Drilling a hole through a calcified sacral hiatus can be a successful alternative approach for caudal anesthesia in patients with severe ankylosing spondylitis where conventional neuraxial or general anesthesia is contraindicated.
May offer an alternative caudal approach when standard techniques are contraindicated; leaves open need for validation before broader use.
A 40 (forty) year old male patient with Ankylosing Spondylitis was admitted for total replacement of left hip joint. Fusion of the axial skeleton, immobility of cervical spines and restricted movement of temporomandibular joint lead to anticipate difficulty in intubation and failure of central neuraxial blockade for total hip replacement. Above factors also compelled to discard the attempts for spinal or epidural or general anesthesia (G.A.) in the conventional way. Last of all, it was decided to operate under caudal anesthesia. But it was difficult to administer caudal anesthesia through calcified sacral hiatus. After through discussion with surgeons, decision was taken to drill the calcified membrane over the sacral hiatus. Through the drilling hole, nerve stimulator needle was introduced and 30 ml of local anesthetic was injected in sacral epidural space after electing dorsiflexion moment of great toe. Satisfied anesthesia developed within 5 minutes. At last, an epidural catheter was inserted within sacral epidural space and kept it left in the sacral epidural space. Operation was completed smoothly without any disturbance from patient's side. No hemodynamic instability was noted.
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Radhashyam Paria (2014) studied this question.
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