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1.  Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section 
Clinics and Practice  2011;1(3):e57.
Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus.
PMCID: PMC3981373  PMID: 24765318
Klippel-Feil syndrome; dexmedetomidine; awake fiberoptic intubation; cesarean section.
2.  Deformity planning for sagittal plane corrective osteotomies of the spine in ankylosing spondylitis 
European Spine Journal  2000;9(6):492-498.
Ankylosing spondylitis (AS) may lead to a severe fixed thoracolumbar kyphotic deformity (TLKD) of the spine. In a few patients, the TLKD is so extreme that a corrective osteotomy of the spine may be considered. Several authors have reported the results of patients treated by a lumbar osteotomy, but there is no consensus on the level of the osteotomy and on the exact degree of correction required. This can be explained by the lack of quantification of the sagittal plane deformity, since compensation mechanisms of the lower extremities have to be reckoned with for the assessment of spinal sagittal balance in AS. Therefore, there is a need for a method of deformity planning for sagittal plane corrective osteotomies of the spine in AS. In this study, a biomechanical analysis and a newly developed planning procedure are presented and illustrated with two cases of AS. Sagittal balance of the spine was defined in relation to the physiologic sacral end plate angle using trigonometric terms. Nomograms were constructed to show the relationship between the correction angle, horizontal position of the C7 plumb line and the level of the spinal osteotomy. The surgical results of two patients were retrospectively analyzed with our method. It showed that the effect of a spinal osteotomy on the horizontal position of the C7 plumb line depends on the combination of correction angle and the level of osteotomy. In one patient, the achieved correction of the deformity proved to correct the sagittal spinal balance and the pelvic sacral endplate angle. In the other patient, the achieved correction was not sufficient. It is concluded that adequate deformity planning for sagittal plane corrective osteotomies of the spine in AS is essential for reliable prediction of the effect of a lumbar osteotomy on the correction of the spine.
PMCID: PMC3611428  PMID: 11189917
Key words Ankylosing spondylitis; Osteotomy; Spine; Methods
3.  Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel–Feil syndrome 
Saudi Journal of Anaesthesia  2014;8(3):412-414.
The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.
PMCID: PMC4141399  PMID: 25191201
Fiberoptic intubation; Klippel-Feil syndrome; laryngeal mask airway; The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children
4.  Airway management in Escobar syndrome: A formidable challenge 
Indian Journal of Anaesthesia  2013;57(6):603-605.
Escobar syndrome is a rare autosomal recessive disorder characterized by flexion joint and digit contractures, skin webbing, cleft palate, deformity of spine and cervical spine fusion. Associated difficult airway is mainly due to micrognathia, retrognathia, webbing of neck and limitation of the mouth opening and neck extension. We report a case of a 1 year old child with Escobar syndrome posted for bilateral hamstrings to quadriceps transfer. The child had adequate mouth opening with no evidence of cervical spine fusion, yet we faced difficulty in intubation which was ultimately overcome by securing a proseal laryngeal mask airway (PLMA) and then by intubating with an endotracheal tube railroaded over a paediatric fibreoptic bronchoscope passed through the lumen of a PLMA.
PMCID: PMC3883398  PMID: 24403623
Difficult airway; Escobar syndrome; proseal laryngeal mask airway
5.  Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer 
Saudi Journal of Anaesthesia  2014;8(Suppl 1):S15-S19.
Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks.
Materials and Methods:
A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted.
The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L.
Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate.
PMCID: PMC4268521  PMID: 25538514
Airway management; bronchoscopy; laryngeal nerves; lidocaine; nebulizers
6.  Airway management in cervical spine ankylosing spondylitis: Between a rock and a hard place 
Indian Journal of Anaesthesia  2013;57(6):592-595.
We report the perioperative course of a patient with long standing ankylosing spondylitis with severe dysphagia due to large anterior cervical syndesmophytes at the level of the epiglottis. He was scheduled to undergo anterior cervical decompression and the surgical approach possibly precluded an elective pre-operative tracheostomy. We performed a modified awake fibreoptic nasal intubation through a split nasopharyngeal airway while adequate oxygenation was ensured through a modified nasal trumpet inserted in the other nares. We discuss the role of nasal intubations and the use of both the modified nasopharyngeal airways we used to facilitate tracheal intubation. This modified nasal fibreoptic intubation technique could find the application in other patients with cervical spine abnormalities and in other anticipated difficult airways.
