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1.  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.
doi:10.4103/0019-5049.123333
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
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.
doi:10.1007/s005860000183
PMCID: PMC3611428  PMID: 11189917
Key words Ankylosing spondylitis; Osteotomy; Spine; Methods
3.  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.
doi:10.1007/s005860050215
PMCID: PMC3611206  PMID: 10664313
Key words Cervical osteotomy; Ankylosing spondylitis; Internal fixation
4.  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 http://www.stega.nl under the heading “research” in the menu.
doi:10.1007/s00586-007-0371-5
PMCID: PMC2200734  PMID: 17440752
Ankylosing spondylitis; Osteotomy; Spine; Computer program; Deformity planning
5.  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.
doi:10.4103/0019-5049.123336
PMCID: PMC3883398  PMID: 24403623
Difficult airway; Escobar syndrome; proseal laryngeal mask airway
6.  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.
doi:10.4103/0970-9185.111666
PMCID: PMC3713682  PMID: 23878456
Cervical instability; classic laryngeal mask airway; cord damage; difficult airway
7.  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
8.  Case Report: Spinal Anesthesia by Mini-laminotomy for a Patient with Ankylosing Spondylitis who was Difficult to Anesthetize 
Background
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.
doi:10.1007/s11999-010-1317-5
PMCID: PMC2974874  PMID: 20300899
9.  Case Report: Spinal Anesthesia by Mini-laminotomy for a Patient with Ankylosing Spondylitis who was Difficult to Anesthetize 
Background
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.
doi:10.1007/s11999-010-1317-5
PMCID: PMC2974874  PMID: 20300899
10.  Surgical outcome after spinal fractures in patients with ankylosing spondylitis 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2474-10-96
PMCID: PMC2745354  PMID: 19646282
11.  Functional outcome after lumbar closing wedge osteotomy in ankylosing spondylitis 
International Orthopaedics  2008;33(4):1049-1053.
This study entails a prospective evaluation of lumbar closing wedge osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. Twenty patients with a median age of 52 years (range, 26–70) underwent follow-up at one year. The lumbar closing wedge osteomtomy was stabilised by metallic rods fixed by transpedicular screws. Outcome measures were quality of life (EuroQol), occiput-to-wall distance, pain, fatigue, complications, technical and radiological evaluation. The technical result was good in 16 and fair in four patients; two had neuropraxia. The deformity was reduced an average of 17° (95% confidence interval 15–25°) at one-year follow-up. Pain during activity, pain at night, and fatigue were significantly reduced. EuroQol improved from 0.42 to 0.69 (p = 0.002) and occiput-to-wall distance from 26 to 18 cm (p = 0.005). Functional outcome was improved after lumbar closing wedge osteotomy in ankylosing spondylitis.
doi:10.1007/s00264-008-0590-3
PMCID: PMC2898970  PMID: 18506442
12.  Transpedicular wedge resection osteotomy for the treatment of a kyphotic Andersson lesion-complicating ankylosing spondylitis 
European Spine Journal  2005;15(2):246-252.
Two cases with a long-standing thoracolumbar kyphosis due to ankylosing spondylitis are presented with a symptomatic localized destructive kyphotic lesion of the spine. Clinical and radiographic findings demonstrated a progressive vertebral and discovertebral kyphotic pseudarthrosis, known as an Andersson lesion, at the L1 and L1-2 level, respectively. Surgical correction and stabilization was performed by an extending transpedicular wedge resection osteotomy to restore spinal stability, to facilitate fracture healing as well as to restore the sagittal balance of the ankylosed spine. To predict the effect of a surgical correction of the Andersson lesion on the sagittal balance, deformity planning was performed preoperatively. The indication for surgery, the surgical technique and the 2 years’ clinical results are described. In addition, the difficulties experienced with preoperative deformity planning are evaluated.
doi:10.1007/s00586-005-1008-1
PMCID: PMC3489406  PMID: 16151717
Ankylosing spondylitis; Andersson lesion; Surgery; Deformity planning
13.  Surgery of the deformities in ankylosing spondylitis: Our experience of lumbar osteotomies in 31 patients 
European Spine Journal  1997;6(4):222-232.
Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery. for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75°. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.
doi:10.1007/BF01322443
PMCID: PMC3454642  PMID: 9294745
Ankylosing spondylitis; Wedge osteotomy; Opening osteotomy; Spinal osteotomy; Spinal kyphosis
14.  Intubation Methods by Novice Intubators in a Manikin Model 
Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1±27.4 sec vs 45.9±39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2±1.0 95%CI [2.9–3.5] vs 2.4±0.9 95%CI [2.1–2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5±0.6 95%CI [3.3–3.7]) and ease of use (1.5±0.7 95%CI [1.3–1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods.
PMCID: PMC3796783  PMID: 24167768
15.  Taylor's approach in an ankylosing spondylitis patient posted for percutaneous nephrolithotomy: A challenge for anesthesiologists 
Saudi Journal of Anaesthesia  2009;3(2):87-90.
We describe a patient with long-standing ankylosing spondylitis who underwent percutaneous nephrolithotomy under spinal anesthesia. At preoperative assessment, it was considered that intubation of the trachea was likely to be difficult. Fiberoptic bronchoscopy was attempted, but without success. As the standard technique for spinal anesthesia failed, a variation of the paramedian approach in the lumbosacral approach, also known as Taylor's approach was successfully attempted. This resulted in adequate sensory and motor blockade for the surgical procedure. The patient did not require airway interventions, but equipment and aids to secure airway were available.
doi:10.4103/1658-354X.57879
PMCID: PMC2876933  PMID: 20532110
Ankylosing spondylitis; Taylor's approach; percutaneous nephrolithotomy
16.  Tracheal intubation in the prone position with an intubating laryngeal mask airway following posterior spine impaled knife injury 
Saudi Journal of Anaesthesia  2011;5(3):329-331.
A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation.
doi:10.4103/1658-354X.84114
PMCID: PMC3168357  PMID: 21957419
Airway management; endotracheal intubation; intubating laryngeal mask airway; prone position
17.  Failed nasal intubation after successful flexible bronchoscopy: Guide wire to the rescue 
Flexible fiberoptic bronchoscope-guided awake intubation is the most trusted technique for managing an anticipated difficult airway. Even after successfully negotiating the bronchoscope into the trachea, the possibility remains that the preloaded tracheal tube might prove to be inappropriately large, and may not negotiate the nasal structures. In such a situation, the most obvious solution is to take out the bronchoscope, replace the tracheal tube with a smaller one, and repeat the procedure. Unfortunately, sometimes the second attempt is not as easy as the first, as minor trauma during the earlier attempt causes tissue edema and bleeding, which makes the subsequent bronchoscopic view hazy and difficult. We present the anesthetic management of five cases with temporomandibular joint ankylosis where, after successful, though slightly traumatic, bronchoscope insertion into the trachea, the tube could not be threaded in. We avoided a repeat bronchoscopy by making an innovative change in the plan.
doi:10.4103/0970-9185.83692
PMCID: PMC3161472  PMID: 21897518
Flexible fiberoptic bronchoscope; guide wire; intubation; nasal
18.  Intubation of patients with angioedema: A retrospective study of different methods over three year period 
Background:
Angioedema (AE) is edema of the skin, subcutaneous tissue and/or submucosal tissues, resulting from extravasation of intravascular fluid. Swelling of the supraglottic mucosa can lead to airway obstruction with consequent hypoxia, brain damage and death. To date, fiberoptic bronchoscope (FOB) intubation of the spontaneously breathing patient is the preferred method for an anticipated difficult intubation. However, other alternative devices can be utilized to intubate angioedema successfully.
Materials and Methods:
A retrospective chart review was performed over a three-year period (2008-2010) of all patients with angioedema that required airway intervention. We hypothesized that fiberoptic intubation would have a higher success rate for intubation attempts; however, would take longer to perform when compared to videolaryngoscopic (VL) intubation. Outcomes for FOB versus VL intubations were reviewed, along with alternative miscellaneous methods of tracheal intubation in the setting of angioedema.
