Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2024 | Month : March | Volume : 18 | Issue : 3 | Page : UR01 - UR05 Full Version

Layered and Thoracic Segmental Spinal Anaesthesia in Patients with Kyphoscoliosis for Various Surgeries: A Case Series


Published: March 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/69108.19154
Prashanth Gowtham Raj, Lagadapati Madhav Avinash, Amingad Basavaraj Bhagyashree, Kaggathi Ramesh Vasantha Kumar

1. Associate Professor, Department of Anaesthesiology, AIMS, Hassan, Karnataka, India. 2. Private Practiotioner, Department of Anaesthesiology, AIMS, Narasaraopet, Andhra Pradesh, India. 3. Associate Professor, Department of Anaesthesiology, HIMS, Hassan, Karnataka, India. 4. Professor, Department of Anaesthesiology, MNR Medical College, Sangareddy, Telagana, India.

Correspondence Address :
Dr. Prashanth Gowtham Raj,
No. 47, 4th Floor, HIMS Doctors Quarters, Hassan-573201, Karnataka, India.
E-mail: rajprashanth83@gmail.com

Abstract

Kyphoscoliosis involves exaggerated anterior and lateral curvatures of the spine, affecting the dorsolumbar spine. Associated multiple organ system dysfunctions cause difficulties with both general and regional anaesthetic techniques. Co-existing neuromuscular disorders, pulmonary infections, difficulties in securing the airway, postoperative pulmonary morbidities, and the need for mechanical ventilation associated with general anaesthesia make neuraxial anaesthesia the most widely used technique in these cases. Continuous neuraxial techniques in these patients offer advantages over single-shot spinal anaesthesia in achieving the desired level of anaesthesia, managing patchy blocks, extending the duration of anaesthesia, and providing postoperative analgesia, but they are technically more challenging. Single-shot spinal anaesthesia can be a simple, safer, and effective alternative for surgical procedures of shorter duration. Performing thoracic segmental spinal anaesthesia in these patients is very challenging due to the complete distortion of anatomy and possible obliteration of neuraxial spaces. Layered spinal anaesthesia involves combining multiple local anaesthetics with different baricities to produce a successful subarachnoid block. Present series is reported with successful and uneventful use of the layered and thoracic segmental spinal anaesthetic technique in patients with kyphoscoliosis for various surgeries, including laparoscopic procedures.

Keywords

Dorsolumbar spine, Layered spinal anaesthesia, Spinal anaesthetic technique

Kyphoscoliosis is a spinal deformity characterised by exaggerated anterior curvature (kyphosis) and lateral curvature (scoliosis) of the vertebral column. Restrictive lung disease and pulmonary hypertension progressing to corpulmonale are the principal causes of death in these patients (1). Difficulties in airway management and cardiopulmonary dysfunctions make general anaesthesia hazardous, whereas regional anaesthesia is also challenging due to technical problems caused by the abnormal curvature of the spine, difficulties in identifying the intervertebral space, and unpredictability in the spread of local anaesthetics or the level of anaesthesia (2). Neuraxial blocks are controversial and pose many challenges, given the difficulties in identifying anatomical landmarks, neuraxial spaces, performing dural puncture, and predicting the extent of the spread of local anaesthetics and the level of anaesthesia block (3),(4). Layered spinal anaesthesia is produced by combining two drugs with different baricities for spinal anaesthesia, which can be single-shot or continuous techniques (4). Several published case reports reveal that spinal anaesthesia is safe and effective in this subset of patients undergoing short-duration surgical procedures (5),(6). Both single-shot and continuous neuraxial anaesthetic techniques are equally favourable in these patients for both open and laparoscopic surgeries (4),(5),(6). Authors report a few cases of kyphoscoliotic deformities with and without co-existing poliomyelitis, sensory and motor deficits managed successfully with single-shot thoracic segmental and layered spinal anaesthesia without any complications. Most previous publications were isolated case reports, but this case series is the first of its kind. Authors have used a modified paramedian approach described by Huang J to perform dural puncture in all the patients (7).

