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Spinal anesthesia in an obese patient with osteogenesis imperfecta

Staffordshire, Uk

To the Editor:

A 33-yr-old gentleman (body mass index of 44) with a history of osteogenesis imperfecta (OI) type IV was scheduled for dynamic screw fixation of a right femoral fracture sustained during an epileptic fit. He had significant co-morbidities. These included non-insulin dependant diabetes mellitus, hypopitutarism, obesity, and learning difficulties. He had limited mobility but clinically had no significant symptoms or signs relevant to his cardiorespiratory system. His medications included thyroxine, hydrocortisone, benzodiazepine, sodium valproate, triazine, carbamazepine, testosterone, and sulphonylurea. A preoperative full blood count, platelets, and coagulation screen were normal. He had consistently low serum sodium (124 mmol•L^-1), chloride (90 mmol•L^-1), and calcium (2.09 mmol•L^-1). Such chronic electrolyte disturbances were due to the associated endocrine dysfunction.

As endotracheal intubation was expected to be difficult and hazardous, spinal block was chosen. Despite the associated kyphoscoliosis no difficulty was experienced finding the subarachnoid space using a midline approach with a 25-gauge spinal needle. Three millilitres of L-bupivacaine and 10 µg of fentanyl produced anesthesia to the level of T8 bilaterally. Temperature was monitored in addition to routine ASA monitoring. The operation lasted for three hours and the patient made an uneventful recovery.

Skeletal abnormalities of the lumbar spine, as in OI, are considered relative contraindications to spinal anesthesia. Associated cardiac lesions and a coagulopathy may also present problems. Management of the difficult airway due to abnormal cervical spine mobility, fragile teeth and the risk of mandibular and facial fractures are the risks associated with general anesthesia. The use of anticholinergics may exacerbate the risk of hyperthermia. Although general and epidural anesthesia have been reported in patients with OI,^1,2 the use of spinal block is infrequent. This is possibly due to technical difficulties, but more importantly due to the difficulty in predicting the spread of local anesthetics. Administration of anesthesia to a patient with OI is a rare and challenging occasion for an anesthesiologist. The problems directly and indirectly associated with the disease affect the anesthetic management. With careful attention to the associated problems, spinal anesthesia appears to be a safe technique and was associated with a favourable outcome in our patient.

References

1 Oliverio RM Jr. Anesthetic management of intramedullary nailing in osteogenesis imperfecta: report of a case. Anesth Analg 1973; 52: 232–6.[Free Full Text]

2 Cunningham AJ, Donnelly M, Comerford J. Osteogenesis imperfecta: anesthetic management of a patient for cesarean section: a case report. Anesthesiology 1984; 61: 91–3.[Medline]

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