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Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 53-55

Caudal anesthesia for hemorrhoidectomy in a patient with ankylosing spondylitis: A case report

Department of Anesthesia, Santosh Deemed to be University, Santosh Medical College Hospital, Ghaziabad, Uttar Pradesh, India

Date of Web Publication6-Dec-2021

Correspondence Address:
Mahima Lakhanpal
Department of Anesthesia, Santosh Deemed to be University, Santosh Medical College Hospital, Ghaziabad, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-1732.331788

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Ankylosing spondylitis has always been a challenge to anesthesiologists due to its multisystem involvement. Both airway management and regional anesthesia administration is quite difficult as vertebral and ligaments fusion makes spine stiff and neck movements difficult. We report a case of a 42-year-old male posted for hemorrhoidectomy with a stiff spine and negligible neck movement. The successful caudal epidural block was administered after failure to reach subarachnoid space in multiple attempts.

Keywords: Ankylosing spondylitis, caudal epidural block, difficult airway

How to cite this article:
Lakhanpal M, Kumar R, Yadav I, Sarkar D, Aggarwal A. Caudal anesthesia for hemorrhoidectomy in a patient with ankylosing spondylitis: A case report. Santosh Univ J Health Sci 2021;7:53-5

How to cite this URL:
Lakhanpal M, Kumar R, Yadav I, Sarkar D, Aggarwal A. Caudal anesthesia for hemorrhoidectomy in a patient with ankylosing spondylitis: A case report. Santosh Univ J Health Sci [serial online] 2021 [cited 2022 Dec 8];7:53-5. Available from: http://www.sujhs.org/text.asp?2021/7/2/53/331788

  Introduction Top

Ankylosing spondylitis (AS) is a type of seronegative spondyloarthropathy affecting mainly the young population.[1] These patients often present with substantial airway restrictions and rigid spines. Spondylitis and marked limitation of lumbar spine motion are common in AS.[1] Regional anesthesia offers many advantages over general anesthesia in these patients,[2] but central neuraxial blocks are known to be difficult to perform; the usual reason cited is that fusion of the vertebral column renders neuraxial anesthesia difficult or impossible depending on the severity of the disease. The anesthetic approach to AS patients is to secure the airway either using fiberoptic or awake endotracheal intubation.[3] However as cervical spine involvement is also very common, anything from a degree of limitation of movement of the neck to complete ankylosis, usually in flexion, and occasionally with a rotational component can be encountered.[3],[4] Difficult intubation can be compounded further when the temporomandibular joint is involved. In severe cervical spine disease, the anesthesiologist may be confronted with the combination of difficult intubation and a predisposition to cervical fracture.[3],[4] Death from a retropharyngeal abscess that resulted from multiple attempts at blind intubation has been also reported.[4] Caudal anesthesia is also a mode of anesthesia that can be used in such patients. This type of anesthesia was successfully performed by DeBoard et al. in patients unwilling to awake endotracheal intubation for total hip replacement.[5] AS presents as a challenge for an anesthesiologist in delivering both regional and general anesthesia administration. In the present case report, we are reporting the management of a case of a patient with AS posted for hemorrhoidectomy. Patient written informed consent regarding the procedure was taken; the patient reviewed the case report and gave written permission for the authors to publish the report including photographs printing.

  Case Report Top

A 42-year-old male came with a history of fresh bleeding per rectum while passing stool. His history went back about 10 weeks when he noticed there were streaks of bright red blood coating his stool and spots of blood on the toilet pan. After a thorough physical examination, the diagnosis was confirmed as a case of hemorrhoids, and surgery was planned. The patient was not having a history of any surgical or medical illness in the past. Physical examination revealed the difficulty in bending forward and lateral with marked stiffness of the spine. The patient had almost negligible movement at the cervical spine. On further history, the patient gave the history of stiffness for more than 15 years gradually progressed to the present situation. Airway examination revealed mallampatti grading-IV with a limited mouth opening of 3 cm with limited movement at both atlantooccipital and atlantoaxial joints. Oral hygiene was poor with no loose teeth or artificial dentures. Routine blood examination was ordered along with X-ray sacroiliac joint with spine lumbar and cervical spine with both AP and lateral view. X-ray Sacroiliac joint showed bilateral erosions with loss of subchondral bone and apparent joint space widening in some areas and ill definition of the joint margin in other areas. X-ray spine both cervical and lumbar spine exhibited extensive formation of vertical syndesmophytes with bridging causing ankylosis [Figure 1]. Some facet joints were fused, best appreciated at the cervical region [Figure 2]. Radiological reports confirmed the diagnosis of AS.
Figure 1:

