Case Report

Spinal Anesthesia in Cesarean Section for Gravida with Severe Scoliosis-Lordosis

Lumbar Vertebrae along with Extensive Scarring in the Lumbar Region

Warsito*; Andriani, Wiwiek**; Prahastini, Erawati**

*Resident of Anesthesiology and Intensive Care Unit of Faculty of Medicine Udayana
University - RSUP Sanglah Denpasar
** Staff of Anesthesiology and Intensive Care Unit of RSUD Dr. Soebandi Jember
ABSTRACT
Introduction
Scoliosis is a condition when there is a deviation in the vertical axis of the vertebrae. Severe
scoliosis is relatively rare in pregnant women (incidence 0.03%), generally are idiopathic.
The degree of severity is determined by the Cobb angle. Lordosis is a normal state where
there is a curvature of the concavity anterior vertebral (normally in the cervical and lumbar
vertebrae). In pregnant women there is an increased lumbar lordosis. Regional anesthesia in
pregnant women with abnormal curvature of the spine provide a challenge for the
anesthesiologist.
Case Reports
Patients 26 years old with diagnosis primigravida 40-41 weeks normal gestation second stage
with the CPD and severe scoliosis-lordosis lumbar and extensive scarring in the lumbar
region. There is no shortness of exertion, motor or sensory disorders in these patients.
Patients with a body weight of 60 kg and a height of 150 cm, blood pressure 130/90 mm Hg,
pulse frequency 88x/minute, respiratory rate 18x/minute, without fetal distress. Patients
decided Cesarean section. The patient is positioned left lateral decubitus. Patients are given
spinal anesthesia with paramedian technique, using 25G spinal needle at the level of Th12-L1
with 0.5% bupivacaine heavy regimen of 12.5 mg and morphine 300 mcg. Sensory level
reached at level thoracic 6, and the operation may begin. Operation duration is 30 minutes.
Hemodynamically stable patients with a blood pressure of 100-115/65-84 mm Hg, pulse
frequency 68-75x/minute. Total fluid given 1500 ml of Ringer's lactate. Born baby boy, birth
weight of 2095 grams, body length of 50 cm with Apgar score of 8/9. Post-surgery, patient
had no complaints of headache and pain around the surgical wound. Sensory and motor
modalities are evaluated 8 hours after normal operation. Patients treated in the room for 2
days.
Discussion
Spine curvature disorder generally accompanied cardiopulmonary disorders and
neuromuscular disorders. Anatomical and functional changes in the body at the gravida
(edema respiratory tract, decreased FRC, impaired gastric passage) with abnormal curvature
of the spine increases the risk of intubation difficulty, hypoxemia, and aspiration while

general anesthesia induction, and also the risk of neonatal depression. Regional anesthesia is
generally chosen. Local anesthetic dose requirement varies greatly in this case. Hyperbaric
local anesthetic solution will be collected at the dependent part of the vertebrae and cause
inadequate block.
In this case the identification of the lumbar intervertebral space is difficult. Administration of
spinal anesthesia chosen because the technique is simple, faster onset, better quality
anesthesia compared to epidural anesthesia. Spinal anesthesia is generally not performed at a
level above L2-3 to prevent injury to the spinal cord. However, lumbar intervertebral space
difficult to identify these patients and so do the intervertebral Th12-L1. Spinal needle used
size 25G so that the identification ligametum flavum and dura mater layer is more easily felt
to avoid injury to the spinal cord. Intrathecal administration of morphine adjuvant may
provide analgesia in the upper segment that may not be affordable due to the curvature of the
vertebral abnormalities and also provides analgesia for up to 24 hours post-surgery.
Conclusion
Carefully giving spinal anesthesia performed in the intervertebral space above L2-3,
especially in cases where the lumbar intervertebral space could not be identified properly.
Keywords: Spinal anesthesia, Gravida, Severe scoliosis-lordosis lumbar, Scarring