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Case Report: Real-Time Ultrasound-Guided Spinal Anaesthesia in a Patient with Ankylosing Spondylitis

David LAM, Henry MAK, Yu-Fai CHUNG, Timmy CHAN
Queen Mary Hospital, Hong Kong

An elderly lady with severe AS and an extensive retrosternal goitre was transferred to our centre for further management of left inter-trochanteric femoral fracture (TOF).

Preoperative computed tomography (CT) assessment and 3-Dimensional (3D-CT) reconstruction of the lumbrosacral spine were used to identify unfused inter-laminar spaces. In view of the high risk of general anaesthesia, SA was attempted under ultrasound (US) guidance.

Real-time US guided SA was performed. Following the identification of posterior complex at the inter-laminar spaces identified on 3D-CT, an 18G Tuohy needle was inserted in an in-plane approach and was kept visible under US at all times. 2.6 ml 0.5% levobupivacaine was injected intrathecally after confirmation of free flow of CSF and negative aspiration.  Proximal Femoral Nail Antirotation (PFNA) was subsequently performed uneventfully for TOF and the patient remained physiologically stable throughout and after surgery. 

3D-CT provides an objective means of identifying unfused interlaminar spaces for the preoperative assessment of the feasibility of SA whilst US offers a good alternative when 3D-CT cannot be made available due to the urgency of the patient’s condition or limited resources.

Of the various techniques of SA explored, real-time US guided SA offers the unique advantage of allowing manipulation and advancement of a needle along the desired path under direct vision without the risk of radiation exposure. As in our case, this may be considered the technique preferred in patients with challenging anatomy, including, but not limited to, those with AS.