Alternative anaesthetic management in ankylosing spondylitis.

A 59-year-old male patient suffering from AS (for 25 years) with a fixed flexion deformity of cervical spine and severely decreased thoracolombar spine mobility (Fig. 1), scheduled for ventral hernia repair with anticipated difficult intubation and neuroaxial blockade. Preoperative anesthetic assessment revealed Mallampati Class IV orophariengeal view, very limited neck movement and thyromental distance was less than 6 cm. His medical history included hypertension for 10 years and he had no other cardiorespiratuary disease. Seven years before, the patient had undergone C4-5 spine osteotomy and umbilical hernia operation under general anesthesia; in which standard spinal anesthetic technique was attempted but not successful and classic LMA has been used during the surgery due to the failed intubation of the difficult airway. In the present operation bilaterally paravertebral block (PVB) planned for the surgery and the patient was informed about the anesthetic procedure. After obtaining the written informed consent, patient was admitted to the operating room. On arrival in the operating room, routine monitoring with pulse oximeter, ECG and NIBP applied; and the patient premedicated with midazolam 2 mg and fentanyl 50 mcg. Owing to the difficult airway access, equipment for difficult airway included LMA and fiberoptic broncoscopy were checked and kept ready. Two peripheral intravenous line and one arteriel line were placed under local anesthesia. Bilaterally thoracic PVB was performed at