Case Report

Case 1

A 42-year-old female, 156 cm in height, 88 kg, Body Mass Index (BMI) 36.2 kg/m2, moderately obese, unmarried, with thoracolumbar kyphoscoliosis and asymmetric thorax, pelvis, and left lower limb shortening, along with multiple right renal pelvic calculi, was scheduled for elective supine Percutaneous Nephrolithotomy (PCNL). She had undergone three corrective spine surgeries for kyphoscoliosis since childhood. Her family reported her snoring while asleep. She exhibited grade 3 clubbing, room air SpO2 of 94%. Airway examination was unremarkable. A long surgical scar from T4 to S5 was observed on spine examination. Another circular scar measuring 4×4 cm was visible in the right upper lumbar paramedian area (Table/Fig 1). Pulmonary function tests indicated severe restrictive lung disease with Forced Expiratory Volume in the first second (FEV1) at 36% and Forced Vital Capacity (FVC) at 40%. A 2D Echocardiogram (ECHO) revealed moderate pulmonary hypertension. Her creatinine level was 1.5 mg/dL, and Magnetic Resonance Imaging (MRI) reconstructive imaging showed excessive lumbar lordosis, scoliotic curvature of the lumbar spine, and kyphotic thoracic spine with axial rotation deformities (Table/Fig 2),(Table/Fig 3). After discussions with the patient, her family, and the urologist, a collective decision was made to proceed with surgery under layered thoracic spinal anaesthesia. She underwent layered spinal anaesthesia, with a spinal tap performed in the sitting position at the T9-T10 level using a 25G Quincke’s needle and a modified paramedian approach. A 0.8 cc of Inj. ropivacaine heavy 0.75% was administered initially, and she was kept seated for five minutes while the spinal needle remained in place with the stylet to prevent Cerebrospinal Fluid (CSF) loss, achieving a dermatomal level of T12 by the end of the five minutes. Subsequently, 1.2 cc of Inj. ropivacaine 0.5% isobaric with Inj. fentanyl 25 μg was injected through the same needle, following which she was positioned supinely. Anaesthesia extending up to the T6 level was achieved. The subarachnoid block was layered with Inj. ropivacaine heavy 0.75% to aid in patient positioning and ureteral catheterisation for imaging, locating renal calculi, and Inj. ropivacaine 0.5% isobaric to achieve anaesthesia for performing percutaneous puncture and nephrolithotomy, respectively. The surgical procedure proceeded uneventfully and lasted for an hour. There was one episode of hypotension, which was managed with Inj. mephenteramine 6 mg and a 200 mL ringer lactate bolus. Following surgery, she was monitored in the High Dependency Unit (HDU) for 24 hours, during which there were no complications. Complete recovery from motor blockade took six hours, with analgesia provided for 14 hours. She was transferred to the postoperative care unit on day 2. Her entire postoperative period was uneventful, and she was discharged on day 4.

Case 2

A 36-year-old female, 152 cm in height, 52 kg in weight, BMI 22.5 kg/m2, with symptomatic calculous cholecystitis and dorsolumbar kyphoscoliosis since childhood, was scheduled for elective laparoscopic cholecystectomy. She had been asthmatic since childhood, using a levosalbutamol metered dose inhaler only during episodes of breathlessness, which typically lasted for 5 to 10 minutes after inhalation. These episodes of breathlessness exhibited seasonal variation, with more occurrences during the winter season, and the most recent episode was three months ago. She displayed grade 3 clubbing, with a moderate obstructive and severe restrictive pattern on pulmonary function tests, and a room air SpO2 of 92-94%. A 2D ECHO revealed moderate pulmonary hypertension. Following counselling of the patient and her family, they agreed to proceed with thoracic segmental spinal anaesthesia. The patient underwent thoracic segmental spinal anaesthesia with a spinal tap at the T8-T9 level using a 25 G Quincke’s needle and 1.6 cc of isobaric Inj. ropivacaine 0.5%, and Inj. fentanyl 25 μg in the lateral position. A block achieving a dermatomal level from T12 to T4 was successful. Intravenous Inj. midazolam 0.6 mg and Inj. ketamine 20 mg were administered to alleviate shoulder pain following pneumoperitoneum creation. Oxygen supplementation was provided via a face mask at 5 L/min. There was one episode of bradycardia and hypotension, which was managed with Inj. atropine 0.6 mg, Inj. ephedrine 6 mg, and intravenous fluids. The patient herself moved to the shifting trolley at the end of the surgery without motor block of the lower limbs and received complete postoperative analgesia for 10 hours. The rest of the perioperative period was uneventful, and she was discharged on day 5.

