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ORIGINAL ARTICLE
Year : 2022 | Volume
: 12
| Issue : 2 | Page : 140-143
Spinal anaesthesia in kyphoscoliotic parturients undergoing caesarean delivery – A retrospective study from a tertiary care centre in India
Ranju Singh1, Rashi Sardana2, Pooja Singh2
1 Department of Anaesthesia, Lady Hardinge Medical College and Shrimati Sucheta Kriplani and Kalawati Saran Children's Hospital, New Delhi, India
2 Department of Anaesthesia, Lady Hardinge Medical College and Smt Sucheta Kriplani and Kalawati Saran Children's Hospital, New Delhi, India
Correspondence Address:
Dr. Pooja Singh
H-32/64, Sector-3, Rohini, Delhi - 110 085
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_78_21
Introduction: Kyphoscoliosis with pregnancy is a rare but serious disorder which often requires caesarean delivery. Both general and regional anaesthesia have been used in these cases but data regarding outcomes with spinal anaesthesia (SA) are limited. Methods: We conducted a retrospective study to identify patients with kyphoscoliosis undergoing caesarean delivery at a tertiary care hospital in India. Those parturients who received SA were compared with those receiving general anaesthesia (GA group) with respect to cardiorespiratory parameters, maternal outcomes and neonatal outcomes. Results: The GA group had significantly worse cardiorespiratory parameters including pulmonary function tests, right atrial pressures and cardiac ejection fraction as compared to SA group. All the GA group patients required mechanical ventilation while no patients in the SA group needed mechanical ventilation. Intraoperative hypotension was more common in the SA group. Neonatal outcomes were worse in the GA group with lower Apgar scores at 1 and 5 min and more nursery admissions than the SA group. No maternal or neonatal deaths occurred in either group. Conclusion: Kyphoscoliotic parturients scheduled for CD can be successfully managed with SA with good maternal and neonatal outcomes. GA may be reserved for severe kyphoscoliotic parturients with cardiorespiratory complications. The safety of SA in severe kyphoscoliosis requires further studies.
Keywords: Anaesthesia, Cobb's angle, kyphoscoliosis, pregnancy
Kyphoscoliosis includes kyphosis which is anteroposterior spinal angulation and scoliosis which is a lateral deviation in the vertical axis of the spine. Kyphoscoliosis and pregnancy represent a perilous association with risks of morbidity and mortality. Severe kyphoscoliosis has been noted in pregnancy with a prevalence ranging from 1:1400 to 1:12,000 cases.[1] While the prevalence of severe kyphoscoliosis is decreasing in most countries, milder cases are being identified more frequently.[2] Kyphoscoliosis leads to restrictive lung disease resulting in hypoxemia and cardiorespiratory compromise. The physiological changes of pregnancy create an additional demand on the already strained respiratory and cardiovascular systems in patients with kyphoscoliosis. Considering the maternal and foetal risks created by this scenario, elective or emergency Caesarean delivery (CD) is often required in such cases. Anaesthetic management of kyphoscoliotic parturients undergoing CD is controversial – both general as well as regional anaesthesia have been tried. General anaesthesia (GA) is recommended in cases where severe cardiorespiratory compromise exists (as there is a possibility of high regional anaesthetic block due to the spinal deformity which can precipitate further respiratory embarrassment) or when the regional anaesthesia appears technically challenging. Regional anaesthesia is now being increasingly recommended as it provides better analgesia (thus reducing catecholamine induced increase in cardiac output) and there are less chances of respiratory depression.[3] However, the data on which these recommendations are based are limited to case reports or small case series. We are presenting the retrospective data of kyphoscoliotic parturients who underwent CD under spinal anaesthesia (SA) at a tertiary care centre for Maternal and Child Health in North India. We have also compared these patients to those who received GA for the same procedure.
MethodologyIn this retrospective study in which we examined the hospital records for parturients with kyphoscoliosis who underwent CD during the period between September 2014 and September 2019, the operation theatre registers were searched for the term “kyphoscoliosis” in the diagnosis of patients undergoing CD. This was followed by retrieval of the case files from the hospital medical record department. The data from the case files were entered into a structured performa. Demographic and obstetric data (age, height, weight, gravidity, antenatal visits and gestational age), details of kyphoscoliosis (cause, location), indication of CD and details of anaesthesia given were recorded. For the purpose of analysis, the patients were divided into two groups: SA group and GA group, on the basis of the anaesthetic modality used for the CD [Figure 1]. The approval of institutional ethics committee was taken. The date is 20 January 2021.
