|Year : 2007 | Volume
| Issue : 6 | Page : 546-549
A case of severe ankylosing spondylitis posted for hip replacement surgery
Nalini Kotekar1, NV Nagalakshmi2, Gururaj3, Mujeeb Rehman3
1 M.D., D.A, Associate professor, Department of Anesthesiology, JSS Medical College, Ramanuja Road, Mysore, India
2 M.D., D.A., Professor & HOD, Department of Anesthesiology, JSS Medical College, Ramanuja Road, Mysore, India
3 P.G. Student, Department of Anaesthesiology, JSS Medical College, Ramanuja Road, Mysore, India
|Date of Acceptance||26-Sep-2007|
|Date of Web Publication||20-Mar-2010|
Department ofAnaesthesiology, J.S.S Hospital,Ramanuja Road, Mysore - 570004
Source of Support: None, Conflict of Interest: None
A 50-year-old male patient with history of ankylosing spondylitis (AS) for 30 years presented for hip replacement surgery. Airway management in ankylosing spondylitis patients presents the most serious array of intubation and airway hazards imaginable, which is secondary to decrease in cervical spine mobility and possible temporo-mandibular joint disease. Literatures support definitive airway management and many authors consider regional anaesthesia to be contraindicated. The reasons cited include inability to gain neuraxial access and the need for urgent airway control in case of complication of regional anaesthesia.
Keywords: Ankylosing spondylitis; Patient positioning; ′Bamboo spine′; Difficult intubation
|How to cite this article:|
Kotekar N, Nagalakshmi N V, Gururaj, Rehman M. A case of severe ankylosing spondylitis posted for hip replacement surgery. Indian J Anaesth 2007;51:546-9
|How to cite this URL:|
Kotekar N, Nagalakshmi N V, Gururaj, Rehman M. A case of severe ankylosing spondylitis posted for hip replacement surgery. Indian J Anaesth [serial online] 2007 [cited 2020 Jan 28];51:546-9. Available from: http://www.ijaweb.org/text.asp?2007/51/6/546/61198
| Introduction|| |
Ankylosing spondylitis is a disease characterized by inflammation and fusion of the sacro-iliac joint and lumbar vertebrae with involvement of the thoracic and cervical spine. It is commonest in males with a high proportion carrying tissue type antigen HLA B27. 
The manifestations include backache and stiffness with the possibilities of spinal cord compression , atlantoaxial subluxation or cervical fracture. Spinal and extradural anaesthesia are usually technically difficult. Tracheal intubation may be difficult due to a stiff or rigid neck or temporo mandibular joint(TMJ) involvement. If thoracic or costovertebral joints are severly affected it results in restricted ventilation.
This case report details the problems faced by the anaesthesiologist in positioning the patient, difficulty in administering neuraxial block and how difficult intubation was over come without using the fibreoptic means for intubating, which had been kept as a last resort. ,
| Case report|| |
A 50-year-old male patient presented with pain in both hip joints since 4 years, after a road traffic accident and was unable to move without support. Pain was insidious in onset and progressive and some relief was got by keeping pillows below knee joints. The patient had a history of cervical and thoraco-lumbar spondylitis since 30 years, with inability to bend forwards or side ways since 12 years. Since 3 years he could get some pain relief with non-steroidal anti-inflammatory drugs. His mother andsister too gave history of ankylosing spondylitis.
The patient had a cautious and antalgic gait (ambulation with crutches) with a fixed flexion deformity of 30 degrees of both hip joints. Movements of spine were restricted and painful. Neck movements were restricted and he was unable to extend, flex or rotate the neck, he had kyphosis of the thoracolumbar spine, he could barely sit on the edge of the bed with the support of both his upper limbs. He took the help of 4-5 pillows to support his neck and cervical spines, if he needed to get to the supine position.
His airway assessment showed restricted mouth opening of 3 cms with ankylosis of temporomandibular joint and a Mallampatti grade 3 score.
His pulse rate was 86 beats per minute and BP was 140/90 mm of Hg. X-ray showed cervical spondylitis, kyphosis of the thoracolumbar spine , total ankylosis of spine along with ankylosis of both hip joints. His pulmonary function tests showed mild restrictive airway disease. Other investigations like haemogram, blood sugars and ECG were within normal limits.
