Anesthesia for Ankylosing Spondylitis Patients Undergoing Transpedicle Vertebrectomy

僵直性脊椎炎病患接受駝背手術麻醉之52個病例報告

林必盛(Bih-Chern Lin) ； 陳英和(Ing-Ho Chen)

《Acta Anaesthesiologica Sinica》 37卷2期 (1999/06) Pp. 73-78

https://doi.org/10.6955/AAS.199906.0073

摘要

背景：僵直性脊椎炎病患之麻醉需要相當程度的經驗和技術，除了困難插管及中央靜脈導管植入之困難以外，如何把病人架設在手術臺上也是一個重要的課題。因爲這類手術可能會造成大量出血或是脊椎神經受傷，所以手術中必須密切監視和保護血液循環和神經系統之功能。
方法：從民國85年7月起，凡僵直性脊椎炎病患需要做嚴重駝背矯正和脊椎體切除術時，均使用以下臨視器：EKG，SpO2，ETCO2，SSEP及Modified tcMMEP，並以Fiberscope插管，在麻醉以後再植入中央靜脈導管和動脈導管。將病人趴著架設在手術臺上的烏龜架上，並在手術中實施低溫和低壓麻醉。
結果：病患共有41位，其中有11位實施兩次脊椎體切除手術，矯正幅度每次約有15º至45º。最後矯正幅度達30º至76º。手術時間長達5至7小時。有2位病患發生困難插管，1位病患在中央靜脈導管植入時造成氣胸，1位病患術中發生大量出血導致休克，但手術後恢復良好。
結論：僵直性脊椎炎病患之麻醉，尤其是在脊椎體切除手術時，必須攷慮困難插管中央靜脈導管之植入，並在手術中實施低溫和低壓麻術，來促護血液循環和神經系統之功能。

關鍵字

僵直性脊椎炎 ； 氣管內管置放術 ； 低壓麻醉 ； 低溫麻醉

並列摘要

Background: Ankylosing Spondylitis (AS) patients present specific challenges to the anesthesiologisis. Airway management, central venous access, positioning, neuraxial monitoring and protection as well as management of massive blood loss may prove to be difficult. We retrospectively reviewed the anesthetic management of consecutive AS patients who underwent transpedicle vertebrectomy (TPV).
Methods: To secure airway and administer anesthesia, we used awake fiberoptic endotracheal intubation. The central venous access was attempted through the infraclavicular approach. The positioning was made possible with modification of the operation table and padding. The neuraxial monitoring was done with both somatosensory evoked potentials (SSEPs) and the modified transcranial magnetic evoked potential (tcMMEP). The spinal cord protection was attempted with deliberate hypothermia. To prevent massive blood loss we did controlled hypotension, and autotransfusion.
Results: Fiberoptic endotracheal intubation was done smoothly in all cases except two. In one of these two cases, endotracheal intubation was successful only after cricothyroidectomy and retrograde intubation. In the other case antegrade stiff catheter guided intubation was attempted to overcome the acute angulation cause by fixed cervical flexion. Central venous access through infraclavicular approach was agreeable except one case of pneumothorax. Massive rapid blood loss during vertebral osteotomy, occurred in one patient with fall of the mean blood pressure to 20 mmHg and ventricular tachycardia for 10 mm, during which all the SSEPs and tcMMEP activities disappeared. The patient recovered without sequelae.
Conclusions: Although it is extremely challenging, with proper planning, anticipation of difficulties and meticulous work in airway management, central venous catheterization and positioning as well as prevention of neurological injury and massive bleeding, we successfully accomplished fine job of anesthesia for the AS patients presented for correction of severe kyphosis.

並列關鍵字

Spondylitis, ankylosing ； Intubation, intratracheal ； Hypotension, controlled ； Hypothermia, induced