PMCID: PMC3883395  PMID: 24403620
Airways; airways - difficult anticipated; co-existing diseases - ankylosing spondylitis; diffuse idiopathic skeletal hyperostosis; fiberoptic; intubation; intubation - awake; modified nasal trumpet; nasal; nasal - airway; split nasopharyngeal airway
7.  Surgical outcome after spinal fractures in patients with ankylosing spondylitis 
Ankylosing spondylitis is a rheumatic disease in which spinal and sacroiliac joints are mainly affected. There is a gradual bone formation in the spinal ligaments and ankylosis of the spinal diarthroses which lead to stiffness of the spine.
The diffuse paraspinal ossification and inflammatory osteitis of advanced Ankylosing spondylitis creates a fused, brittle spine that is susceptible to fracture. The aim of this study is to present the surgical experience of spinal fractures occurring in patients suffering from ankylosing spondylitis and to highlight the difficulties that exist as far as both diagnosis and surgical management are concerned.
Twenty patients suffering from ankylosing spondylitis were operated due to a spinal fracture. The fracture was located at the cervical spine in 7 cases, at the thoracic spine in 9, at the thoracolumbar junction in 3 and at the lumbar spine in one case. Neurological defects were revealed in 10 patients. In four of them, neurological signs were progressively developed after a time period of 4 to 15 days. The initial radiological study was negative for a spinal fracture in twelve patients. Every patient was assessed at the time of admission and daily until the day of surgery, then postoperatively upon discharge.
Combined anterior and posterior approaches were performed in three patients with only posterior approaches performed on the rest. Spinal fusion was seen in 100% of the cases. No intra-operative complications occurred. There was one case in which superficial wound inflammation occurred. Loosening of posterior screws without loss of stability appeared in two patients with cervical injuries.
Frankel neurological classification was used in order to evaluate the neurological status of the patients. There was statistically significant improvement of Frankel neurological classification between the preoperative and postoperative evaluation. 35% of patients showed improvement due to the operation performed.
The operative treatment of these injuries is useful and effective. It usually succeeds the improvement of the patients' neurological status. Taking into consideration the cardiovascular problems that these patients have, anterior and posterior stabilization aren't always possible. In these cases, posterior approach can be performed and give excellent results, while total operation time, blood loss and other possible complications are decreased.
PMCID: PMC2745354  PMID: 19646282
8.  C7 decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis 
European Spine Journal  2007;16(9):1471-1478.
Our objective is to report on the clinical and radiological outcome following a decancellisation closing wedge osteotomy for the correction of fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis. The only treatment available for severe fixed flexion deformity of the cervical spine in these patients is an extension osteotomy. Traditionally an anterior opening, posterior closing wedge osteotomy is performed with or without internal fixation. We describe a decancellisation closing wedge osteotomy of C7 accompanied by secure segmental internal fixation. Eight patients operated between 1990 and 2003 with mean age of 54 years and minimum follow up of 2 years were retrospectively evaluated. Restoration of normal forward gaze was achieved in all patients. No patient suffered spinal cord injury or permanent nerve root palsy. There was no loss of correction or pseudarthrosis at final follow up. C7 decancellisation closing wedge osteotomy supplemented with secure segmental internal fixation in experienced hands provides a safe and effective treatment for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis.
PMCID: PMC2200755  PMID: 17334795
Cervico-thoracic kyphosis; Cervical osteotomy; Segmental fixation; Ankylosing spondylitis
9.  Cervical osteotomy for ankylosing spondylitis: an innovative variation on an existing technique 
European Spine Journal  1999;8(6):505-509.
Ankylosing spondylitis can produce severe fixed flexion deformity in the cervical spine. This deformity may be so disabling that it interferes with forward vision, chewing, swallowing and skin care under the chin. The only treatment available is an extension osteotomy of the cervical spine. Existing techniques of cervical osteotomy may be associated with risk of neurological injury. We describe a variation on an existing technique, which provides a controlled method of reduction at the osteotomy site, eliminating sagittal translation. The method employs a modular posterior cervical system consisting of lateral mass and thoracic pedicle screws linked to titanium rods. Our technique substitutes the titanium rod with a temporary malleable rod on one side, allowing controlled reduction of the osteotomy as this rod bends and slides through the thoracic clamps. Once reduction is complete definitive contoured rods are inserted to maintain the correction while fusion takes place. This method appears less hazardous by eliminating sagittal translation, and may reduce the risk of neurological injury during surgery. It achieves rigid internal fixation, obviating the need for a halo vest in the postoperative period.
