Anesth Pain Med 2012; 7: 236～239 ￭Case Report￭

Anaesthetic experience in a patient with severe thoracolumbar -A case report-

Department of Anesthesiology and Pain Medicine, Asan Medical Center, *National Police Hospital, Seoul, Korea

Hyungseok Seo, Sung-Hoon Kim, Tae-in Ham*, and Seung-il Ha

Kyphosis is a deformity characterized by anterior flexion of the Surgical Inc., CA, USA). He had a history of untreated back . When severe, kyphosis may decrease lung trauma at the age of 3 years, which resulted in a progressive volume and compliance, leading to increased work of breathing and thoracic kyphosis. Otherwise, the patient’s medical history deterioration of pulmonary function. Moreover, postoperative respiratory failure is a common problem for patients with severe included only a 40 pack-year history of remote tobacco use spinal deformities. We describe the successful case of general and benign prostatic hypertrophy. anaesthesia in a 71-year-old male patient with severe thoracolumbar Preoperative chest radiography revealed a severe kyphotic kyphosis undergoing open surgery converted from robotic surgery. (Anesth Pain Med 2012; 7: 236∼239) deformity of the thoracolumbar spine (Fig. 1 and 2), and computed tomography showed centrilobular emphysema in the Key Words: Kyphosis, Pulmonary atlectasis, Respiratory insuffi- upper lobes of both lungs. The posterior angle of the ciency, Robotics, Surgery computer assisted. thoracolumbar kyphosis, measured according to the method described by Dickson, was approximately 130 degrees [3]. The patient complained of mild dyspnea (NYHA class II) in a Kyphosis is a spinal deformity characterized by anterior daily activities and the results of preoperative pulmonary func- flexion of the vertebral column [1]. This skeletal deformity of tion tests showed a mild restrictive pattern [forced expiratory the spinal column is known to be associated with cardiac and volume in 1 second (FEV1): 2.33 L (62%); functional vital pulmonary dysfunction, which may result in abnormal postope- rative performance of the cardiopulmonary system [2]. How- ever, a few reports describe the anaesthetic management of patients with severe thoracolumbar kyphosis. We herein describe our recent experience and review the literature.

CASE REPORT

A 71-year-old male patient, who was 144 cm tall and weighed 49 kg, was scheduled for low anterior resection of rectal cancer using minimally invasive robotic surgery with the Ⓡ da Vinci surgical system (da Vinci surgical system, Intuitive

Received: May 11, 2012. Revised: 1st, May 21, 2012; 2nd, June 10, 2012. Accepted: June 15, 2012. Corresponding author: Seung-il Ha, M.D., Department of Anesthesiology and Pain Medicine, Asan Medical Center, 388-1, Pungnap-dong, Songpa- gu, Seoul 138-736, Korea. Tel: 82-2-3010-3868, Fax: 82-2-470-1363, Fig. 1. Plain chest radiograph (posteroanterior view) of the patient shows E-mail: [email protected] a narrow intercostal space due to severe distortion of the thoracic cage.

236 Hyungseok Seo, et al：Anesthesia of thoracolumbar kyphosis 237 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Fig. 2. Plain chest radiograph (lateral view) shows severe kyphotic Fig. 4. Plain chest radiograph (anteroposterior view) shows atelectasis of changes from T9 to L1 (arrow). By Dickson’s method, measurement of the lungs bilaterally. this kyphotic angle is made by lines drawn along the posterior margins of the vertebral bodies above and below the lesion, and is approximately 130 degrees. supine position with supportive rolls under the head and upper back (Fig. 3). Induction of anaesthesia was performed with intravenous lidocaine (40 mg), propofol (80 mg), and rocuro- nium (30 mg), and a target-controlled infusion of remifentanil Ⓡ (Orchestra Base Primea, Fresenius Kabi Inc., Bad Homburg, Germany) was given at 2−3 ng/ml of effect site concen- tration. The patient’s lungs were ventilated with oxygen, medical air, and desflurane. After intubation with a #8.0 endotracheal tube (ETT) and temporary fixation at 18 cm from the incisor teeth, the depth of the ETT was identified by fiberoptic bronchoscopy. Fresh gas flow was maintained at 2 L/min with 50% fraction of inspired oxygen and 6% volume of desflurane. Target controlled infusion of remifentanil was continued until the end of surgery. The surgical procedure itself was initially attempted with

