An approach to neuraxial anaesthesia for the severely scoliotic spine.

We report on a case in which computed tomography was used to guide placement of an epidural catheter in a patient with severe scoliosis and congenital dwarfism. In addition, the computed tomograms were corroborated with ultrasound and fluoroscopic images in the patient. Three years later, the patient had a spinal anaesthetic performed with only the use of ultrasound-guidance. Ease of placement of the epidural and spinal was greatly enhanced by imaging. We present an algorithmic approach to neuraxial anaesthesia in the patient with scoliosis to help guide placement. The algorithm first directs the provider to determine the type and severity of the scoliosis from the patient's history, physical examination, and any prior radiologic studies. If the anaesthesia provider understands and is comfortable with the patient's anatomy, then the provider may cautiously proceed with placement. Depending upon the degree of lateral curvature (Cobb angle), idiopathic scoliosis is classified as mild (11-25°), moderate (25-50°), or severe (>50°). Mild idiopathic scoliosis is managed with good positioning. Moderate idiopathic scoliosis is managed with a paramedian approach on the convex-side of the curve or a midline approach with angulation towards the convex-side or with the aid of imaging such as ultrasound. Severe idiopathic scoliosis is managed with the assistance of imaging or an alternative form of pain management should be considered. A systematic approach may facilitate safe, efficient, and successful neuraxial anaesthesia procedures in the scoliotic patient.