PMCID: PMC3611206  PMID: 10664313
Key words Cervical osteotomy; Ankylosing spondylitis; Internal fixation
10.  Safe intubation in Morquio-Brailsford syndrome: A challenge for the anesthesiologist 
Morquio-Brailsford syndrome is a type of mucopolysaccharidoses. It is a rare disease with features of short stature, atlantoaxial instability with risk of cord damage, odontoid hypoplasia, pectus carinatum, spine deformities, hepatomegaly, and restrictive lung disease. Neck movements during intubation are associated with the risk of quadriparesis due to cervical instability. This, along with the distortion of the airway anatomy due to deposition of mucopolysaccharides makes airway management arduous. We present our experience in management of difficult airway in a 3-year-old girl with Morquio-Brailsford syndrome posted for magnetic resonance imaging and computerized tomography scan of a suspected unstable cervical spine. As utmost sagacity during intubation is required, the child was intubated inside operation theatre in the presence of experienced anesthesiologists and then shifted to the peripheral location. Intubation was done with an endotracheal tube railroaded over a pediatric fibreoptic bronchoscope passed through the lumen of a classic laryngeal mask airway, keeping head in neutral position.
PMCID: PMC3713682  PMID: 23878456
Cervical instability; classic laryngeal mask airway; cord damage; difficult airway
11.  Biomechanical assessment of balance and posture in subjects with ankylosing spondylitis 
Ankylosing spondylitis is a major chronic rheumatic disease that predominantly affects axial joints, determining a rigid spine from the occiput to the sacrum. The dorsal hyperkyphosis may induce the patients to stand in a stooped position with consequent restriction in patients’ daily living activities. The aim of this study was to develop a method for quantitatively and objectively assessing both balance and posture and their mutual relationship in ankylosing spondylitis subjects.
The data of 12 healthy and 12 ankylosing spondylitis subjects (treated with anti-TNF-α stabilized), with a mean age of 51.42 and 49.42 years; mean BMI of 23.08 and 25.44 kg/m2 were collected. Subjects underwent a morphological examination of the spinal mobility by means of a pocket compass needle goniometer, together with an evaluation of both spinal and hip mobility (Bath Ankylosing Spondylitis Metrology Index), and disease activity (Bath Ankylosing Spondylitis Disease Activity Index). Quantitative evaluation of kinematics and balance were performed through a six cameras stereophotogrammetric system and a force plate. Kinematic models together with a test for evaluating balance in different eye level conditions were developed. Head protrusion, trunk flexion-extension, pelvic tilt, hip-knee-ankle flexion-extension were evaluated during Romberg Test, together with centre of pressure parameters.
Each subject was able to accomplish the required task. Subjects’ were comparable for demographic parameters. A significant increment was observed in ankylosing spondylitis subjects for knee joint angle with the target placed at each eye level on both sides (p < 0.042). When considering the pelvic tilt angle a statistically significant reduction was found with the target placed respectively at 10° (p = 0.034) and at 30° (p = 0.019) less than eye level. Furthermore in ankylosing spondylitis subjects both hip (p = 0.048) and ankle (p = 0.029) joints angles differs significantly. When considering the posturographic parameters significant differences were observed for ellipse, center of pressure path and mean velocity (p < 0.04). Goniometric evaluation revealed significant increment of thoracic kyphosis reduction of cervical and lumbar range of motion compared to healthy subjects.
Our findings confirm the need to investigate both balance and posture in ankylosing spondylitis subjects. This methodology could help clinicians to plan rehabilitation treatments.
