Title:Ultrasound for intrathecal injections in pediatric patients with severe scoliosis: isolated use or common practice?
Author(s): Garcia B. , Reinoso F. , Fernández E. , Huercio I. , Martínez M.
Background: Previous reports show that 60 to 80% of spastic quadriplegia patients develop scoliosis. Baclofen has been shown to improve quality of life for these patients. Case report: The patient is a 12-year-old male weighing 15 kg, ASA III, with a history of encephalopathy, Smith-Lemli-Opitz syndrome, severe congenital scoliosis and increased spasticity. The patient´s existing regimen of baclofen 10mg q8h and botulinum toxin every 3 months was replaced by intrathecal injection of baclofen performed under deep sedation using a face mask and 1 to 2% Sevoflurane, with spontaneous ventilation. Methimazole was administered following the procedure. Ultrasound was used to facilitate intrathecal injection, performed with a 22 gauge meedle in the suspected L4-L5 space. The successful trajectory deviated significantly from the classical midline or paramedian approach. The procedure was completed successfully and without complication in 18 minutes after only one attempt. Spasticity improved after approximately 25 minutes; thus intrathecal pump implantation was recommended. Discussion: Ultrasound or fluoroscopy can be considered as an adjunct for accurate localization of vertebral level in challenging patients (Level I). Further research is needed to establish a safe, effective procedure for intrathecal access to the subarachnoid space in paediatric scoliosis patients. References: 1.The Second ASRA Practice Advisory on Neurologic Complications Associated with Regional Anesthesia and Pain Medicine Executive Summary 2015 joseph M. Neal et al. Reg Anesth Pain Med 2015; 40: 401-430. Learning points: The use of ultrasound has the potential to reduce procedure time and the incidence of multiple punctures. Furthermore, ultrasound is portable, safe, relatively inexpensive and free of ionizing radiation. Confirming accurate anatomic localization during the baclofen test is crucial, as the success of this test determines indication for pump implantation-a standard tool for improving these patients´quality of life.