Case 3

A 25-year-old male, 154 cm in height, 52 kg in weight, BMI 21.9 kg/m², with acute appendicitis and suspected impending rupture of an appendicular abscess, along with a dorsolumbar kyphoscoliotic spine and poliomyelitis involving both lower limbs, was scheduled for emergency laparoscopic appendicectomy. He presented with a fever of 101°F, tachycardia (HR 128/min), grade 2 clubbing, room air saturation of 95%, power grade 0 in both lower limbs with deformities and shortening. Neutrophilic leucocytosis was also noted. Clinically, he appeared to have toxaemia but was haemodynamically stable. An emergency 2D ECHO revealed mild pulmonary hypertension. Due to the emergency nature of the situation, only bedside pulmonary function tests could be conducted. The patient demonstrated a breath-holding time of 15 seconds, forced expiratory time of three seconds, and a match blow test performed at a distance of 15 cm. After obtaining informed written consent, thoracic segmental spinal anaesthesia was performed at the T8-T9 level using a 25G Quincke’s needle, with 1.6 cc of isobaric Inj. ropivacaine 0.5% and Inj. fentanyl 25 μg administered in the sitting position, followed by immediate supine positioning. Anaesthesia was achieved at the T12 to T6 dermatomal level. Intravenous Inj. midazolam 0.8 mg and Inj. ketamine 20 mg were given to alleviate shoulder pain before the initiation of pneumoperitoneum. Oxygen supplementation was provided via a face mask at 5 L/min. The surgical procedure lasted for 1 hour 30 minutes and was uneventful. The patient remained haemodynamically stable throughout the procedure, without requiring additional sedation or analgesia intraoperatively. He experienced excellent postoperative analgesia for 12 hours.

Case 4

A 22-year-old female with dorsolumbar kyphoscoliosis, weighing 48 kg, 148 cm in height, BMI 21.9 kg/m², a primigravida at 39 weeks of single live intrauterine gestation in labour with severe cephalopelvic disproportion, was referred from a remote area for an emergency caesarean section. She exhibited grade 3 clubbing, with a heart rate of 120/min, blood pressure of 102/66 mmHg, asymmetric thorax and pelvis. Her SpO2 was 92% on room air, with a respiratory rate of 22/min. She had a history of atleast four admissions in the last five years due to breathlessness and was diagnosed with severe pulmonary hypertension, requiring management in the Intensive Care Unit (ICU) with non invasive ventilation atleast two times during previous hospital admissions. She was on some oral medications but was irregular with them. The patient was taken for an emergency caesarean section due to severe cephalopelvic disproportion with thick meconium-stained amniotic fluid. She was positioned in the left lateral position with continuous oxygen supplementation via a face mask at 6 L/min. Coloading with Ringer’s lactate was continued. Inj. ranitidine 50 mg and Inj. metoclopramide 10 mg were administered slowly intravenously before transferring her to the operating room. Thoracic segmental spinal anaesthesia was performed at the T10-T11 interspace with a 26G Quincke’s needle. Inj. levobupivacaine isobaric 1.2 cc with Inj. fentanyl 20 μg was given to achieve a dermatomal block from L1 to T4 with minimal motor block involving both lower limbs within two minutes. A lower segment caesarean section was performed with a surgical duration of 60 minutes. The induction to delivery time was three minutes. Inj. oxytocin 2U diluted in 10 cc of 0.9% saline, followed by an infusion of eight units to aid uterine contraction, was administered. The patient experienced two episodes of hypotension, managed with Inj. ephedrine 6 mg+6 mg intravenously and intravenous fluid boluses. The rest of the intraoperative period was uneventful. She was transferred to the surgical ICU postoperatively for continuous monitoring. She had an uneventful postoperative period in the ICU with analgesia for eight hours and was later shifted to the postoperative ward two days following the lower segment caesarean section, and discharged on day 5.

