Esketamine combined with sevoflurane anaesthesia for transurethral resection of the prostate in ankylosing spondylitis with severe thoracolumbar kyphoscoliosis: a case report and literature review

Dear Editor,
Ankylosing spondylitis (AS) is a chro­nic inflammatory disease, which causes inflammation and structural damage to the sacroiliac joints and spine, resulting from autoimmunity and calcium deposition. The major clinical manifestation of the early phases of AS patients are sacroiliitis, spondylitis, spondylodiscitis, and spondylarthritis. In the late phase, AS patients develop a progressive rigidity of the entire spine and sacroiliac joints and subsequent structural changes with a downward and forward shift in the spine, which leads to fixed thoracolumbar kyphosis [1, 2].
Anaesthesia management for patients with severe AS is a specific challenge to the anaesthesiologist. The limitation of cervical spine mobility and possible temporomandibular joint disease raise the potential difficulty in airway management for general anaesthesia with endotracheal intubation. In the meantime, the thoracic cage deformity causes a decrease in chest wall compliance, functional residual capacity, inspiratory capacity, and vital capacity. There is a significant increase in ventilation-perfusion mismatch, which leads to arterial hypoxemia. In the cardiovascular system, the increased pulmonary vascular resistance may lead to right ventricular hypertrophy and right heart failure. This, along with the difficulty in airway management and restrictive lung disease, increases the risk associated with general anaesthesia. At the same time, central neuraxial blocks are met with technical difficulties as a consequence of ossification of the ligament and deformity of the lumbar spine in higher grades of ankylosing spondylitis [3, 4].
We report a challenging case of a 73-year-old male with severe kyphoscoliosis, presenting with benign prostatic hyperplasia planned for transurethral resection of prostate (TURP) under regional anaesthesia. However, due to the failure of epidural anaesthesia, a scenario of esketamine combined with sevoflurane anaesthesia was successfully applied for transurethral resection of the prostate. Esketamine, a new intravenous anaesthetic with sedative and analgesic effects, was chosen because of the favourable cardiovascular profile and preservation of respiratory function [5, 6]. To our knowledge, this is the first description of successful use of esketamine combined with sevoflurane anaesthesia for TURP in severe thoracolumbar kyphosis.
A 73-year-old male (weight 55 kg, ASA status III) was scheduled to undergo TURP due to...


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