A case of ultrasound-guided under-waist-hard joint anesthesia in patients with strong direct spinitis

Strong scoliosis is a disease with inflammation of the joints and spinal attachment points as the main symptomBecause some microorganisms (such as Crespour) and susceptible tissue have a common antigen, often cause an abnormal immune response, resulting in large joints of limbs, intervertebral disc fiber ring and nearby connective tissue fibrosis and bone, with the spine as the main lesions, often tired of the tibia joints, and cause different degrees of eye, lung, muscle, bone lesionsthe lumbar spine is affected, most of them show limited lower back and lower back movementThe front bend, back extension, side bend and rotation of the waist are limitedA physical examination revealed lumbar spinal altrude tenderness, lumbar muscle spasms, and later lumbar muscle atrophyWhen the thoracic spine is tired, it is characterized by back pain, chest and side chest pain, most commonly hunchback malformationIf the rib vertebral joint, the chest joint, the chest lock joint and the rib cartilage between the joint sesame is affected, the band chest pain, chest expansion is limited, when inhaling coughing or sneezing chest pain aggravatedSevere chest profile remains in exhalation state, chest expansion than normal people reduced by more than 50%, so only rely on abdominal breathing assistanceBecause the chest abdominal cavity capacity is reduced, resulting in heart and lung function and digestive dysfunctiona few patients first showed cervical vertebratit, first with cervical pain, along the neck to the head arm radiationThe neck muscles begin with spasms and later atrophy, and the progression of the lesions can develop to the post-cervical protrusion deformityHead movement is obviously limited, often fixed to the front flexor, can not look up, side bend or turn, can not look upFor the choice of anesthesia method, patients often because of lumbar hyperplhesis to increase the difficulty of puncture in the vertebral tube, and because the cervical spine is strong straight fixed, intubation difficulties caused by difficult airwaysWe used ultrasound-guided lower-waist-hard joint anesthesia in 1 case of severe scoliosis, and achieved better clinical resultsIt is reported below1 Case information the patient male, 51 years old, weighing 68 kg, height 168 cm, was admitted to hospital due to a fractured tibia on the left side, the proposed open reset intra-bone fixation Have a history of hypertension, diabetes, coronary heart disease At present, taking antihypertensive drugs to control blood pressure, oral sugar-lowering drugs to control blood sugar; 2 years ago installed coronary stents 2 pieces, the current heart function is still ok, occasionally chest tightness, take dansan drop pills can be alleviated Aspirin stopped taking the drug for 1 week and switched to a preventive dose of low-molecular heparin underthecut The low-molecule heparin stopped taking the drug 12 hours before surgery Strong history of spinabitis, back front and back back stretch difficulty, chest spine into a hunchback deformity; Auxiliary examination: (1) echocardiogram aortic valve mild reflux, EF65%, left chamber fat 2 electrocardiogram: sinus heart rate, occasional chamber early (3) Chest X-ray tablets show that the double lung texture thickens (4) The pelvic X-ray flat sheet shows the joint surface blurring, the edge of the joint hardens, the boundary blurs, the joint gap narrows, the right hip is narrow (Figure 1) a pelvic X-ray of a patient in Figure 1 The patient had severe cirrhosis of the tibia joint, lumbar vertebral hyperplor, and the right hip stenosis 2 Anaesthetic Management 1) Anaesthetic Selection: the choice of anaesthetic mode is of great significance to the patient The choice of general anaesthetic depends on the characteristics of the condition, the nature and requirements of the operation, the advantages and disadvantages of the anaesthetic method itself, the experience of the anesthesiologist, the condition of the equipment and other factors, and also consider the surgeon's opinion on the choice of anesthesia and the patient's own wishes as far as possible General anesthesia can be used in almost any operation and is the most commonly used form of anesthesia General anesthesia has many advantages, is the most familiar anaesthetic doctors, the effect is accurate, muscle relaxation effect is good, easy to control the airway strain and adjust breathing state, the patient feels