure points were adequately padded. Body temperature was maintained using warm IV fluids, warming blankets and ambient OR temperature. Incision was given from C2-D5 and freehand lateral mass screws were inserted from C4-C6 (left) and C3-5 (right) with bilateral dorsal pedicle screws from D2-4. Fused and osteoporotic bones were suggestive of ankylosed spine. A C7 pedicle subtracting osteotomy was done along with laminectomy at C7-D1. Fused facet joints were drilled and finally gradual manual correction was done after application of temporary rod on dorsal aspect on one side and cervical aspect on other side. Further correction could be achieved by tightening the pre-contoured rod and finally fixing it in desirable position. A significant drop in MEP amplitude of abductor pollicis brevis bilaterally and right lower limb muscles was encountered immediately after neck extension which improved gradually after partial adjustment of head position [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. Simultaneously, a single dose of IV methylprednisolone 1500 mg (30 mg/kg) was administered over 1 hour. Total blood loss of 1200 ml during surgery was adequately replaced with fluids and blood. The total duration of surgery and anesthesia were 600 and 720 minutes respectively. The patient was electively ventilated after the surgery and extubated successfully on the 2nd postoperative day. Chin-brow angle in the postoperative period was calculated to be 59°. Thus, a correction of chin-brow angle of 44° was achieved [Figure 1]b. The patient was finally discharged from the hospital on the 14th postoperative day without any neurological deficit.
Figure 1: Showing orientation of head and neck of the patient in standing position in preoperative (a) and postoperative period (b)

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Figure 2: (a-d) showing trends of motor evoked potentials during surgery

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 » Discussion Top


AS is classified as an autoimmune seronegative spondyloarthropathy that primarily affects the spine and sacroiliac joints and eventually causes fusion and rigidity of the spine (bamboo spine). Symptoms develop before the third decade of life in 80% of patients and the mortality rate is 1.5–4 times higher than the general population.[1],[2] Chin-on-chest deformity that develops as a sequelae of AS causes severe pain and dysphagia in addition to patient's inability to look straight. Moreover, the high incidence of cervical vertebral fractures due to osteoporosis places such patients at a significant risk of neurological insult.[3] In our case, the major intraoperative anesthetic challenges included management of difficult airway, patient positioning, blood loss, neurophysiological monitoring, venous air embolism, temperature and thromboembolism.

In our patient, due to abnormal, fixed chin-brow angle (103°) and restricted mouth opening (3 cm breadth), we planned awake, nasotracheal FOI. The goal of awake intubation was to avoid the loss of airway under anesthesia and to continuously monitor neurological status. We administered a lignocaine dose of about 3.2 mg/kg (160 mg) for conducting topical anesthesia of the airway, which was well within the safe-limit of 8.2 mg/kg as recommended by the British Thoracic Society for bronchoscopy.[4] Rather than intubating the trachea by standing behind the patient, we did intubation from the front of the patient which provided an upside down view. Although other potential substitutes such as laryngeal mask airway (LMA), Glidescope, Bullard Laryngoscope and Pentax –AWS,[5],[6],[7],[8] have been used successfully for tracheal intubation in patients of severe AS, in our case, their use were limited by severe fixed flexion deformity, tilting of head to right side and restricted mouth opening. Again, retrograde intubation and invasive airway access were not possible as the anterior neck structures including the larynx, the trachea, and the carotid arteries were not identifiable and not palpable.

In our case, we had employed both SSEP and MEP to monitor sensory and motor tracts respectively. Since inhalational anesthetics cause dose-dependent decrease in amplitude and increase in latency,[9],[10] we maintained anesthesia with intravenous propofol and opioid. Evoked potentials were recorded before and during the process of manual neck extension. Following extension of the neck, there was decrease in the amplitudes of few muscles (as mentioned above), the systemic physiological parameters remaining within normal limits and close to baseline. This, however, improved gradually after partial adjustment of head position. This signifies the importance of evoked potentials for early detection of compromised neuronal structures in spine surgery. At the same time, we administered methylprednisolone which has been shown to attenuate neurological complications and improve evoked potentials following iatrogenic spinal cord handling during spine surgery.[11],[12] However, it should be remembered that methylprednisolone is not indicated in the context of an acute traumatic spinal cord injury.

