Surgical anesthesia with a combination of T12 paravertebral block and lumbar plexus, sacral plexus block for hip replacement in ankylosing spondylitis: CARE-compliant 4 case reports

Abstract

Background: Anesthesia management for patients with severe ankylosing spondylitis scheduled for total hip arthroplasty is challenging due to a potential difficult airway and difficult neuraxial block. We report 4 cases with ankylosing spondylitis successfully managed with a combination of lumbar plexus, sacral plexus and T12 paravertebral block.

Case presentation: Four patients were scheduled for total hip arthroplasty. All of them were diagnosed as severe ankylosing spondylitis with rigidity and immobilization of cervical and lumbar spine and hip joints. A combination of T12 paravertebral block, lumbar plexus and sacral plexus block was successfully used for the surgery without any additional intravenous anesthetic or local anesthetics infiltration to the incision, and none of the patients complained of discomfort during the operations.

Conclusions: The combination of T12 paravertebral block, lumbar plexus and sacral plexus block, which may block all nerves innervating the articular capsule, surrounding muscles and the skin involved in total hip arthroplasty, might be a promising alternative for total hip arthroplasty in ankylosing spondylitis.

Keywords: Ankylosing spondylitis; Case report; Lumbar plexus block; Paravertebral block; Sacral plexus block; Total hip arthroplasty.

Fig. 1

Radiograph of lumbo-sacral vertebrae and pelvis shows bamboo like bony bridge, narrowed intervertebral space, fusion of both sacroiliac joints and extreme deformity of both hip joints

Fig. 2

The lateral decubitus position and surface anatomic landmarks

Fig. 3

Ultrasonography and the corresponding positions of transducer. a: ultrasonography of T12 paravertebral space, when ultrasound probe was positioned as in panel d; b: ultrasonography of lumbar plexus when the ultrasound probe was positioned transversely as in panel e; c: ultrasonography of sacral plexus when ultrasound probe was positioned transversely at the level of sacral hiatus as in panel f. AP = articular process; SP = spinous process; ITL = intertransverse ligament; PV space = paravertebral space; ESM = erector spinae muscle; LP = lumbar plexus; PMm = psoas major muscle; GM = gluteus maximus muscle; sciatic n. = sciatic nerve; P = posterior; A = anterior; L = left, R = right

Fig. 4

Ultrasonography of a 3D-printed pelvic phantom bathing in water, to mimic the greater sciatic foramen. PBI = posterior border of ischium

Fig. 5

Ultrasonography of the sacral plexus bathing in local anesthetic deep to the pirifomis muscle and medial to the PBI. (LA = Local anesthetic, PBI = posterior border of ischium, triangle indicates the needle)