Cervical epidural analgesia in a case of oral cancer undergoing reconstructive surgery

Abstract

We report a case of successful administration of cervical epidural analgesia in combination with general anaesthesia for a 50-year-old male patient of chronic obstructive pulmonary disease with carcinoma of tongue undergoing reconstructive surgery. Cervical epidural analgesia was provided with intermittent doses of 0.25% bupivacaine intraoperatively in addition to general anaesthesia and intermittent doses of 0.125% bupivacaine with tramodol 1 mg/kg postoperatively. It provides marked decrease in requirement of anaesthetic drugs, rapid recovery, reduced intensive care unit stay, and less pulmonary complications.

INTRODUCTION

Cervical epidural analgesia (CEA) is successfully used in the management of chronic pain. This approach is common even in the operation theatre for number of surgeries.[1] Oral cancer patients with prior optimization of co-morbidities pose significant operative risks.[2] CEA with general anaesthesia provides balanced anaesthesia and analgesia.[3] We report one such case of the management of reconstructive oral cancer surgery in our hospital.

CASE REPORT

A 50-year-old-male patient presented with carcinoma tongue, and was posted for haemiglossectomy, haemimandibulectomy, radical neck dissection and reconstructive surgery. He was a known case of chronic obstructive pulmonary disease.

On clinical examination he was poorly built and poorly nourished. A 2.5×3 cm hard lymph node was present in the right submandibular region. His vital signs were pulse 56 beats/min, blood pressure 110/70 mm of Hg, respiratory rate 16/min. A growth was seen on the right lateral border of the tongue. The mouth opening was adequate, revealing a Mallampatti classification II airway. Chest auscultation revealed bilateral rhonchi and crepitations. Routine haematological and biochemical investigations were normal. Chest X-ray showed an emphysematous picture. Electrocardiogram showed sinus bradycardia. Echocardiography was normal.

Possible stabilization of general condition was done before surgery. We planned to give cervical epidural block prior to induction of anaesthesia. After taking informed consent, procedure was explained to the patient. Tab. Alprazolam 0.25 mg was given the night before the surgery. In the operation theatre baseline vital parameters were recorded. Peripheral intravenous access was secured.

The patient was put in a left lateral position, C₇-T₁ space was identified with flexion of neck. Taking all aseptic precautions, epidural puncture at C₇-T₁ intervertebral space was performed by 18-G tuohy needle using loss of resistance to air technique, catheter was introduced 3 cm cranially into the epidural space, 3 ml 2% lignocaine with adrenaline was given as test dose. A bolus dose of 10 ml of 0.25% bupivacaine was given through catheter, sensory block was attained up to C₂-T₆ level.

General anaesthesia was given 15 min after the cervical epidural block. Patient was premedicated with glycopyrrolate 0.2 mg intravenous (IV), midazolam 1 mg IV, fentanyl 80 μg IV, and induced with 1% propofol 100 mg IV. Airway was secured with an 8-mm nasal tube after suxamethonium 100 mg IV, then after thorough oral pack, anaesthesia was maintained with nitrous oxide in oxygen, vecuronium and minimal concentration of isoflurane. At the end of the surgery the trachea was extubated after administration of reversal agents. The endotracheal tube was kept in the pharynx as a nasal airway. Haemodynamic and respiratory parameters were maintained within normal limits during the operative procedure. Analgesia was maintained through the catheter with top-up dose of 6 ml of inj bupivacaine 0.25% every hour in the perioperative period and with 6 ml inj. bupivacaine 0.125% with tramodol 50 mg six-hourly in the postoperative period for 72 h.

DISCUSSION

The prevalence of oral cancer is high among men, the sixth most prevalent cancer worldwide. In India, the incidence rate is 12.6 per 100000 population. Many of these patients are elderly and frail, often with significant medical co-morbidities. Reconstructive surgery for oral cancer is a lengthy procedure with moderate blood loss. The occurrence of systemic complications, advanced extended clinical severity stage, and staying in an intensive care unit adversely affect the prognosis.

CEA is frequently used in the head, neck, face, shoulder and upper extremity pain management practice. In the operation theatre it is used as the sole anaesthetic procedure for mastectomy, neck surgery, carotid endarterectomy and upper limb surgery.[1] Intraoperative use of the epidural catheter as a part of combined epidural, general anaesthesia technique results in less pain and accelerated patient recovery immediately after surgery compared with general anaesthesia followed by systemic opioids.

We decided to proceed with CEA before general anaesthesia to avoid masking of epidural-related complications and the use of IV analgesics till the completion of oral surgery because CEA provides sensory blockade of the superficial cervical, brachial plexus and upper thoracic dermatomes. Approach to the epidural space at the C₇-T₁ interspace is easy because of prominent landmarks and the space is wide compared to the lumbar space. Patients can be placed in the sitting or lateral position. The spread of local anaesthetic is approximately 0.7 to 1.0 ml/segment and maximum volume should be 10 ml.[4] 5 to 7 ml is adequate for most pain management in adults. Local anaesthetics used are 1.0% lignocaine, or 0.25% bupivacaine.[5] It has minimal effects on respiratory and cardiac variables.[5,6]

Use of CEA for reconstructive surgery has not been reported in recent literature. This procedure was found to be easy, less costly, reduced drug requirements, minimized blood loss, reduced ICU stay and reduced postoperative complications. This case report may pave the way for future research in using this technique for managing oral cancer reconstructive surgery, it may be especially useful in a resource-limited setting.