Spinal Anesthesia for Emergency Cesarean Section in a Patient with Prior Thoracic Scoliosis Surgery: A Case Report

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Spinal Anesthesia for Emergency Cesarean Section in a Patient with

Prior Thoracic Scoliosis Surgery: A Case Report

Dr. Deepshika R

, Dr. Manimaran S

Postgraduate, Assistant Professor

Department of OBG, Coimbatore Government Medical College,

Email: rdeepshika101@gmail.com

Submission Date: 26.06.2025

Accepted Date: 23.07.2025

Published Date: 31.07.2025

DOI: 10.65188/nurexus.1033

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Scoliosis correction surgery, particularly involving thoracic spinal fusion and instrumentation, poses

challenges for neuraxial anesthesia due to altered spinal anatomy, scarring, and hardware presence. However, when

the lumbar spine remains unaffected, regional anesthesia may still be feasible for cesarean delivery.

Case Presentation: We report the case of a 26-year-old primigravida with a history of thoracic scoliosis surgery

(T1–L2 fusion) who presented at term with decreased fetal movements and non-reassuring cardiotocography,

requiring emergency lower segment cesarean section. Pre-anesthetic evaluation revealed a healed thoracic scar,

with preserved lumbar anatomy and palpable landmarks. Spinal anesthesia was successfully administered at the

L3–L4 interspace using a 26-G Quincke needle. The procedure was uneventful, achieving adequate sensory block

(T6) and resulting in the safe delivery of a healthy male infant. The intraoperative and postoperative periods were

stable, with no neurological or anesthetic complications.

Conclusion: This case illustrates that spinal anesthesia can be safely and effectively employed in obstetric patients

with prior thoracic scoliosis correction, provided the lumbar spine is preserved. Careful preoperative assessment,

multidisciplinary planning, and readiness for alternative approaches are key to successful anesthetic outcomes in

such scenarios.

Keywords: Spinal anesthesia, Cesarean section, Scoliosis surgery, Thoracic spinal fusion, Obstetric anesthesia,

Neuraxial block.

Introduction

The anesthetic care of obstetric patients who have previously undergone corrective surgery for scoliosis

presents a distinct set of challenges. Scoliosis, particularly when corrected surgically through spinal

fusion and instrumentation, often results in significant anatomical alterations of the vertebral column.

These changes can hinder the feasibility of neuraxial block placement, which is otherwise the preferred

anesthetic technique for caesarean delivery due to its favorable maternal and fetal safety profile [1,2].

Corrective spinal surgery, especially involving thoracic segments, may lead to obliteration of the epidural

space, scarring, and distortion or fusion of vertebrae. These structural changes can obscure traditional

anatomical landmarks, making the identification of appropriate intervertebral spaces difficult and raising

concerns regarding both efficacy and safety of neuraxial techniques [3]. Moreover, metallic

instrumentation, such as rods or pedicle screws, can obstruct needle trajectory or mislead the practitioner

about insertion level and depth [4]. Despite these potential obstacles, neuraxial anaesthesia remains a

viable and often preferable option, particularly when the lumbar spine is anatomically preserved. In such

cases, regional techniques may be safely performed with appropriate planning and technique

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modifications. The benefits of regional anaesthesia in obstetrics are well-documented, including reduced

systemic drug exposure to the fetus, the maintenance of maternal consciousness during delivery, and

avoidance of airway manipulation - especially relevant in patients with potentially difficult airways [5,6].

A thorough pre-anaesthetic assessment is essential. This includes reviewing prior surgical records,

evaluating spinal imaging when available, and identifying accessible lumbar interspaces. In some cases,

the use of pre-procedure ultrasound can aid in mapping the spine and optimizing needle placement [7].

Collaboration with orthopaedic or neurosurgical teams may further aid in understanding the extent of

fusion and potential interspaces for access [8]. This case highlights the successful administration of spinal

anaesthesia in a term primigravida with a history of thoracic spinal fusion for scoliosis correction. The

patient presented for an emergency lower segment caesarean section (LSCS), necessitating rapid

anaesthetic management. As the lumbar spine was not surgically involved and landmarks were palpable, a

single-shot spinal anaesthetic was administered successfully without complications. The intraoperative

period was uneventful, and the postoperative course was stable for both mother and baby. This case

exemplifies that, with individualized planning and appropriate technique selection, neuraxial anesthesia

can still be safely utilized in obstetric patients with prior scoliosis surgery [9].

Case Description

A 26-year-old primigravida, referred to here as Ms. XXX, a resident of Coimbatore, presented to the

obstetric emergency department at 39 weeks and 4 days of gestation. She reported reduced fetal

movements over the past 6 hours. There were no complaints of abdominal pain, vaginal bleeding, leaking,

or fever. She had been under regular antenatal care in the last 9 weeks of gestation. Routine investigations,

including complete blood count, blood grouping, serology, glucose challenge test, and obstetric

ultrasounds (NT scan, anomaly scan, growth scan), were within normal limits. She was fully immunized

with two doses of tetanus toxoid. There was no significant family or personal medical history except for

prior spinal surgery. At the age of 11, Ms. XXX underwent surgical correction of thoracic scoliosis, which

included spinal fusion and instrumentation. She had since remained asymptomatic without any

neurological sequelae.

