Ankylosing spondylosis is always a challenge when patient has severe deformities to choose between general anaesthesia versus regional anaesthesia. Regional anaesthesia is always a choice either at institutionally or at smaller private hospital set ups.
Schewley and colleagues compared regional versus general anaesthesia over 10 years and shown that regional anaesthesia is equally good choice.[1]
There are many case reports which suggest that regional anaesthesia could be a safer option in severe Ankylosing spondylosis patients.[2]
Author has managed to achieve neuraxial access by using fluoroscopy. However, interpretation of images by fluoroscopy could be difficult for anaesthetists without chronic pain management background. Also, availability of fluoroscopy could be variable as it may be busy in other theatres to be available later for surgery.
Use of ultrasound to view spaces could be useful in cases with difficult neuraxial access to find the space. Most of the anaesthetists practising regional anaesthesia have expertise in using ultra-sound and also are comfortable to interpret the images. USG could also be helpful in pre-operative setting to identify and plan for central neuraxial blockade. [4]
There are many case reports of use of USG guidance for neuraxial anaesthesia in such cases. [3]
However, central neuraxial blocks in these patient comes with risks. The placement of epidural anaesthesia is technically difficult and is associated with an increased risk of an epidural haematoma.
Wulf reported five out of 51 patients with spinal haematoma occurred in patients with AS in a comprehensive review of spinal haematoma associated with epidural anaesthesia over a 30?year period. These were related to difficult or traumatic insertion. In this his review article, he also mentions Ankylosing spondylosis as one of the risk factor for spinal or epidural haemoatoma. [5]
Li et al also present a case report where patient developed epidural haematoma after epidura
Epidural anaesthesia and spinal haematoma
