Fluoroscopic guided epidural anaesthesia: A rescuing skill in difficult anaesthetic management

A 26-year-old, male patient, American society of Anesthesiologists (ASA) physical status class II, was posted for urethroplasty for urethral stricture. He had severe scoliosis in thoracolumbar area with a Cobb’s angle of 70° [Figure 1a and b]. His breath holding time was 10 s, he had severe restrictive lung disease on pulmonary function tests and moderate pulmonary arterial hypertension. In view of poor cardiopulmonary reserve and a difficult back, fluoroscopy-guided epidural anaesthesia via interlaminar approach was planned and an informed written consent was obtained. In the operative room, standard monitors were applied and the patient was laid in prone position on the operating table with bolsters below the abdomen. True anteroposterior (AP) view (i.e., pedicles of vertebra appear equidistant from their spinous process) followed by squarring of adjoining endplates of third and fourth lumbar vertebra (L3--L4) on fluoroscopic image were achieved. Lamina of L4 vertebrae over right side was identified and needle entry point was marked using a metallic marker. Under all aseptic precautions and C-arm guidance, a 18 gauge Tuohy’s needle was advanced to touch the targeted ipsilateral L4 lamina [Figure 2a]. Thereafter, the needle was directed cranially aiming towards the edge of lamina. Subsequently, contralateral oblique view of C-arm (orbital rotation of C-arm) was obtained where lamina appear like tear drops. The needle was advanced further of lamina in this view using loss of resistance (LOR) technique. Vertical spread of contrast in posterior epidural space [Figure 2b] further confirmed correct needle placement. A 20G epidural catheter was placed 4 cm in the epidural space. T10 dermatome sensory blockade could be achieved with injection of 10 ml of 0.75% ropivacaine.