Equipment to assist or maintain airway was immediately available.Adifficult intubation cart which had a selection of oropharyngeal airway, nasopharyngeal airway, gumelastic bougie, laryngeal mask airway, fibreoptic laryngoscope, cricothyroidotomy needle and surgical set for tracheostomy, was kept ready.
The patient was shifted to O.T. on a trolley in supine position with 5 pillows under the back and head and two pillows under the knee joint[Figure 1]. With an aim to avoid airway manipulation, patient was put in lateral position and few attempts of epidural (for catheter insertion) and sub arachnoid block were made but proved impossible because of the rigid and deformed spine.
The patient was put back to supine position with all 5 pillows. To be able to perform laryngoscopy, the anaesthesiologist had to stand on a big foot stool so as to get the position directly above the patient's face because the distance of the patient's mouth from the O.T. table surface was about 1½ ft , with a rigid neck which could not be flexed or extended[Figure 2].
It was decided to keep the fibreoptic intubation option as the last resort, so that we could have the experience of intubating such a challenging case in the conventional way, just as we would do in the absence of a sophisticated setting.
Pre oxygenation was done for 3 min with 100% O 2 after pre medication with fentanyl 30 mcg and glycopyrrolate 0.2 mg. Induction was done with propofol 2mg.kg -1 and 1mg.kg -1 succinylcholine was given after confirming the possibility of adequate mask ventilation. One assistant stabilized the head so that undue manipulation of the head and neck was avoided. Laryngoscopy was performed with another assistant giving firm pressure over the cricoid and anterior larynx so as to bring the trachea into the intubating plane. Vocal cords could not be visualized. Blind attempts were made with no.7 oral endotracheal tube with a stylette, with the hand above the neck acting as a firm guide to confirm the correct positioning of the tube. Oxygenation was given intermittently between attempts of intubation. The third attempt with an acutely curved endotracheal tube proved successful, without the SpO 2 dropping below 96%. Bilateral air entry was equal and was confirmed by capnography. Patient was maintained on N 2 O and O 2 with controlled ventilation and vecuronium, fentanyl 40 mcg and midazolam 1mg were administered. During the 3 h procedure patient received 1000 ml of Ringer lactate and 1000 ml of DNS. Total blood loss was 3000 ml. After reversal with neostigmine 2.5 mg and atropine 1.2 mg patient was extubated after suctioning the oral cavity under direct laryngoscopy and assuring that patient maintained 99% saturation on roomair The patient's post operative course was unremarkable.
| Discussion|| |
Ankylosing spondylitis (AS) is a disease that may deform any portion of the spine and may be encountered in patients who present for corrective surgery of the hips or knees. The uniform development of widespread annular fibrous ossification and the formation of bony bridges (syndesmophytes) are largely responsible for the classic radiographic appearance of the "bamboo spine" of end-stage ankylosing spondylitis. The closely applied posterior longitudinal ligament and more remote interspinous ligaments may become converted to continuous bony bars, augmenting the spinal rigidity. These pathological changes can make airway management and mid-line placement of epidural or spinal needles difficult or impossible. Several textbooks of anaesthesia consider that any form of anaesthesia, whether general or more particularly regional, is hazardous despite reports of the successful use of caudal epidural anaesthesia. ,
The aetiology of AS is unknown but numerous bacteria and viruses have been blamed for inducing disease in genetically susceptible individuals. Astrong association has been found between a genetic marker HLAB27 and AS. The incidence of HLA-B27 is less than one percent in general population whereas it is present in more than 85% of patients with AS  .
The diagnosis of AS is made clinically according to accepted criteria. A small proportion of sufferers develop complete spinal ankylosis with or without extraarticular complications. There is restricted movement of the costovertebral joints, which reduces vital capacity and ventilation becomes progressively dependent on diaphragmatic function. This results in a death rate from respiratory causes 2.5 to 3 times higher than normal. Stiffness of the cervical spine, atlanto-occipital, temporomandibular and cricoarytenoid joints may cause problems with tracheal intubation. 