Fig. 3. Position of the patient during the operation. The anteroposterior robotic assistance; however, movement of the robotic arm of Ⓡ diameter is elongated because of the kyphotic spine. Multiple supportive the da Vinci system proved difficult given the small rolls are used to support the head and upper back. intraperitoneal space due to the severe thoracic deformity. Moreover, peak inspiratory pressure of the patient was steeply capacity (FVC): 1.76 L (67%); FEV1/FVC ratio: 76%], and increased from 11 mmHg to 22 mmHg. As a consequence, the preoperative echocardiography revealed normal findings, with surgery was converted to an open procedure, which was then normal right ventricular size and preserved right ventricular completed without any complications. Peak inspiratory pressure contractility. The patient had no preoperative medications also dropped down to 11−15 mmHg after laparotomy. Airway prescribed. pressure parameters such as peak inspiratory pressure and In the operating room, intraoperative monitoring included plateau pressure of the patient were normally maintained and 3-lead electrocardiography, pulse-oximetry, end-tidal carbon oxygen saturation also 99−100% during the operation. After dioxide (CO2) detection, and invasive arterial blood pressure the surgery, the patient was fully awakened and showed no monitoring at the radial artery. The patient was placed in a respiratory distress signs. Hence, we decided to extubate and 238 Anesth Pain Med Vol. 7, No. 3, 2012 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 transfer to recovery room after discussion with the operator and is notable when the kyphosis angle is greater than 55 despite the patient was planned to go to intensive care unit degrees [12]. In our case, the kyphosis angle was 130 degrees, preoperatively. such that there was high risk of respiratory insufficiency On postoperative day 1, the patient complained of mild during the perioperative period. Despite this severe kyphotic dyspnea while on the general ward and a chest radiograph deformity, the patient did not have a significant respiratory demonstrated atelectasis of the lung fields bilaterally (Fig. 4). problem in daily life, and he had a New York Heart The patient was thus treated for 8 hours with physiotherapy Association classification of only II. Perhaps this was because and the administration of supplemental O2 at 3 L/min via the kyphotic area involved a relatively lower level in the nasal cannula, with subsequent resolution of his dyspnea. On vertebral column, the ninth thoracic vertebra to the second postoperative day 7, the patient was discharged without any lumbar vertebra, and the patient was chronically adapted to the surgical or anaesthetic complication. deformity. Most importantly, the patient’s respiratory function was well maintained during the perioperative period. The DISCUSSION resistive pressure, the difference between peak and plateau inspiratory pressure, was maintained normally within 2−3

Kyphoscoliosis is a progressive spinal deformity characterized cmH2O with peripheral oxygen saturation of 99−100%. For by anterior flexion and lateral curvature of the vertebral this reason, we did not have to check arterial blood gas column. Patients with severe spinal deformities usually have analysis intraoperatively. Although the result of blood gas smaller lung volumes and the loss of thoracic elasticity, analysis on postoperative day 1 suggested metabolic acidosis, resulting in increased energy requirements for ventilation. atelectasis on chest radiography and postoperative pain were Additionally, in patients with kyphosis, severe deformities of suspected for the patient’s respiratory compromise. Moreover the thoracic cage cause a reduction in vital capacity, lung opioid, meperidine 25 mg intravenously, used for postoperative compliance, and tidal volume, while residual volume and total pain control resulted in further decrease of ventilatory effort. lung capacity are maintained. Furthermore, the abnormal Finally, chest deformities are known to increase pulmonary mechanical properties of the distorted thoracic cage increase vascular resistance by preventing the development of the the work of breathing and airway resistance. Consequently, pulmonary vascular system. When persistent, the increased patients with kyphotic deformities constantly hyperventilate and pulmonary vascular resistance can cause pulmonary hyperten- are more likely to experience respiratory failure such as sion and potentially right heart failure. Although we did not hypercapnia, hypoxemia, and respiratory acidosis in case of evaluate and monitor the pulmonary arterial pressure of this respiratory insufficiency [4]. During laparoscopic and robotic- kyphotic patient in the perioperative period, the results of assisted surgery, the pneumoperitoneum and Trendelenberg preoperative echocardiography showed a normal size of the position can significantly affect respiratory function, and right ventricle, with preserved right ventricular contractility. postoperatively these patients are at risk for hypoventilation, Patients with severe kyphosis are at high risk for respiratory mismatched ventilation-perfusion and acute respiratory failure and cardiovascular complications in the perioperative period. [2,5-7]. Therefore, a thorough preoperative evaluation and meticulous In our case, anesthetic management was focused to maintain anaesthetic management are required during surgical procedures. respiratory function in perioperative period. For full awakening We report this case to describe the careful perioperative and recovery at emergence, we used anesthetic agents such as management of the patient with severe kyphosis, even after the desflurane and rocuronium which have a rapid onset and short surgery is complete. duration. In addition, target -controlled infusion of remifentanil, an ultrashort-acting opioid, is effective to reduce the amount of REFERENCES desflurane in maintaining anesthetic depth and to promote a smooth and rapid emergence [8]. 1. Roberta H, Katherine M. Stoelting's Anesthesia and co-existing The severity of pulmonary derangement in patients with disease. 5th ed. Philadelphia, Churchil Livingstone. 2008, pp. 459-60. kyphoscoliosis is related to the angle of deformity [9,10]. In 2. Libby DM, Briscoe WA, Boyce B, Smith JP. Acute respiratory addition, the impairment of pulmonary function in kyphosis failure in or kyphosis: prolonged survival and treatment. correlates with spinal mobility (especially forward flexion) [11] Am J Med 1982; 73: 532-8. Hyungseok Seo, et al：Anesthesia of thoracolumbar kyphosis 239 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

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