PMCID: PMC3517897  PMID: 22931459
Ankylosing Spondylitis; Postural balance; Biomechanics
12.  Laparoscopic cholecystectomy in patients with anesthetic problems 
Laparoscopic cholecystectomy is a standard operation for benign gallbladder disease. As experience with laparoscopic cholecystectomy has increased, the procedure has become possible in patients with anesthetic problems. Patients with ankylosing spondylitis or severe kyphosis represent a challenging group to anesthesiologists and laparoscopic surgeons since these diseases are associated with difficult intubation, restrictive ventilatory defects, and cardiac problems. The relatively new approach of awake fiberoptic intubation is considered to be the safest option for patients with anticipated airway difficulties. Laparoscopic cholecystectomy is usually performed under general anesthesia but considerable difficulties in anesthetic management are encountered during laparoscopic surgery; for example, hemodynamic instability may develop in patients with cardiopulmonary dysfunction due to pneumoperitoneum and position changes during the operation. Nonetheless, regional anesthesia can be considered as a valid option for patients with gallbladder disease who are poor candidates for general anesthesia due to cardiopulmonary problems. We report three cases of laparoscopic cholecystectomy successfully performed in patients with anesthetic problems that included cardiopulmonary disease, severe kyphosis, and ankylosing spondylitis.
PMCID: PMC3732860  PMID: 23922485
Laparoscopic cholecystectomy; Kyphosis; Ankylosing spondylitis; Anesthetic problems
13.  Severe lingual tonsillar hypertrophy and the rationale supporting early use of wire-guided retrograde intubation 
Saudi Journal of Anaesthesia  2010;4(2):102-104.
An expanding body of literature exists which describes the airway challenges and management options for lingual tonsillar hypertrophy (LTH). The use of retrograde intubation to secure a patient‘s airway in the setting of LTH has been previously unreported and should be considered early in the event of a cannot intubate, cannot ventilate scenario. A 55-year-old man, who had previously been described as an easy intubation, presented an unexpected cannot intubate, cannot ventilate scenario secondary to LTH. Various noninvasive airway maneuvers were attempted to restore ventilation without success. We describe the advantages of early use of wire-guided retrograde intubation as an alternative to a surgical airway for obtaining a secure airway in a patient with LTH, in whom noninvasive airway management maneuvers have failed. Multiple different noninvasive approaches to management of LTH have been previously described including the laryngeal tube, laryngeal mask airway, and fiberoptic bronchoscopy. Unfortunately, none of these noninvasive airway maneuvers successfully ventilated this patient and an invasive airway became necessary. Retrograde intubation is a less invasive alternative to the surgical airway with potentially less risk for complications. Retrograde intubation may be particularly effective in the setting of LTH as it may stent open an otherwise occluded airway and allow passage of an endotracheal tube. Skillful use of this technique should be considered early as a viable option in any case of unexpected difficult intubation due to LTH.
PMCID: PMC2945505  PMID: 20927270
Lingual tonsillar hypertrophy; retrograde intubation; difficult intubation
14.  Role of intraoperative Iso-C based navigation in challenging spine trauma 
Indian Journal of Orthopaedics  2007;41(4):312-317.
Pedicle screw fixation is the most preferred method of stabilizing unstable spinal fractures. Pedicle screw placement may be difficult in presence of fractured posterior elements, deformed spine, gross instability and spinal pathology. Challenging spine-fracture fixation is defined as the presence of one or more of the following: 1) obscured topographical landmarks as in ankylosing spondylitis, 2) fractures in occipitocervical or cervicothoracic regions and 3) preexisting altered spinal alignment. We report a series of pedicle screw insertion with guidance of navigation in difficult fixation problems..
Materials and Methods:
Fourteen patients [hangman's fracture (n=3), odontoid fracture (n=4), C1C2 fracture (n=1) and spinal fracture with coexistent ankylosing spondylitis (n=6)] underwent posterior stabilization. Intraoperatively after surgical exposure, images were acquired by Iso-C 3D C-arm and transferred to navigation system. Instrumentation was performed with navigational assistance. Postoperatively, placements of pedicle screws were evaluated with radiographs and CT scan.
Sixty-seven pedicle screws (cervical, n=33; thoracic, n=6; lumbar, n=26; sacral n=2) and 15 lateral mass screws were inserted with navigation guidance. The average time of image data acquisition by Iso-C 3D C-arm and its transfer to workstation was 4 minutes (range, 2-6 minutes). Postoperative CT scan revealed ideal placement of screws in 63 pedicles (94%), grade 1 cortical breaches (<2 mm) in 3 pedicles (4.5%) and grade 2 cortical breach (2-4 mm) in one pedicle (1.5%). There were no neurovascular complications. Deep infection was encountered in one case, which settled with debridement.