Results:
Thirty-three patients were grouped, according to the chosen method of intubation into FOB (n=12), VL (n=11), and miscellaneous (n=10) groups. No significant difference was found in first intubation attempts or number of intubation attempts between the three groups. Duration of time to perform successful intubation revealed a significantly shorter intubation time (P<0.05) in the VL group (6.9±0.9 min) and miscellaneous group (9.1±2.0 min) than that of the FOB group (10.4±0.7 min).
Conclusion:
This retrospective review of intubation methods showed that VL could be performed faster than FOB without an increase in adverse events.
doi:10.4103/2229-5151.114267
PMCID: PMC3743334  PMID: 23961454
Airway obstruction; angioedema; bronchoscope; bronchoscopy; intubation–laryngeal mask; videolaryngoscope
19.  Awake Glidescope® intubation in a patient with a huge and fixed supraglottic mass -A case report- 
Korean Journal of Anesthesiology  2010;59(Suppl):S26-S29.
Intubating patients with a huge, fixed supraglottic mass causing an obstruction of the glottis is difficult to most anesthesiologists. We attempted awake fiberoptic orotracheal intubation assisted by Glidescope® Videolaryngoscope (GVL) following topical anesthesia with 4% lidocaine spray and remifentanil infusion. The glottis could not be identified by the GVL view. However, by entering toward the right side of the mass with bronchoscope, the glottis was found. Due to stiffness of the mass, we were unable to further enter the area using the bronchoscope. Alternatively, we attempted to expose the glottis by GVL blade and then successfully intubated the patient by manually pressing the cricoids cartilage. GVL is nonetheless an excellent instrument in airway management compared to fiberoptic bronchoscope for patients with a huge and fixed supraglottic mass.
doi:10.4097/kjae.2010.59.S.S26
PMCID: PMC3030048  PMID: 21286452
Difficult airway; Fiberoptic bronchoscope; Glidescope; Stylet; Supraglottic mass
20.  Comparison of three types of lumbar osteotomy for ankylosing spondylitis: a case series and evolution of a safe technique for instrumented reduction 
European Spine Journal  2011;20(12):2252-2260.
Introduction
The principles of correction of thoraco-lumbar kyphotic deformity (TKLD) in ankylosing spondylitis (AS) are essentially centred on lordosing osteotomies such as pedicle subtraction closing wedge osteotomy (CWO), polysegmental posterior lumbar wedge osteotomies (PWO) and Smith Peterson’s open wedge osteotomy (OWO) of the lumbar spine. There have been no studies that compared the results of the three osteotomies performed by a single surgeon with a long-term follow-up.
Materials and Methods
A retrospective review of 31 patients with AS was performed: 12 patients underwent CWO, 10 had OWO, and 9 had PWO. Radiographic assessment was performed at 6, 12, 24, and 52 weeks and annually thereafter. Clinical assessment included blood loss, intensive care unit (ICU) stay, and surgical time recordings. All patients were assessed clinically at regular intervals and outcome measures recorded included Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for pain, and SRS-22 (recorded in 23 patients).
Results
The mean age at surgery was 54.7 years (40–74 years) and mean duration of symptoms was 3 years (range, 5–8 years). Mean follow-up was 5 years (range, 2–10 years). There was no statistically significant difference between the three techniques with regard to mean duration of surgery and ICU stay. The mean duration of surgery was 7 h (range, 4–9 h) (OWO cases had shorter period than CWO and PWO cases, and the longest period was for CWO cases). The mean ICU stay was 3 days (range, 2–20 days) (the period of stay was shorter in general for OWO and slightly longer for CWO and PWO). Blood loss was expressed as percentage of estimated blood volume (EBV). The mean blood loss in PWO was 23 ± 15.4% (range, 9–36%), CWO was 28 ± 4.5% (range, 12–40%) and in OWO was 15 ± 11% (range, 13–99%). Mean correction of kyphosis was 38° (range, 25°–49°) with CWO, 28° with OWO (range, 24°–38°) and 30° with PWO (range, 28°–40°). In comparison to preoperative scores, statistically significant improvement was noted in all three groups in the postoperative period with regard to ODI, VAS and SRS-22 (p = 0.001, Wilcoxon signed-rank test).