Case 5

A 45-year-old male patient, weighing 72 kg and 158 cm in height, with a BMI of 28.91 kg/m², presented with symptomatic calculous cholecystitis and thoracolumbar kyphoscoliosis, and was scheduled for laparoscopic cholecystectomy. He had been suffering from poliomyelitis involving his right lower limb since childhood, which had led to progressive spinal deformity resulting in thoracolumbar kyphoscoliosis and complete flaccid paralysis of the right lower limb with deformity. He exhibited grade 3 clubbing, a heart rate of 84/min, blood pressure of 130/82 mmHg, respiratory rate of 18/min, and SpO2 of 94% on room air. A 2D ECHO revealed moderate pulmonary hypertension with right ventricular hypertrophy. The FEV1/FVC ratio was 0.5. After counselling and obtaining informed written consent, thoracic segmental spinal anaesthesia was performed with a spinal tap at the T9-T8 intervertebral space using a 25G Quincke’s needle in the sitting position. Inj. ropivacaine 0.5% isobaric 1.6 cc and Inj. fentanyl 25 μg were administered, and the patient was immediately placed in a supine position after injection. A dense dermatomal block from T12 to T6 was achieved 10 minutes after drug injection. Inj. midazolam 1 mg and Inj. ketamine 25 mg were given to sedate the patient and alleviate shoulder pain from the pneumoperitoneum. The entire surgical procedure lasted one hour and 15 minutes, during which one episode of bradycardia with hypotension occurred intraoperatively and was treated with Inj. atropine 0.6 mg intravenously and a fluid bolus of 250 mL Ringer’s lactate. The patient was able to move his unaffected lower limb without experiencing pain or discomfort during the surgical procedure. He was transferred to the Post Anesthesia Care Unit (PACU), where the analgesia lasted for eight hours, and the remainder of his hospital stay was uneventful.

Case 6

A 38-year-old unmarried female, weighing 60 kg and standing at 152 cm with a BMI of 25.9 kg/m², had dorsolumbar kyphoscoliosis (Table/Fig 4),(Table/Fig 5) since childhood and severe abnormal uterine bleeding secondary to multiple large leiomyomas of the uterus. She was scheduled for a total laparoscopic hysterectomy. On admission, she appeared clinically pale with 2+ clubbing, had moderate anaemia with an Hb level of 7.6 gm%, a heart rate of 112/min, and an SpO2 of 94%. A 2D ECHO revealed mild right ventricular hypertrophy, moderate pulmonary hypertension with a Pulmonary Arterial Systolic Pressure (PSAP) of 54 mmHg, concentric Left Ventricular Hypertrophy (LVH), grade 2 Left Ventricular Diastolic Dysfunction (LVDD), and an Ejection Fraction (EF) of 55%. Her FEV1/FVC ratio was 0.5. She was admitted, received correction for anaemia with two units of Packed Red Blood Cells (PRBCs) transfused, underwent chest physiotherapy, incentive spirometry, deep breathing exercises, and was given bronchodilators to prepare for the procedure. A layered thoracic spinal with a spinal tap at the T9-T10 interspace using a 26G Quincke’s spinal needle was performed with the patient in a sitting position. Inj. levobupivacaine 0.5% heavy 0.6 cc was given, followed by Inj. ropivacaine 0.5% isobaric 1.4cc, and Inj. dexmedetomidine 5 μg. The patient was then placed supine. A dense block up to T6 was observed, and after 15 minutes, the block progressed to T6. Inj. midazolam 0.6 mg and Inj. ketamine 15 mg intravenously were given to alleviate shoulder pain. Oxygen at 2 L/min was administered through nasal prongs, maintaining SpO2 levels between 94-96%. The surgical procedure lasted almost two hours and was uneventful. The patient remained haemodynamically stable throughout the procedure with analgesia for 14 hours. The patient was discharged on the fifth day without any complications.

The details of all the cases are summarised in (Table/Fig 6),(Table/Fig 7). All patients were evaluated; pre-existing co-morbidities were optimised as time permitted. Elective cases were prepared with chest physiotherapy, incentive spirometry, deep breathing exercises, and bronchodilators. All patients were taken up only after explaining possible complications involved in the anaesthetic procedure and obtaining informed written consent. IV access was secured with an 18G cannula, Ringer’s lactate or 0.9% saline solution was used as maintenance fluid perioperatively. ASA standard monitoring and NPO guidelines were followed. Postoperative analgesia was managed with Inj. paracetamol 1 gm IV TDS. After discharge, each patient was kept in touch constantly with frequent communication for atleast three months. None of the patients had any neuronal, local anaesthetic, or procedure-related complications. All patients consented to publish their data, but only two patients consented to publish their pictures.