Intraoperative Iso-C 3D C-arm based navigation is a useful adjunct while stabilizing challenging spinal trauma, rendering feasibility, accuracy and safety of pedicle screw placement even in difficult situations.
PMCID: PMC2989511  PMID: 21139784
Computer-assisted surgery; neuronavigation; pedicle screw; spine fracture; challenging spinal trauma
15.  ASKyphoplan: a program for deformity planning in ankylosing spondylitis 
European Spine Journal  2007;16(9):1445-1449.
A closing wedge osteotomy of the lumbar spine may be considered to correct posture and spinal balance in progressive thoracolumbar kyphotic deformity caused by ankylosing spondylitis (AS). Adequate deformity planning is essential for reliable prediction of the effect of surgical correction of the spine on the sagittal balance and horizontal gaze of the patient. The effect of a spinal osteotomy on the horizontal gaze is equal to the osteotomy angle. However, the effect of a spinal osteotomy on the sagittal balance depends on both the correction angle and the level of osteotomy simultaneously. The relation between the correction angle, the level of osteotomy and the sagittal balance of the spine can be expressed by a mathematical equation. However, this mathematical equation is not easily used in daily practice. We present the computer program ASKyphoplan that analyses and visualizes the planning procedure for sagittal plane corrective osteotomies of the spine in AS. The relationship between the planned correction angle, level of osteotomy and sagittal balance are coupled into the program. The steps taken during an ASKyphoplan run are outlined, and the clinical application is discussed. The application of the program is illustrated by the analysis of the data from a patient recently treated by a lumbar osteotomy in AS. The software can be used free of charge on the internet at under the heading “research” in the menu.
PMCID: PMC2200734  PMID: 17440752
Ankylosing spondylitis; Osteotomy; Spine; Computer program; Deformity planning
16.  Case Report: Spinal Anesthesia by Mini-laminotomy for a Patient with Ankylosing Spondylitis who was Difficult to Anesthetize 
Orthopaedic surgeons frequently encounter patients with ankylosing spondylitis who would benefit from various types of lower limb operations; however, some of these patients present challenges for anesthesiologists.
Case Description
We report the case of a 65-year-old patient with a fractured femoral component 30 years after a cemented THA. The patient had severe tracheal stenosis and ankylosing spondylitis making general endotracheal and conventional neuraxial anesthesia nearly impossible.
Literature Review
Possible alternative anesthetic approaches described in the literature include awake fiberoptic bronchoscopic guided intubation, laryngeal mask airway, and caudal anesthesia.
Purposes and Clinical Relevance
We achieved successful anesthesia using spinal laminotomy with the patient under local anesthesia followed by insertion of a spinal catheter and injection of an anesthetic agent. The loosened component was revised to a cementless THA.
PMCID: PMC2974874  PMID: 20300899
17.  Case Report: Spinal Anesthesia by Mini-laminotomy for a Patient with Ankylosing Spondylitis who was Difficult to Anesthetize 
Orthopaedic surgeons frequently encounter patients with ankylosing spondylitis who would benefit from various types of lower limb operations; however, some of these patients present challenges for anesthesiologists.
Case Description
We report the case of a 65-year-old patient with a fractured femoral component 30 years after a cemented THA. The patient had severe tracheal stenosis and ankylosing spondylitis making general endotracheal and conventional neuraxial anesthesia nearly impossible.
Literature Review
Possible alternative anesthetic approaches described in the literature include awake fiberoptic bronchoscopic guided intubation, laryngeal mask airway, and caudal anesthesia.
Purposes and Clinical Relevance
We achieved successful anesthesia using spinal laminotomy with the patient under local anesthesia followed by insertion of a spinal catheter and injection of an anesthetic agent. The loosened component was revised to a cementless THA.