Conclusion
Better radiographic correction was noted in the CWO and PWO groups, although this was associated with increased blood loss, multiple levels of instrumentation, and increased surgical time compared to OWO. A new safe technique of instrumentation using temporary malleable rods to prevent sagittal translation during the reduction manoeuvre is also described.
doi:10.1007/s00586-011-1894-3
PMCID: PMC3229721  PMID: 21800034
Ankylosing spondylitis; Thoraco-lumbar kyphotic deformity; Instrumented lumbar osteotomy
21.  Intubation in a pediatric difficult airway using an adult flexible fiber-optic bronchoscope and a j-tipped guidewire: An innovation in adversity 
Saudi Journal of Anaesthesia  2011;5(4):414-416.
Management of an anticipated difficult airway relies heavily on flexible fiber-optic bronchoscope (FFB) guided awake intubations. In a pediatric patient with difficult airway, doing an awake procedure may be difficult, and hence the child is either deeply sedated or anesthesia is induced before attempting intubation with an appropriate sized FFB. We present the anesthetic management of a 6-year-old child with a lacerated tongue and fractured mandibular condyle, with subsequent inability to open his mouth, who was posted for urgent exploration and open reduction under anesthesia. Unhindered by a damaged pediatric FFB, we innovated by positioning the tip of an adult FFB just outside the larynx, passing a j-tipped guidewire through the working channel of the FFB, and successfully railroaded a naso-tracheal tube over the guidewire. The surgery, reversal and extubation, and the postoperative period were uneventful.
doi:10.4103/1658-354X.87272
PMCID: PMC3227312  PMID: 22144930
Flexible fiber-optic bronchoscope; guidewire; pediatric difficult airway; working channel
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.
doi:10.4103/1658-354X.82813
PMCID: PMC3139321  PMID: 21804809
Fluroscopy; temporomandibular joint ankylosis; difficult intubation
23.  Corrective surgery for deformity of the upper cervical spine due to ankylosing spondylitis 
Indian Journal of Orthopaedics  2014;48(2):211-215.
Rotational and flexion deformity of C1-C2 due to ankylosing spondylitis is rare. We did surgical correction in one such case by lateral release, resection of the posterior arch of C1 and mobilization of the vertebral arteries, wedge osteotomy of the lateral masses of C1 and internal fixation under general anesthesia. There were no vascular and neurological complications during the surgery. After operation the atlantoaxial rotational deformity was corrected and the normal cervical lordosis was restored. At 1 year followup his visual field and feeding became normal and internal fixation was stable.
doi:10.4103/0019-5413.128771
PMCID: PMC3977379  PMID: 24741145
Ankylosing spondylitis; cervical deformity; internal fixation; osteotomy
24.  Lessons learned from cervical pseudoarthrosis in ankylosing spondylitis 
European Spine Journal  2005;14(7):689-693.
This case report illustrates three learning points about cervical fractures in ankylosing spondylitis, and it highlights the need to manage these patients with the neck initially stabilised in flexion. We describe a case of cervical pseudoarthrosis that is a rare occurrence after fracture of the cervical spine with ankylosing spondylitis. This went undetected until the development of myelopathic symptoms many months later. The neck was initially stabilised in flexion using tongs, and then slowly extended before anterior and posterior fixation was performed. The myelopathic symptoms resolved, and the patient had a good result at 18 months. We conclude that any increased movement of the spine after trauma in ankylosing spondylitis must be considered suspect and fully investigated.
doi:10.1007/s00586-004-0742-0
PMCID: PMC3489221  PMID: 15789232
Ankylosing spondylitis; Cervical fracture; Pseudoarthrosis
25.  Dexmedetomidine premedication for fiberoptic intubation in patients of temporomandibular joint ankylosis: A randomized clinical trial 
Saudi Journal of Anaesthesia  2012;6(3):219-223.
Background:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/1658-354X.101211
PMCID: PMC3498658  PMID: 23162393
Dexmedetomidine; fiberoptic intubation; propofol; sedation

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