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CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2021; 08(03): 228-229
DOI: 10.1055/s-0040-1719227
Correspondence

Anesthetic Management of an Ankylosing Spondylitis Patient with Normal Pressure Hydrocephalus for the Ventriculoperitoneal Shunt

Sakshi Thakore 
1   Department of Anesthesia, Paras Hospital, Gurgaon, Haryana, India
,
Varun Jain 
2   Department of Neuroanesthesia, Paras Hospital, Gurgaon, Haryana, India
,
Mukesh Gupta
2   Department of Neuroanesthesia, Paras Hospital, Gurgaon, Haryana, India
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Ankylosing spondylitis (AS) poses unique challenges to anesthesiologists owing to difficult airway and cardiorespiratory compromise.[1] [2] [3] We describe the anesthetic management of a case of AS with normal pressure hydrocephalus (NPH) for lumbar puncture (LP) followed by ventriculoperitoneal shunt (VPS) surgery.

A 68-year-old male weighing 65 kg, case of AS for 25 years, American Society of Anesthesiologists (ASA) grade III presented with gradually progressive slowness of gait and urinary incontinence for 5 months. Computed tomography scan of head was suggestive of hydrocephalus. Magnetic resonance imaging cervical spine revealed ankylosis of cervical vertebrae with arthrosis of the atlantoaxial joint ([Fig. 1]). LP was performed in left lateral position with limited hip and knee flexion. 40 mL cerebrospinal fluid (CSF) was drained at a pressure of 12 mm Hg. Patient showed significant improvement in gait and a diagnosis of NPH was established. He was then posted for VPS the next day. Preanesthetic evaluation of the airway revealed restricted mouth opening (2 cm), Mallampati class IV, fixed flexion deformity of neck, and loss of cervical and lumbar lordosis. Breath holding time was 20 seconds and pulmonary function test revealed severe restrictive lung disease (forced expiratory volume in 1 second [FEV1] 34%, forced vital capacity [FVC] 33%, FEV1/FVC 101%). Risks of anesthesia pertaining to difficult airway and perioperative pulmonary complications were explained and consent for anesthesia was obtained, but patient refused for awake fiberoptic bronchoscopic (FOB) intubation. He was taught deep breathing exercises (DBE) and incentive spirometry (IS).

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Fig. 1 Left side: Noncontrast computed tomography (NCCT) head (axial cut) showing hydrocephalus. Right side: Magnetic resonance imaging (MRI) cervical spine (T1 sequence sagittal) showing ossified vertebral column.

On the day of surgery, standard ASA monitoring was applied and a stack of pillows and gel-ring were placed under the head and neck in Trendelenburg position ([Fig. 2]). After preoxygenation with 100% oxygen for 5 minutes, induction was done with 100 mcg fentanyl and 20 mg graded boluses (total 60 mg) of propofol to preserve spontaneous breathing. However, breathing became shallow and jerky due to backward falling of tongue and airway obstruction. Bag mask ventilation (BMV) was inadequate with nasopharyngeal airway (NPA) (size 8.0) but became possible with oropharyngeal airway (OPA). Due to failed attempt through oral FOB, plan was changed to nasal FOB. Glottic opening could be visualized only after pulling the tongue anteriorly and 7.5 mm endotracheal tube was advanced under vision into the trachea. Anesthesia was maintained with oxygen, air, desflurane, and atracurium. Because of nonmaneuverability of the neck, conventional surgical position with neck rotation was not possible and shunt was manipulated from the cranial burr (Kocher’s point) in three passes. Patient was shifted to intensive care unit postoperatively. After the reversal of neuromuscular blockade, he was extubated when fully awake, obeying commands with adequate spontaneous respiratory efforts. DBE and IS were continued in the postoperative period. He was discharged on second postoperative day and was doing well with improvement in symptoms at 2 weeks’ follow-up.

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Fig. 2 Patient positioning (head low with pillows) to support head in fixed flexion deformity.


Publication History

Article published online:
03 December 2020

© 2020. Indian Society of Neuroanaesthesiology and Critical Care. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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