On physical examination

On physical examination, the patient had a well-healed midline thoracic surgical scar extending from T1 to

L2, approximately 25 cm in length, consistent with her prior spinal fusion surgery. There was no spinal

tenderness or deformity in the lumbar region, and neurological examination revealed no motor or sensory

deficits. Her vital signs were stable, with a pulse rate of 76 bpm, blood pressure of 126/80 mmHg,

respiratory rate of 14/min, and oxygen saturation of 100% on room air. Abdominal examination showed a

fundal height appropriate for term, with regular and audible fetal heart tones and no uterine contractions.

On vaginal examination, the cervix was posterior, soft, uneffaced, and closed. In view of the reduced fetal

movements and non-reassuring cardiotocography findings, the obstetric team decided to proceed with an

emergency lower-segment cesarean section (LSCS).

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Figure 1: X-ray finding of surgical correction of thoracic scoliosis

Anaesthetic Planning and Technique

Considering her history of thoracic spine surgery, a multidisciplinary discussion was held involving

obstetricians, anesthesiologists, and pediatricians. Imaging records of the scoliosis surgery were

unavailable, but the patient recalled no lumbar spine involvement. On examination, lumbar spinous

processes were palpable and aligned, with no signs of scarring or deformity in the lumbar region. Hence,

spinal anaesthesia was deemed feasible.

Preparation

Informed written consent was obtained from the patient after explaining the procedure and associated risks.

Standard monitors, including non-invasive blood pressure (NIBP), electrocardiography (ECG), and pulse

oximetry, were applied to ensure continuous hemodynamic and respiratory monitoring. Two large-bore

(18G) intravenous lines were secured, one in each upper limb, to facilitate fluid administration and

medication delivery. The patient was preloaded with 500 mL of Ringer’s lactate solution to reduce the

likelihood of post-spinal hypotension and maintain adequate intravascular volume before the administration

of regional anesthesia.

Procedure

The patient was positioned sitting upright, and under strict aseptic precautions, a 26G Quincke spinal

needle was introduced at the L3–L4 interspace using a midline approach. Clear cerebrospinal fluid was

obtained on the first attempt, and an intrathecal injection consisting of 0.5% hyperbaric bupivacaine 2 mL

with fentanyl 12.5 µg was administered. The patient was immediately positioned supine with left uterine

displacement, and a sensory block up to the T6 dermatome was achieved within five minutes. Surgery

commenced after confirming adequate sensory and motor blockade. The caesarean section proceeded

uneventfully with stable intraoperative vitals - pulse 100 bpm, blood pressure 128/78 mmHg, and SpO₂

100% on room air. There were no episodes of hypotension, bradycardia, or respiratory compromise. A live

male infant was delivered at 7:56 PM, weighing 3.92 kg, with Apgar scores of 9 and 10 at 1 and 5 minutes,

respectively. Oxytocin 10 units IV (slow infusion) and 10 units IM were administered to promote uterine

contraction. The estimated blood loss was approximately 600 mL, the uterus contracted well, and no

intraoperative complications were noted. The patient was shifted to the postoperative recovery unit in a

hemodynamically stable condition and was pain-free with adequate analgesia.

Discussion

The anaesthetic management of obstetric patients with a history of spinal surgery - particularly for

scoliosis - presents a unique clinical challenge. The choice between neuraxial and general anaesthesia

must be made with careful consideration of multiple factors, including the type, level, and extent of prior

spinal surgery, the presence of spinal instrumentation, residual deformities, and the urgency of the

caesarean delivery [10,11]. Scoliosis is a structural, lateral curvature of the spine associated with rotation

of the vertebrae and alteration in the alignment of the spinal column. Severe forms often necessitate

surgical correction, commonly involving spinal fusion and instrumentation with rods, screws, and bone

grafts. The resultant changes can significantly alter the anatomy of the vertebral column and surrounding

soft tissue, complicating access to the epidural or subarachnoid space. In particular, scarring, obliteration

of landmarks, fusion of spinous processes, and mechanical barriers posed by spinal hardware all increase

the difficulty and potential failure rates of neuraxial blocks. In this case, the patient had undergone

thoracic scoliosis correction from T1 to L2. Fortunately, the lumbar region - including the commonly

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accessed L3–L4 interspace remained uninvolved and free from instrumentation or scarring. This critical

anatomical detail made the administration of spinal anaesthesia technically feasible and ultimately

successful [12,13].