comfortable, there is no limit to the position and so on However, its adverse reactions can not be ignored, such as reflux mis-suction, whole hemp drug suppression of circulation, airway secretions increased, the incidence of lung infection searly infection searly disease increased, elderly lung patients often need a long period of mechanical ventilation after surgery, poor postoperative analgesic effect, postoperative delirium and cognitive dysfunction this case of patients before the history of coronary heart disease, 2 years ago installed coronary stents 2 pieces, the current activity can be, occasionalchest tightness, take dansan droppills can be alleviated, echocardiogram left chamber blood score 65%, suggesting that the patient's heart function can withstand the vertebral tube or general anesthesia, heart function should not affect the choice of general anesthesia or intra-vertebral anesthesia However, this case of patients, due to the neck spine strong straight, cervical vertebrae into a forward flexstate state, and can not back up and turn, although the opening degree 2 cross fingers, but the risk of difficult airways is very large; intravertebral anesthesia is also one of the important anaesthetic methods of lower limb surgery in elderly patients The puncture in elderly patients is more difficult, such as the plane is too high, and the effect on circulation and breathing is greater Anesthesiologists need to pay attention to their indications and contraindications when choosing intravertebral anaesthetic, such as clotting dysfunction, lumbar fractures, puncture or systemic infections, circulatory instability, pelvic or spinal fractures leading to potential shock patient's oral aspirin of pythmynin, stopped taking the drug for 1 week, and has been treated with low-molecular heparin anticoagulant The hypocheparin has been suspended for 12 hours, and the patient's clotting condition does not affect the choice of anesthesia in the vertebral tube However, the patient's lumbar spine is strong, bone hyperplus, vertebral plate gap bone hyperplor, resulting in the narrowness or closure of the vertebral plate gap, to the lumbar puncture caused difficulties The traditional X-ray and CT techniques have better appearance of bone structure and are widely used in the examination of spinal structure, such as spinal fractures, congenital malformations and scoliosis Mr MRI is better for soft tissue imaging, and is widely used in spinal-related structures such as spinal cord, intervertebral disc and so on by contrast, ultrasound can dynamically obtain real-time images of the observed tissue site, no radiation hazards to operators and patients, clearly showing muscles, ligaments, blood vessels, joints and solid organs and other structures, but the bone structure is poorly distinguished The spinal structure is irregular, and there is a "window" of soft tissue covering such as intervertebral holes, vertebral plate gaps, intervertebral joints, etc This feature of spinal structure provides excellent "conditions" for ultrasound to display the structure associated with the spine on the one hand, ultrasound can not penetrate bone tissue, so can not distinguish the internal structure of bone tissue, but can clearly display the bone surface, through ultrasound on the spinal bone surface irregular structure display, can judge the corresponding spinal structure such as intervertebral joints, vertebral plates, echinothroids, transverse, cervical vertebral before and after nodules On the other hand, the ultrasonic beam can penetrate the "window" of the spinal structure, through which the ultrasound can show the internal structure of the vertebral tube, such as the epidural sac, spinal cord, cerebrospinal fluid, etc Clinically, the identification of spinal bone signs and the internal structure of the vertebral tube can be identified by ultrasound, the location of the relevant organizational structure, distance and angle of the skin can be facilitated to carry out intravertebral puncture, and the accuracy and safety of punctures can be improved although the patient due to strong scoliosis, the lumbar spine will have significant growth, vertebral plate gap may be narrow, but in the ultrasonic real-time scanning technology, it is possible to show that the vertebral plate gap has not been fully closed (i.e puncture path), so the use of ultrasound-guided under vertebral puncture technology, can complete intravertebral anesthesia, to avoid the difficultaire risk caused by the whole