Figure 1: Flowchart summarizing data collection process of the study. CD: Caesarean delivery, SA: Spinal anaesthesia, GA: General anaesthesiaWe compared the preoperative cardiorespiratory parameters, maternal outcome and neonatal outcomes between these two groups. The cardiorespiratory parameters which were assessed preoperatively included cardiac ejection fraction, right atrial pressure, Cobb's angle, pulmonary function test [forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF)] and partial pressure of oxygen (PaO2). The maternal outcomes included intraoperative hypotension, intraoperative bradycardia, intensive care unit (ICU) admission, need for mechanical ventilation postoperatively and maternal death. The foetal outcomes were Apgar score at 1 and 5 min, nursery admission and intrauterine death. The categorical variables were expressed as n (%) while continuous variables were expressed as mean ± SD. Chi square test was used for comparing categorical variables while Student's t test was used for comparing means. The analysis was carried out on Statistical Package for Social Sciences (SPSS) version 17 (IBM Inc., NY, USA).
ResultsA total of 45 women with kyphoscoliosis underwent CD during the 5-year period studied. The demographic and clinical data are shown in [Table 1]. Majority of the patients (88%) were primigravida, most (71%) did not receive any antenatal care and 66% of patients underwent CD under emergency conditions. The indications for CD are shown in [Figure 2]. The cause of kyphoscoliosis was idiopathic in majority of the cases. Thoracolumbar kyphoscoliosis was more common than thoracic kyphoscoliosis. Data about the Cobb's angle were available in 20 patients only—12 had Cobb's angle <20° while 8 had Cobb's angle between 20 and 40°.
A total of 32 patients (71%) received SA while the remaining 13 (29%) were operated under GA. The drug used for SA was 0.5% hyperbaric bupivacaine with a mean dose of 1.4 ± 0.2 ml. The mean number of attempts taken to administer SA was 2.1 ± 0.5. There were no failed or patchy blocks. The mean level of block was T4.
The comparison between the SA and GA groups regarding the cardiorespiratory parameters is shown in [Table 2]. The patients who underwent GA had significantly lower PaO2, FEV1, FVC and PEF as compared to those who underwent SA. The ejection fraction was lower and right atrial pressures were higher in the GA group. The severity of kyphoscoliosis as assessed by Cobb's angle was greater in GA group but the data for the SA group were based on 7 patients alone as information regarding Cobb's angle for the remaining 25 patients was not available in the hospital records. Maternal and foetal outcomes in the two groups are shown in [Table 3] and [Table 4], respectively. All patients receiving GA needed postoperative ICU admission and mechanical ventilation whereas two patients from the SA group needed ICU admission for postoperative monitoring; however, they did not require any mechanical ventilation. Hypotension occurred intraoperatively in 12 out of 45 patients, out of which 10 patients had received SA and 2 had received GA, the difference being significant (P < 0.05) as depicted in [Table 3]. No maternal deaths occurred in either group.
The Apgar score at 1 and 5 min was significantly worse in the GA group and a higher percentage of nursery admissions were noted. No intrauterine deaths occurred in either group. Prematurity was seen in 9 out of 13 patients in the GA group while only 2 out of the 32 in the SA group were born before term.
DiscussionIn our study, more than 70% of parturients with kyphoscoliosis underwent CD under SA with good maternal and neonatal outcomes. However, these patients had more favourable cardiorespiratory parameters and presumably milder kyphoscoliosis. All those who underwent CD under GA needed postoperative ICU care and mechanical ventilation. The Apgar score was lower and need for nursery admissions was higher in these cases. To the best of our knowledge, this is the largest series of kyphoscoliotic parturients undergoing CD, most of the previous data is in the form of case reports.