The identification of a patient at an increased risk of complications, because of problems in the maintenance of the airway, requires discussion with the patient regarding the options for airway management. A patient who is likely to have upper airway problems immediately after lossof consciousness requires ananaesthetic plan in which tracheal intubation is accomplished before anaesthetic induction or immediately after an expeditious induction. ,
It is believed that the patency of airway is surprisingly well maintained despite the loss of bony mobility and most peripheral procedures, for example on the limbs, are carried out without tracheal intubation. The degree of difficulty in maintaining the airway, either by mask, laryngeal mask airway or by tracheal intubation under direct vision, can range from none to impossible. The difficulty for each technique may be independent, and may change with time. Difficulty in managing the airway is the single most important cause of major anaesthesia-related morbidity and mortality. Whatever technique is selected, the airway must be managed in such a way that it is continuously patent. Various techniques and algorithms for airway management have been published, but there will still be occasions where anaesthetists are faced with failure to secure the airway, for reasons such as those highlighted above.
Patients with AS may have cardiac and pulmonary disease and therefore are at increased anaesthetic risk.
Extra-articular manifestations inAS: In addition to articular symptoms.Apatient with ankylosingspondylitis may have the following extra-articular manifestations: 
- Ocular: About 25 percent patients with ankylosing spondylitis develop at least one attack of acute iritis some times during the natural history of the disease. Many suffer from recurrent episodes which may result in scarring and depigmentation of the iris.
- Cardiovascular: Patients with ankylosing spondylitis, especially those with a long standing illness, develop cardiovascular manifestations in the form of aortic incompetence, cardiomegaly, conduction defects, pericarditis etc.
- Neurological: Patients may develop spontaneous dislocation and subluxation of the atlanto-axial joint or fractures of the cervical spine with trivial trauma, and may present with signs and symptoms of spinal cord compression.
- Pulmonary: The involvement of the costovertebral joints lead to painless restriction of the thoracic cage. This can be detected clinically by diminished chest expansion, or by performing pulmonary function test (PFT). Bilateral apical lobe fibrosis with cavitation may also occur, which remarkably simulate tuberculosis on the X-ray.
- Systemic: Generalized osteoporosis occurs commonly, occasionally, a patient may develop amyloidosis.
Most anaesthesia-related problems occur because of difficult tracheal intubation. The management of difficult intubation has been simplified as more experience is gained with fibreoptic technique. A planned and unhurried fibreoptic intubation represents a safe, predictive alternative management strategy for patients with AS. Concern also exists that if the tracheal intubation has been difficult, the extubation may be hazardous.
Regional anaesthesia is a valuable option if thescope of the surgery is appropriate. It requires the surgery to be defined precisely in duration and site, patient acceptance, easy and accessible anatomy and to incorporate both intraoperative and postoperative analgesia into a single approach. Use of regional anaesthesia in AS is not new and has been used for appropriate surgery. Wittman and Ring considered epidural or spinal anaesthesia to be contra-indicated in AS because the placement of an epidural or spinal needle may be difficult or impossible due to ossification of interspinous ligaments and bony bridges and tracheal intubation may still be required should there be a complication from the regional technique, such as intravenous injection of local anaesthetic or a very high block. 
Management of anaesthesia in patients with ankylosing spondylitis is influenced by the magnitude of upper airway involvement by the disease, the presence of restrictive patterns of breathing due to costochondral rigidity and flexion deformity of the thoracic spine, and the degree of cardiac involvement.Awake fibreoptic tracheal intubation is performed if the spinal column deformity is extensive. Excessive manipulation of the cervical spine could injure the spinal cord. Intra operatively, ventilation of the lungs should be supported, as the chest wall is stiff and breathing is diaphragmatic. Neurologic monitoring should be considered. Epidural or spinal anaesthesia is an acceptable alternative to general anaesthesia in the presence of ankylosing spondylitis and perineal or lower limb surgery. Regional anaesthesia may be technically difficult owing to limited joints mobility and closed inter spinous spaces, although ossification of the ligamentum flavumis uncommon in these patients. ,,,.
In conclusion anesthetic considerations for the patient with ankylosing spondylitis include difficulty with positioning, difficult or impossible access to the airway, chronic central neuropathy, and increased technical difficulty with neuraxial aneasthesia.
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[Figure 1], [Figure 2]