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Figure 2:

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Due to refusal of general anesthesia and awake intubation, a subarachnoid block was planned. The patient has explained the difficulty and failure of the procedure due to his existing disease condition. After informed written consent on the day of surgery, difficult airway management equipment was kept ready, as difficult intubation was anticipated. After thorough preparation subarachnoid block was attempted by three experienced anesthesiologist but even after multiple attempts by both median and paramedian approaches subarachnoid space could not be reached. Due to the unavailability of an ultrasound Case was postponed on that day. The case was again posted after 2 days with the planning of a caudal epidural block with the availability of a difficult intubation cart. Anesthesia plan was thoroughly discussed with the patient with explaining the need for awake intubation in case of failed caudal epidural block. After thorough preparation with the patient in the left lateral position, identification of sacral hiatus was made and a 22G needle was inserted till a “click” was felt, after confirming negative aspiration and “whoosh test,” 30-mL volume solution (20 ml of 0.5% Bupivacaine + 10 ml normal saline) was given as a single shot. The patient was then changed to the supine position. O2 inhalation was started with a face mask at 3 L. After 15 min block was assessed by alcohol wick test and loss of an anal reflex. After confirming and assuring the adequacy of the block, the surgeon was told to proceed. Surgery was done in 45 min with no requirement of any other mode of anesthesia and analgesia. There was no significant intraoperative problem with no requirement of vasopressors. Sensory and motor function returned to normal after 5 h. The patient was discharged after 2 days from the hospital.

  Discussion Top

AS has always been a challenge for anesthesiologists due to multisystem involvement. Stiffness of the cervical spine, atlantooccipital, temporomandibular, and cricoarytenoid joints may cause problems during endotracheal intubation. In AS, the inflammatory process usually begins at the sacroiliac joints and spreads upward to involve the spine and costovertebral joints resulting in lower back pain, limited rotation of the lumbar spine in all three planes, limited chest expansion, and neck stiffness.[3] The administration of neuraxial anesthesia and general anesthesia becomes difficult in these patients. As cervical fusion and limited neck, movement makes general anesthesia difficult, also ossification of interspinous ligaments and formation of syndesmophytes resulting in classical Bamboo spine makes the placement of spinal and epidural needle difficult.[4] DeBoard et al. in a case report mentioned successful administration of caudal block in a case of total hip replacement. As even in a severe disease where subarachnoid and epidural block is not possible caudal canal can be assessed by sacral hiatus.[5] In AS, functional limitations are more common in patients with more long-standing disease these limitations have largely been attributed to reduced spinal flexibility due to vertebral fusion. Breathing restriction, hip arthritis, peripheral arthritis, and AS activity may also contribute.[6],[7]

  Conclusion Top

As in this case report, successful management of a case of AS was done by administration of caudal block. We would advocate this mode of anesthesia in patients with AS posted for the lower abdomen, perineal surgeries. Nevertheless, it must be discussed with the patient and proper planning with an advanced airway cart should be ready.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Woodward LJ, Kam PC. Ankylosing spondylitis: Recent developments and anaesthetic implications. Anaesthesia 2009;64:540-8.  Back to cited text no. 1
Schelew BL, Vaghadia H. Ankylosing spondylitis and neuraxial anaesthesia – A 10 year review. Can J Anaesth 1996;43:65-8.  Back to cited text no. 2
Sinclair JR, Mason RA. Ankylosing spondylitis. The case for awake intubation. Anaesthesia 1984;39:3-11.  Back to cited text no. 3
Hill CM. Death following dental clearance in a patient suffering from ankylosing spondylitis – A case report with discussion on management of such problems. Br J Oral Surg 1980;18:73-6.  Back to cited text no. 4
DeBoard JW, Ghia JN, Guilford WB. Caudal anesthesia in a patient with ankylosing spondylitis for hip surgery. Anesthesiology 1981;54:164-6.  Back to cited text no. 5
Landewé R, Dougados M, Mielants H, van der Tempel H, van der Heijde D. Physical function in ankylosing spondylitis is independently determined by both disease activity and radiographic damage of the spine. Ann Rheum Dis 2009;68:863-7.  Back to cited text no. 6
Ward MM, Learch TJ, Gensler LS, Davis JC Jr., Reveille JD, Weisman MH. Regional radiographic damage and functional limitations in patients with ankylosing spondylitis: Differences in early and late disease. Arthritis Care Res (Hoboken) 2013;65:257-65.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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