PMCID: PMC2974874  PMID: 20300899
18.  Surgical Outcomes after Traumatic Vertebral Fractures in Patients with Ankylosing Spondylitis 
Ankylosing spondylitis is an inflammatory rheumatic disease mainly affecting the axial skeleton. The rigid spine may secondarily develop osteoporosis, further increasing the risk of spinal fracture. In this study, we reviewed fractures in patients with ankylosing spondylitis that had been clinically diagnosed to better define the mechanism of injury, associated neurological deficit, predisposing factors, and management strategies.
Between January 2003 and December 2013, 12 patients with 13 fractures with neurological complications were treated. Neuroimaging evaluation was obtained in all patients by using plain radiography, CT scan, and MR imaging. The ASIA Impairment Scale was used in order to evaluate the neurologic status of the patients. Management was based on the presence or absence of spinal instability.
A total of 9 cervical and 4 thoracolumbar fractures were identified in a review of patients in whom ankylosing spondylitis had been diagnosed. Of these, 7 fractures were associated with a hyperextension mechanism. 10 cases resulted in a fracture by minor trauma. Posttraumatic neurological deficits were demonstrated in 11 cases and neurological improvement after surgery was observed in 5 of these cases.
Patients with ankylosing spondylitis are highly susceptible to spinal fracture and spinal cord injury even after only mild trauma. Initial CT or MR imaging of the whole spine is recommended even if the patient's symptoms are mild. The patient should also have early surgical stabilization to correct spinal deformity and avoid worsening of the patient's neurological status.
PMCID: PMC4200357  PMID: 25328647
Ankylosing spondylitis; Trauma; Vertebral fracture; Spinal cord injury; Surgery
19.  Lumbar osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. A structured review of three methods of treatment 
Annals of the Rheumatic Diseases  1999;58(7):399-406.
OBJECTIVES—Three operative techniques have been described to correct thoracolumbar kyphotic deformity (TLKD) resulting from ankylosing spondylitis (AS) at the level of the lumbar spine: opening wedge osteotomy, polysegmental wedge osteotomies, and closing wedge osteotomy. Little knowledge exists on the indication for, and outcome of these corrective lumbar osteotomies.
METHODS—A structured review of the medical literature was performed.
RESULTS—A search of the literature revealed 856 patients reported in 41 articles published between 1945 and 1998. The mean age at time of operation was 41 years, male-female ratio 7.5 to 1. In 451 patients an open wedge osteotomy was performed. Polysegmental wedge osteotomies were performed in 249 patients and a closing wedge osteotomy in 156 patients. Most of the studies primarily focus on the surgical technique. Technical outcome data were poorly reported. Sixteen reports, including 523 patients, met the inclusion criteria of this study, and could be analysed for technical outcome data. The average correction achieved with each surgical techniques ranged from 37 to 40 degrees. Loss of correction was mainly reported in patients treated by open wedge osteotomy and polysegmental wedge osteotomies. Neurological complications were reported in all three techniques. The perioperative mortality was 4%. Pulmonary, cardiac and intestinal problems were found to be the major cause of fatal complications.
CONCLUSION—Lumbar osteotomy for correction of TLKD resulting from AS is a major surgery. The indication for these lumbar osteotomies as well as the degree of correction in the lumbar spine has not yet been established. Furthermore, there is a need for a generally accepted clinical score that encompasses accurate preoperative and postoperative assessment of the spinal deformity. The results of this review suggest that the data from the literature are not suitable for decision making with regard to surgical treatment of TLKD resulting from AS.

PMCID: PMC1752916  PMID: 10381482
20.  A modification in the tube guide to facilitate retrograde intubation: A prospective, randomised trial 
Indian Journal of Anaesthesia  2011;55(5):499-503.
The technique of anterograde over a retrograde guide is considered to be more reliable and preferable in comparison to only retrograde one, for improving the success rate of retrograde intubation. As the prior technique requires a lengthy guidewire to negotiate the whole channel of a tube guide, we designed a side eye at one end of tube guide, which obviated the above requirement while maintaining the integrity of the whole channel assembly. The efficacy of this modified technique was compared with the conventional one for retrograde intubation procedure.
In a prospective, randomised fashion, 98 cases posted for surgery of carcinoma buccal mucosa were included in this trial. These cases were randomised to the conventional (Group I) or the modified technique (Group II) for retrograde intubation. Intubation time (first attempt), total number of successful intubations, cause of failures and any associated side effects were recorded and compared between the groups.