Preoperative Assessment

A detailed pre-anaesthetic evaluation is crucial in such cases to ensure optimal planning and safety. It

should encompass a thorough history of the extent and level of previous spinal surgery, along with any

prior anaesthetic experiences, particularly failed or complicated neuraxial attempts. A comprehensive

physical examination is essential to assess the spine’s surface anatomy, identify deformities or surgical

scars, and evaluate for any neurological deficits. When available, radiologic imaging such as MRI or spinal

X-rays can provide valuable information regarding fused segments, hardware placement, and potential

interspaces suitable for neuraxial access. Although imaging was not available in this case, clinical judgment

was carefully exercised based on physical findings and patient history [14].

Choice of Anesthesia

In obstetric anaesthesia, neuraxial blocks such as spinal, epidural, or combined spinal-epidural techniques

are generally preferred over general anaesthesia for caesarean sections due to their multiple maternal and

fetal advantages. These include maintaining maternal consciousness and allowing active participation in

childbirth, reducing fetal exposure to systemic anaesthetic agents, lowering the risk of aspiration and failed

intubation, and providing superior postoperative analgesia. However, in patients with spinal deformities or

a history of spinal surgery, neuraxial anaesthesia poses greater technical challenges and potential

complications such as unintentional dural puncture, patchy or inadequate block, unpredictable spread of

local anaesthetics leading to high spinal block, and possible neurological injury if the needle contacts neural

structures or hardware. Despite these risks, several studies have demonstrated the feasibility of neuraxial

anaesthesia in selected patients with previous scoliosis correction. Peralta et al. reported successful

neuraxial anaesthesia in 78% of obstetric patients with prior scoliosis surgery, emphasizing the significance

of detailed pre-procedural evaluation and awareness of surgical anatomy [1]. Similarly, Hebl et al.

concluded that neuraxial blocks are not absolutely contraindicated in such patients and can be safely

administered with appropriate precautions and expertise [2]. Davies and Paech also noted that although

technical difficulties are more frequent, neuraxial anaesthesia remains the preferred approach whenever

feasible [15,16].

Technical Considerations

In this patient, several key factors facilitated the success of spinal anaesthesia:

1. The surgical correction was limited to the thoracic spine.

2. The lumbar vertebrae were anatomically intact and accessible.

3. There was no evidence of residual spinal curvature or deformity in the lumbar region.

4. Clear anatomical landmarks were present, and the spinal needle was successfully inserted on the

first attempt.

5. A midline approach was employed, which is preferred over paramedian when landmarks are

well preserved [17]

Role of Ultrasound and Imaging

In more complex cases where landmarks are obscured or hardware is suspected in the lumbar area,

ultrasound-guided neuraxial techniques can significantly enhance the success rate. Ultrasound helps in

visualizing the vertebral interspaces, estimating depth to the ligamentum flavum and dura, and identifying

deformities or hardware that may interfere with needle placement [4,5]. When administering neuraxial

anaesthesia in patients with a history of spinal deformity or prior spine surgery, meticulous preparation

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and caution are essential. The anaesthesia team should maintain a low threshold for converting to general

anaesthesia in the event of block failure or inadequate analgesia. Airway management equipment must be

readily available, as obstetric patients inherently have a higher risk of aspiration and airway difficulty.

Informed consent should be obtained after the increased likelihood of technical challenges, complications,

or failure has been clearly explained. Additionally, close multidisciplinary coordination with the obstetric

and neonatal teams is crucial to ensure optimal maternal and fetal safety throughout the perioperative

period [18,19]. Postoperatively, patients with prior spinal surgery who receive neuraxial anaesthesia

require close surveillance for early detection and management of complications. Careful neurological

monitoring is essential to identify any new motor or sensory deficits, and clinicians should remain vigilant

for signs of post-dural puncture headache, particularly after multiple needle attempts. Hemodynamic

stability must be monitored and supported as needed, and adequacy of analgesia should be assessed

frequently - multimodal analgesia with paracetamol, NSAIDs, and judicious opioid use is recommended

when appropriate. The literature supports individualized perioperative planning and close follow-up:

Kuczkowski emphasized tailored anaesthetic strategies in pregnant patients with prior spinal fusion, while

Munhall and Lee reported successful neuraxial techniques without complications when lumbar anatomy

was preserved. Combined spinal–epidural anaesthesia (CSEA) has been described as a useful approach to

increase initial block success and provide an option for extension of analgesia if needed. Multidisciplinary

coordination and prompt readiness to convert to general anaesthesia remain key components of safe care

in these cases [20].

Conclusion

This case highlights that spinal anesthesia can be safely and effectively used in select obstetric patients

with a history of thoracic scoliosis correction. When the lumbar spine is preserved, proper clinical

assessment, vigilant monitoring, and preparedness for alternative plans allow regional anesthesia to remain

the modality of choice. Such individualized approaches not only optimize maternal safety and comfort but

also enhance fetal outcomes by avoiding general anesthesia in urgent obstetric settings

Conflict of Interest: Nil

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