line 2) Ultrasound-guided intratube anesthesia: based on the above analysis, we decided to use the ultrasound-guided intravertebral anaesthetic (lumbar-hard joint anesthesia) We intend to use the side positive long shaft oblique scanning technology, the plane in-line needle will Tuohy epidural outer needle pierced into the lumbar 3-4 horizontal vertebral plate gap of the yellow ligament, and then use a resistance-free syringe, through the resistance disappearance method to confirm the needle tip into the epidural outer gap Then place the lumbar needle, give a weight of 0.5% (1% ropixain 1.5 ml plus 10% glucose 1.5 ml) ropcoun 15 mg (3 ml), pull out the lumbar needle, through the Tuohy needle placed in the epidural outside the catheter 3) Anaesthetic implementation and inoperative management: after patients into the operating room, check the narcotic drugs and rescue drugs and intubation substances equipment ready in place Raise the temperature of the operating room and keep warm with a heater At the same time pay attention to communication with the patient, reduce the patient's anxiety After everything is ready, anaesthetic begins First open peripheral intravenous infusion, sleeve band blood pressure of 148/87mm-Hg, heart rate 68 times / minute, end blood oxygen saturation of 97% Give the anaesthetic mask oxygen absorption and continuously monitor the cuff blood pressure adjust the operating head of the operating bed about 15 degrees high, the patient put left in the left position (the patient's limb in the lower), the use of portable ultrasound, the coupling agent is applied to the patient's waist back, the ultrasonic probe long axis placed in the right side of the waist section next to the center 2 cm or so, in the ultrasound image of a smooth surface of the high echo line is the tibia, further to the head side to distinguish the same L5S1 small joint, L4/5 small Joint, L4/5 small After confirming the L3/4 small joint, the ultrasonic probe scan angle is adjusted to the direction of the spine midline scanning, the appropriate head and tail side to move the probe, pay attention to the ultrasonic image to distinguish the disc, at this time the ultrasound image of the vertebrae plate showed as a high echo "horse head" sign, the upper and lower two vertebral plate is not connected mark the position of the ultrasound probe on the patient's skin with a marker pen Disinfecting scarves, will convex ultrasonic probe cover asteria plastic sleeve, under the above method for ultrasonic scanning, using epidural tuohy needle plane puncture, needle tip pointing to L3/4 vertebral plate gap, when the needle tip reaches the yellow ligament, connected withno resistance The syringe continues to advance until there is a sense of failure, placed in the lumbar needle, there is cerebrospinal fluid reflux, give a heavy proportion of 0.5% ropone cadine 15mg, pull out the lumbar needle, through the Tuohy needle placed in the epidural catheter (Figure 2) Figure 2 a positive medium long axis scan next to the spine Figure (1) shows the position of the probe and puncture needle under the positive and medium long shaft scan next to the ultrasonic Figure (2) shows the ultrasound image of the lower spinal structure scanned by the positive and medium long axis next to the ultrasonic side H, head side; T, tail side; A, vertebral plate; B, yellow ligament; C, back side epidural; D, abdominal epidural to keep the patient in the right side of the position for 5 minutes, then flat The measured anaesthetic plane has reached the T9 level There is no obvious discomfort in the patient after anesthesia Continuously monitor the patient's breathing, blood pressure, heart rate, during surgery breathing frequency of 16 to 18 times / minute The operation lasted about 65 minutes, blood pressure fluctuated between 115 to 138/58 to 82mmHg, and the end blood oxygen saturation remained at 99% The amount of bleeding during the operation is about 50 ml, and the amount of urine in the operation is about 200 ml Surgically remove the epidural catheter Return to the ward and continue to absorb oxygen and electrocardiogram 4) Postoperative Management: postoperative patients use a preventive dose of low-molecular heparin to prevent blood clots The patient used intravenous patientself to control analgesics, diluted to 100 ml at 100 ml per hour Mild nausea and vomiting after surgery, giving Hinbey 5mg to improve after treatment The patient was discharged after 1 week without anaesthetic-related complications