The total number of successful intubations were significantly higher in group II (95.83%, 46/48 cases) as compared to group I (66.66%, 31/48 cases) (P<0.001). Mean intubation time was 118±22 second in group I versus 124±26 second in group II (P=0.39). The side effects did not differ significantly between the groups.
Improvising the tube guide resulted in a significant rise in the number of successful intubations through a modified retrograde intubation technique, with no side effects. This should encourage the use of retrograde intubation technique as a first option for difficult airway management.
PMCID: PMC3237151  PMID: 22174468
Carcinoma buccal mucosa; difficult airway; guidewire; retrograde intubation; tube guide
21.  Iso-C3D navigation assisted pedicle screw placement in deformities of the cervical and thoracic spine 
Indian Journal of Orthopaedics  2010;44(2):163-168.
Pedicle screw instrumentation of the deformed cervical and thoracic spine is challenging to even the most experienced surgeon and associated with increased incidence of screw misplacement. Iso-C3D based navigation has been reported to improve the accuracy of pedicle screw placement, however, there are very few studies assessing its efficacy in the presence of deformity. We conducted a study to evaluate the accuracy of Iso-C3D based navigation in pedicle screw fixation in the deformed cervical and thoracic spine.
Materials and Methods:
We inserted 98 cervical pedicle screws (18 patients) and 242 thoracic pedicle screws (17 patients) using Iso-C3D based navigation for deformities of spine due to scoliosis, ankylosing spondylitis, post traumatic and degenerative disorders. Two independent observers determined and graded the accuracy of screw placement from postoperative computed tomography (CT) scans.
Postoperative CT scans of the cervical spine showed 90.8% perfectly placed screws with 7 (7%) grade I pedicle breaches, 2 (2%) grade II pedicle breaches and one anterior cortex penetration (< 2mm). Five lateral pedicle breaches violated the vertebral artery foramen and three medial pedicle breaches penetrated the spinal canal; however, no patient had any neurovascular complications. In the thoracic spine there were 92.2% perfectly placed screws with only six (2%) grade II pedicle breaches, eight (3%) grade I pedicle breaches and five screws (2%) penetrating the anterior or lateral cortex. No neuro-vascular complications were encountered.
Iso-C3D based navigation improves the accuracy of pedicle screw placement in deformities of the cervical and thoracic spine. The low incidence of pedicle breach implies increased safety for the patient.
PMCID: PMC2856391  PMID: 20419003
Navigation; pedicle screw fixation; thoracic and cervical deformity
22.  Fluroscopic assisted airway intubation in temporomandibular joint ankylosis: A novel technique 
Saudi Journal of Anaesthesia  2011;5(2):226-228.
Airway management is considered one of the most difficult and challenging procedures among the various anesthetic procedures. It becomes tougher when there is a diseased temporomandibular joint (TMJ) due to inadequate mouth opening. In the current scenario there are only a few methods that ensure a safe, uneventful intubation in a TMJ ankylosis patient with a difficult airway. These include techniques ranging from minimally invasive techniques like blind nasal intubation, retrograde intubation using a guide wire, the latest technique of intubating with the help of a fiberoptic laryngoscope and the time tested tracheostomy. All these techniques have got their own disadvantages. So we report a case series of five patients with TMJ ankylosis who underwent fluoroscopic-assisted intubation for airway management. We found that this technique is 100% successful in managing the airway in these patients. To the best of our knowledge, this is the first case series detailing this novel technique in the entire English medical literature.
PMCID: PMC3139321  PMID: 21804809
Fluroscopy; temporomandibular joint ankylosis; difficult intubation
23.  Dexmedetomidine premedication for fiberoptic intubation in patients of temporomandibular joint ankylosis: A randomized clinical trial 
Saudi Journal of Anaesthesia  2012;6(3):219-223.
Fiberoptic intubation is the gold standard technique for difficult airway management in patients of temporomandibular joint. This study was aimed to evaluate the clinical efficacy and safety of dexmedetomidine as premedication with propofol infusion for fiberoptic intubation.
