Abstract ID: A38
Abstract Title: Fluoroscopic Imaging for Technically Difficult Spinal Anesthesia
Poster Type:
ABSTRACT BODY
Introduction:: Fluoroscopic imaging has been demonstrated to facilitate numerous regional anesthetic and invasive pain procedures. We present the first report to our knowledge of fluoroscopic guidance to implement spinal anesthesia
Case Report: A 43 year-old, 155 cm, 130 kg female with morbid obesity (BMI 54) presented with subchondral cyst of the left distal femur. She was planned for excision of the cyst with left iliac crest bone graft transplant to the lateral femoral condyle. The patient firmly refused general anesthesia but agreed to a spinal anesthetic. In the operating room the patient was placed in the sitting position. On examination, the vertebral landmarks were poorly appreciated and the midline could not be easily determined. Numerous attempts to locate the intrathecal space using the conventional "blind technique" were futile. It was then decided to perform the spinal anesthesia under fluoroscopic guidance. The patient remained in the sitting position. However, successful regional anesthesia still could not be implemented notwithstanding multiple attempts using both 24g, 12.0 cm Sprotte and 22g, 17.78 cm Quincke needles inserted into the L4-L5 and L5-S1 inter-spaces. Subsequently the patient was placed in the prone position and the fluoroscopic image became significantly clearer. Yet again the subarachnoid space could not be located at the L5-S1 level using a 22g, 17.78 cm Quincke needle without introducer. Next a 17g 9.84cm long Tuohy needle was inserted to the hub at the L4-L5 level to function as the introducer. Under fluoroscopic guidance using single shot PA and lateral views a 22g, 17.78cm Quincke spinal needle was used to successfully identify the intrathecal space at a depth of 16 cm. A satisfactory block was obtained and the patient underwent uneventful surgery. There were no apparent complications and on follow-up post dural-puncture headache was not reported.
Discussion: It is not unusual for a patient to refuse general anesthesia. However, in this case our alternatives were further limited because lower extremity blockade would not have provided adequate anesthesia to obtain the iliac crest bone graft. Essentially, our only option was spinal anesthesia. The patient’s body habitus and the formidable depth of 16 cm to the intrathecal space resulted in futile placement of the spinal anesthetic using the conventional blind method. The use of the Tuohy needle as an introducer has been previously reported (1) and was essential to reach the deeply located ligamentous structures. The prone position compressed the abdomen and significantly improved the clarity of the fluoroscopic resolution. Ultimately though, the procedure would not have been possible without the radiological guidance provided by the fluoroscopic c-arm. Our case demonstrates the utility of fluoroscopy to facilitate technically difficult spinal anesthesia and the higher degree of safety imaging affords when the intrathecal space is located significantly deep. Moreover, the case illustrates that even after multiple attempts at regional anesthesia, each with increasing degrees of complexity, perseverance pays!
Ref: 1. Nouri M et al, Utilization of a Tuohy needle for insertion of a spinal needle, Ann Fr Anesth Reanim, 1999;18:69
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A38