Discussion

Kyphoscoliotic patients have an asymmetric thoracic and pelvic cavity, limb shortening, sensory and motor deficits, and restrictive lung disease that decreases vital capacity, functional residual capacity, and tidal volume, while increasing respiratory rate, ventilation-perfusion mismatch, progressive cardiopulmonary dysfunction, and cor pulmonale, among other conditions (6),(8). General anaesthesia is not favoured due to difficulties in intubation, the presence of pulmonary infections, poor respiratory reserve, challenging extubation, and the potential need for postoperative ventilation. Regional anaesthesia and neuraxial blocks are also technically challenging to perform due to difficulties in positioning, spine and landmark identification, and lower success rates (8). Low cerebrospinal fluid volume and unpredictable spread of local anaesthetics make it very difficult to choose the type of local anaesthetic, volume of local anaesthetics, dose of opioids, and other adjuvants (9). In case number 1, it was impossible to locate the epidural space due to substantial scarring and obliterated interspinous and intervertebral spaces resulting from multiple previous corrective surgeries on her spine. Distortion of the epidural space after corrective surgeries for scoliosis prevents the normal spread of the local anaesthetics, resulting in a patchy block (9). A single-shot spinal anaesthesia technique is simple, easy, and was considered the best anaesthetic choice because the intrathecal space is not directly affected, and the spread of local anaesthetic is more reliable than via the epidural route.

Huang J described a modified paramedian approach for neuraxial anaesthesia in patients with kyphoscoliosis (Table/Fig 8) (7). Intervertebral spaces, rather than interspinous spaces, were used to perform dural puncture in all the patients. The intervertebral spaces were identified by tracing the spine from the cervical region. Hyperbaric and isobaric drugs were used to layer the subarachnoid block in case no.1 and in case no.6 purposefully to aid proper positioning of the patient in lithotomy and surgical needs, similar to a previous report on layered block for caesarean section after patchy epidural labour analgesia (4). In three other patients, isobaric local anaesthetics with opioids were used to restrict the level of anaesthesia only to lower and mid-thoracic dermatomes to produce true thoracic segmental anaesthesia for laparoscopic surgeries without any complications (10). The intrabdominal pressure of pneumoperitoneum was kept below 12 mmHg. A lower intra-abdominal pressure is advantageous, particularly in gynaecological laparoscopic surgeries due to the patient being positioned head down in the Trendelenburg position (11),(12). Low doses of ketamine, along with midazolam intravenously, before creating pneumoperitoneum to alleviate shoulder tip pain, worked excellently without any excessive or residual sedation. Also, the thoracic segmental spinal technique was successfully used even in a case of emergency caesarean section (case no.6) using the “Rapid sequence spinal” no-touch, preoxygenation technique (13). Surgical anaesthesia was achieved within two minutes. Authors suggest adopting such unique single-shot anaesthetic techniques in patients with kyphoscoliosis only when experienced surgeons are performing the surgical procedure. A well-experienced surgeon not only reduces the surgical time duration due to their technical expertise but also helps in managing difficulties or complications.

Conclusion

Thoracic segmental and layered spinal anaesthesia techniques can be simple, safe, effective, reliable, and economic alternatives in difficult situations for major but limited abdominal and laparoscopic surgeries. A skilled anaesthesiologist, together with an experienced surgeon, is essential in choosing such unconventional yet reliable techniques. Meanwhile, adequate patient preparation and patient cooperation play a major role in performing these anaesthetic procedures without any perioperative events or complications.

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DOI and Others

DOI: 10.7860/JCDR/2024/69108.19154

Date of Submission: Dec 15, 2023
Date of Peer Review: Jan 15, 2024
Date of Acceptance: Feb 07, 2024
Date of Publishing: Mar 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 16, 2023
• Manual Googling: Jan 18, 2024
• iThenticate Software: Feb 05, 2024 (5%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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