Anaesthetic management of a vaginal hysterectomy case with an unanticipated failure of epidural injection due to fused lumbar spine
A 45-year-old female, weighing 60 kg, reported to the gynecological outpatient department with the chief complaint of “something coming out of the vagina” for the past 3 months. The patient did not elicit any history of fall or trauma. On clinical and systemic examination, she was diagnosed as a case of 2nd degree uterine prolapse with cystocele and was scheduled for elective vaginal hysterectomy.\nDuring the pre-anesthetic check-up, the patient did not give any past history of systemic medical disease, drug allergy, hospitalization, any previous surgery, and as such, her entire medical record was not of much clinical significance. On clinical examination, a regular pulse rate of 76/min and a blood pressure reading of 130/82 mmHg was recorded. No abnormality was detected in any of the organ system functions. Airway examination revealed an adequate mouth opening with Mallampatti class of I, normal thyromental distance and normal neck movements. The clinical and biochemical profile revealed hemoglobin level of 12.4 g/dl, normal electrocardiograph and chest X-ray, as well as normal values of all the routine investigations. Local examination of the spine showed no abnormal findings. Consent was taken from the patient, after explaining to her about the regional anesthesia procedure during the check-up.\nAs a part of premedication, she was prescribed ranitidine 150 mg and alprazolam 0.25 mg tablets, at night and in the morning of the surgery, 2 hours prior to the procedure. In the operation theater, a good peripheral venous access was secured and preloading was carried out with 500 ml of lactated ringer solution. Monitoring devices were attached for the heart rate, electrocardiogram, non-invasive blood pressure and pulse oximetry. All the baseline parameters were observed and recorded. Taking all aseptic precautions, local infiltration of lumbar spine at L4–5 intervertebral space was achieved with 1 ml of 2% lignocaine hydrochloride solution. Lumbar puncture with an 18 G Touhy epidural needle at L4–5 space was performed in the sitting position. Unfortunately, bony resistance was encountered in the next three attempts, both in the midline and paramedian site. Similar failures were encountered at L3–4 and L2–3 intervertebral space, both in the midline as well as the paramedian site, at a depth of 4–4.5 cm from the skin surface. The procedure was performed by a consultant anesthesiologist after the first failed attempt by a senior resident. Fortunately, a successful subarachnoid block was established in the third attempt at L3–4 intervertebral space with a 23 G spinal needle inserted through paramedian entry point. A total of 3.5 ml of “heavy” bupivacaine hydrochloride was injected into subarachnoid space which was admixed with 45 mg of clonidine hydrochloride. Surgical procedure started only when the effect of drug was established up to T-10 dermatome. The entire surgical procedure was uneventful with stable parameters and the procedure lasted for about 2 hours. Postoperatively, X-ray of lumbar and cervical spine was done which revealed fusion of the lumbar spine, and surprisingly, cervical spine was absolutely normal. On thorough investigations, she was diagnosed as a rare case of isolated lumbar spine fusion by the orthopedician without any other articular or extra-articular manifestations to be labeled as ankylosing spondylitis (AS). The postoperative course was uneventful and she was discharged on the 8th postoperative day.