The choice of anaesthesia in parturients with kyphoscoliosis undergoing CD is a difficult one. GA in kyphoscoliotic parturients is not without risks. Severe kyphoscoliosis is associated with difficult positioning and altered anatomy of the airway causing difficulty in laryngoscopy and intubation.[4] Pulmonary hypertension is also associated with kyphoscoliosis – this can increase during laryngoscopy and intubation, positive pressure ventilation and use of nitrous oxide. Patients with severe restrictive lung disease due to kyphoscoliosis may be difficult to extubate, requiring postoperative ventilation, with difficulty in weaning, as was seen in our patients too. In scoliosis with neuromuscular aetiology, laryngeal incompetence and impaired swallowing may be present, which increase the chances of pulmonary aspiration. Adequate analgesia may not be achieved, especially as opioid analgesics are not recommended due to risk of respiratory compromise. This may lead to an increase in cardiac output due to catecholamine release setting the stage for a high output cardiac failure.[3] Gupta et al.[4] have described the use of GA in a parturient with kyphoscoliosis with severe respiratory distress. In our patients too, GA was administered in 29% of the patient, mainly for severe maternal cardiorespiratory disease. All these patients were shifted to the ICU for elective mechanical ventilation. In fact, one of our patients with severe cardiorespiratory disease required ventilatory support for approximately 1 month with a prolonged and difficult weaning.
Neuraxial anaesthesia is a viable and safe alternative for CD. However, identification of the epidural and spinal space is difficult as there may be significant vertebral rotation, necessitating multiple attempts, as was seen in our patients too.[5] Ultrasonography may assist in the localization of difficult-to-palpate interspaces. Although the successful use of epidural anaesthesia (EA) has been described, SA may be a better alternative to EA for CD due to a high incidence of difficulties during EA such as false loss-of-resistance, unintentional dural puncture and failed block.[6] SA was technically challenging but failed block or high block or patchy effect which are expected problems with SA in a kyphoscoliotic parturient were not seen in our patients. The high success rate in our study may partially be due to milder kyphoscoliosis in the SA group although data on Cobb's angle in this group were limited to seven patients only. Despite the technical challenges, several reports of successful SA even in emergency settings exist. Even a repeat SA after a failed spinal block for elective CD has been reported by Kumar et al.[7] Combined spinal EA has also been used without any complications for severe kyphoscoliosis undergoing CD by Saxena et al.[8] In cases where a corrective surgery for scoliosis has been done, there is a distortion of the epidural space with greater chances of patchy blockade and a higher incidence of accidental dural puncture; SA is recommended as the technique of choice by Veliath et al.[9]
Local anaesthetic (LA) dose requirements for SA in scoliosis are variable and the level of block is unpredictable. Sometimes, with a severe scoliotic curve, hyperbaric LA solution may pool in dependent portions of the spine, resulting in an inadequate block and sometimes decreased cerebrospinal fluid volume can enhance level of block.[9],[10] The associated vertebral rotation and short stature add to the unpredictability of the block height. Mean dose of LA used in our patients was only 1.4 ml which gave a block height of T4, thus indicating that low doses are adequate for these patients. A continuous technique can be an alternative so that the dose of LA can be titrated to the desired segmental level of anaesthesia.[11]
The maternal and neonatal outcomes in the SA group were excellent. These findings are in line with recent reports from India as well as the Western countries which did not show adverse maternal or neonatal outcomes.[2],[12] It is possible that severe kyphoscoliosis which was seen earlier related to diseases such as poliomyelitis or tuberculosis has now become less common. Most of our SA group patients do not appear to have severe kyphoscoliosis and their cardiorespiratory parameters were significantly better than the GA group. This may explain the favourable outcomes seen in this group. However, even in the GA group, no maternal mortalities were observed, although prolonged ICU stay was required for many cases. Neonatal outcome was significantly better in patients receiving SA as compared to GA, may be because patients who received GA had severe cardiorespiratory compromise and were not able to carry their pregnancies till term, thereby adversely affecting the foetal well-being.
In conclusion, our study shows that a kyphoscoliotic parturient scheduled for CD can be successfully managed with SA with good maternal and neonatal outcomes. GA may be reserved only for severe kyphoscoliotic parturients with cardiorespiratory complications. Although the safety record of SA in our pregnant patients with kyphoscoliosis is excellent, more studies are required in such patients.
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Conflicts of interest
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