A0010 Perioperative Anesthetic Management of a Patient with Chin-on-Chest Deformity Presenting for Reconstructive Spine Surgery: A Case Report

Background: Ankylosing spondylitis (AS) can present significant challenges to the anesthetist due to potential difficult airway, cardiorespiratory complications, osteoporotic bones, and increased risk of venous thromboembolism.

Case Description: A 33-year-old woman (50 kg/152 cm) presented with extreme fixed flexion deformity of neck as a sequela of AS and was scheduled for corrective surgery. Sensory and motor functions were intact. On airway examination, mouth opening was found to be 3 cm wide. Evaluation of Mallampati and other airway scorings were not possible. Midline neck structures including trachea were not accessible. Other complicated issues were inability to gargle, lack of landmarks for airway blocks, left-sided deviated nasal septum, and no scope for surgical airway. As a result of anticipated difficult airway, preoperative mock drills were performed. We planned awake fiberoptic intubation (FOI) through the right nostril. On the day of surgery, her airway was prepared using xylometazoline nasal drop, 10% lignocaine spray (orally) and 4% lignocaine nebulization. Awake nasal FOI was performed successfully using “spray as you go” (SAYGO) technique. Induction of anesthesia was achieved with fentanyl (150 µg) and propofol (100 mg). Rocuronium (50 mg) was used during induction. Anesthesia was maintained with O₂:air along with infusions of propofol and fentanyl. No muscle relaxant was administered further in view of motor evoked potentials (MEPs) monitoring. Maintenance of ventilation, circulation, temperature, and DVT prophylaxis were done accordingly. Corrective surgery was done uneventfully with a blood loss of 1,200 mL. The patient was electively ventilated after the surgery and extubated successfully on second postoperative day. She was discharged on the 14th postoperative day without any neurological deficit.

Conclusions: Ankylosing spondylitis and consequent fixed flexion neck deformity bring forth tremendous anesthetic challenges. In this context, the role of preoperative planning, anticipation of complications, and preparedness to deal with complications may not be over-emphasized.