An approach to neuraxial anaesthesia for the severely scoliotic spine

Abstract

We report on a case in which computed tomography was used to guide placement of an epidural catheter in a patient with severe scoliosis and congenital dwarfism. In addition, the computed tomograms were corroborated with ultrasound and fluoroscopic images in the patient. Three years later, the patient had a spinal anaesthetic performed with only the use of ultrasound-guidance. Ease of placement of the epidural and spinal was greatly enhanced by imaging. We present an algorithmic approach to neuraxial anaesthesia in the patient with scoliosis to help guide placement. The algorithm first directs the provider to determine the type and severity of the scoliosis from the patient's history, physical examination, and any prior radiologic studies. If the anaesthesia provider understands and is comfortable with the patient's anatomy, then the provider may cautiously proceed with placement. Depending upon the degree of lateral curvature (Cobb angle), idiopathic scoliosis is classified as mild (11-25°), moderate (25-50°), or severe (>50°). Mild idiopathic scoliosis is managed with good positioning. Moderate idiopathic scoliosis is managed with a paramedian approach on the convex-side of the curve or a midline approach with angulation towards the convex-side or with the aid of imaging such as ultrasound. Severe idiopathic scoliosis is managed with the assistance of imaging or an alternative form of pain management should be considered. A systematic approach may facilitate safe, efficient, and successful neuraxial anaesthesia procedures in the scoliotic patient.

Development of an Ultrasound Phantom for Spinal Injections With 3-Dimensional Printing

“…It is increasingly being used to guide needle insertions in the spinal region such as central neuraxial and paravertebral blocks, 1-3 particularly in patients with complex anatomies. 4,5 In a recent review by Kirkham and Chin,6 the use of ultrasound is said to reduce the number of needle insertions and redirections, minimize the risk of traumatic needle placements, and improve block effectiveness after epidural placement. However, interpreting ultrasound images and maintaining visibility of the needle tip can be challenging, particularly for trainees.…”

Thoracolumbar curve and Cobb angle in determining spread of spinal anesthesia in Scoliosis. An observational prospective pilot study

“…Investigators have suggested techniques like use of high-tech imaging modalities to assess the depth and intervertebral space identification to guide the needle angulation for a successful lumbar puncture. [ 10 ] In our study, with the use of simple instrument (Goniometer), we found that an acute angulation of 4° ± 2.45° for Cobb angle <50° and 9.14° ± 2.45° for Cobb angle >50° was noted for successful SAB. This was easier and the best way to approximate needle angle for successful SAB based on severity of scoliotic curve.…”

Anaesthetic Considerations in Neurofibromatosis Complicated with Kyphoscoliosis and Restrictive Lung Disease

“…In cases where the spinous processes are palpable and a median approach is planned the needle should be forwarded in the transverse plane towards the convex side. The authors recommend ultrasound guided access of the subarachnoid space or an alternate modality of pain management for a severely scoliotic spine (cobb's angle >50 degrees) [15] .…”