Consent was obtained from 46 adult patients of temporomandibular joint ankylosis, scheduled for gap arthroplasty. They were enrolled for thisdouble-blind, randomized, prospective clinical trial with two treatment groups – Group D and Group P, of 23 patients each. Group D patients had received premedication of dexmedetomidine 1 μg/kg infused over 10 min followed by sedative propofol infusion and the control Group P patients were given only propofol infusion to achieve sedation. Condition achieved at endoscopy, intubating conditions, hemodynamic changes and postoperative events were evaluated as primary outcome.
The fiberoptic intubation was successful with satisfactory endoscopic and intubating condition in all patients. Dexmedetomidine premedication has provided satisfactory conditions for fiberoptic intubation and attenuated the hemodynamic response of fiberoptic intubation than the propofol group.
Fiberoptic intubation was found to be easier with dexmedetomidine premedication along with sedative infusion of propofol with complete amnesia of the procedure, hemodynamic stability and preservation of patent airway.
PMCID: PMC3498658  PMID: 23162393
Dexmedetomidine; fiberoptic intubation; propofol; sedation
24.  Prevalence of vertebral compression fractures due to osteoporosis in ankylosing spondylitis. 
BMJ : British Medical Journal  1990;300(6724):563-565.
OBJECTIVE--To determine the prevalence of vertebral compression fractures due to osteoporosis in patients with ankylosing spondylitis. DESIGN--Prospective study of 111 consecutive patients; patients with vertebral compression fractures were entered into a case-control study. SETTING--Outpatient clinic at the centre for rheumatic diseases, Glasgow. PATIENTS--111 Consecutive patients with ankylosing spondylitis. Patients with compression fractures were matched for age and sex with two controls selected from the rest of the group. Patients with biconcave vertebral fractures were also studied. MAIN OUTCOME MEASURES--Assessments of spinal deformity and mobility and analysis of lateral radiographs of spines for presence of syndesmophytes. RESULTS--Fifteen patients with compression fractures and five with biconcave fractures were studied. Compared with the controls the patients with compression fractures had increased formation of syndesmophytes in the lumbar spine, whereas those with biconcave fractures had increased formation throughout the spine. Patients with compression fractures also had a greater degree of spinal deformity (distance from wall to tragus 24.5 cm v 12.7 cm in controls), less spinal mobility (20 v 45.6 degrees of flexion), and reduced chest expansion (2 cm v 3cm). CONCLUSION--Vertebral compression fractures due to osteoporosis are a common but frequently unrecognised complication of ankylosing spondylitis and may contribute to the pathogenesis of spinal deformity and back pain.
PMCID: PMC1662343  PMID: 2108749
25.  Nasotracheal Fiberoptic Intubation: Patient Comfort, Intubating Conditions and Hemodynamic Stability During Conscious Sedation with Different Doses of Dexmedetomidine 
The study aims to evaluate the efficacy of two doses of dexmedetomidine for sedation during awake fiberoptic intubation (AFOI). The study was designed in a prospective, randomized, double-blinded manner and carried out in an academic medical university. Forty young co-operative patients aged 15–45 years of either sex belonging to ASA class I-II, planned for elective maxillo-facial surgery formed the study group. All patients received midazolam 0.05 mg/kg, glycopyrrolate 0.2 mg, ondansetron 4 mg, and ranitidine 50 mg IV 15 min before as premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. Patients were randomly assigned to one of the groups; dexmedetomedine 1 μg/kg IV (Group L), or dexmedetomidine 1.5 μg/kg IV (Group H). Observer’s Assessment of Alertness/Sedation (OAA/S) was assessed. Primary outcome measurements were: HR, MAP, SpO2 and EtCO2 and secondary outcome measurements were: intubation scores by vocal cord movement, coughing and limb movement, fiberoptic intubation comfort score, nasotracheal intubation score and airway obstruction score. On the first post-operative day, recall, level of discomfort during fiberoptic intubation, adverse events and satisfaction score were also assessed. There were no significant hemodynamic differences between the two groups. OAA/S was significantly better with dexmedetomidine 1.5 μg/kg (p < 0.05) and patients were significantly calmer, more cooperative and satisfied during awake fiberoptic intubation with dexmedetomidine 1.5 μg/kg with fewer transient adverse effects. Dexmedetomidine 1.5 μg/kg proved to be more effective for sedation for awake fiberoptic intubation.
PMCID: PMC3955476  PMID: 24644397
Dexmedetomidine; Awake fiberoptic intubation

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