No undue complications occurred in our patient despite extensive surgical resection in sitting position. Fluid and blood were replaced appropriately as per the losses. It was prudent to ventilate the patient after surgery due to extensive surgery, prolonged duration, airway edema and difficult airway. In the ICU, emphasis was stressed on early extubation, resumption of feeding, and early ambulation.


 » Conclusion Top


Fixed flexion neck deformity due to ankylosing spondylitis presenting for corrective spine surgery brings forth tremendous anesthetic challenges. The risk of complications increases several folds due to difficult airway, sitting position surgery, underlying osteoporosis, increased risk of venous thromboembolism, lengthy surgical duration and large amount of blood loss. Emphasis should be made on thorough preoperative assessment, appropriate planning, anticipation of complications and preparedness to deal with complications.

Acknowledgement

We sincerely acknowledge the contribution of Dr David Victor Kumar (Associate Professor, Department of ENT, AIIMS, New Delhi).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Woodward LJ, Kam PC. Ankylosing spondylitis: Recent developments and anaesthetic implications. Anaesthesia 2009;64:540-8.  Back to cited text no. 1
    
2.
Shaikh S. Ankylosing spondylitis: Recent breakthroughs in diagnosis and treatment. J Can Chiropr Assoc 2007;51:249-60.  Back to cited text no. 2
    
3.
Jacobs WB, Fehlings MG. Ankylosing spondylitis and spinal cord injury: Origin, incidence, management, and avoidance. Neurosurg Focus 2008;24:E12.  Back to cited text no. 3
    
4.
Williams KA, Barker GL, Harwood RJ, Woodall NM. Combine nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth 2005;95:549-53.  Back to cited text no. 4
    
5.
Kumar R, Prashast, Wadhwa A, Akhtar S. The upside-down intubating laryngeal mask airway: A technique for cases of fixed flexed neck deformity. Anesth Analg 2002;95:1454-8.  Back to cited text no. 5
    
6.
Lai HY, Chen IH, Chen A. The use of the GlideScope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 2006;97:419-22.  Back to cited text no. 6
    
7.
Gorback MS. Management of the challenging airway with the Bullard laryngoscope. J Clin Anesth 1991;3:473-7.  Back to cited text no. 7
    
8.
Cheng WC, Jimmy-Ong, Lee CL, Lan CH, Chen TY, Lai HY. Pentax-AWS Airway Scope for tracheal intubation breaks through the limitation of neck motion in an ankylosing spondylitis patient wearing halo vest-a case report. Acta Anaesthesiol Taiwan 2010;48:180-1.  Back to cited text no. 8
    
9.
Pechstein U, Nadstawek J, Zentner J, Schramm J. Isoflurane plus nitrous oxide versus propofol for recording of motor evoked potentials after high frequency repetitive electrical stimulation. Electroencephalogr Clin Neurophysiol 1998;108:175-81.  Back to cited text no. 9
    
10.
Pelosi L, Stevenson M, Hobbs GJ, Jardine A, Webb JK. Intraoperative motor evoked potentials to transcranial electrical stimulation during two anaesthetic regimens. Clin Neurophysiol 2001;112:1076-87.  Back to cited text no. 10
    
11.
Wiginton JG 4th, Brazdzionis J, Mohrdar C, Sweiss R, Lawandy S. Spinal cord reperfusion injury: Case report, review of the literature, and future treatment strategies. Cureus 2019;11:e5279.  Back to cited text no. 11
    
12.
Jeon DG, Park YG, Cho YE, Kim DP, Park J. Effects of intravenous methylprednisolone on intraoperative neurophysiological monitoring during spinal cord tumor surgery: A case report. J Intraoper Neurophysiol 2019;1:50-4.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2]



 

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