Remifentanil-Based Monitored Anesthesia Care in a Paraplegic Patient With Severe Kyphoscoliosis, Non-palpable Spinal Landmarks, and Coagulation Abnormality Undergoing Ischiorectal Abscess Drainage: A Case Report

Severe kyphoscoliosis with prior spinal surgery presents significant anesthetic challenges, including anticipated difficult airway, restrictive pulmonary physiology, and technical impracticality of neuraxial anesthesia. We report the anesthetic management of a 23-year-old paraplegic female patient with a massive dorsal gibbus deformity and completely non-palpable spinal landmarks who presented with recurrent ischiorectal abscess. Preoperative evaluation revealed moderate anemia, leukocytosis, mild hypokalemia, and prolonged international normalized ratio (INR). Due to inability to tolerate the supine position, anticipated airway difficulty, unknown prior spinal instrumentation, and relative contraindication to neuraxial anesthesia, the procedure was performed in the left lateral position under remifentanil-based monitored anesthesia care with adjunct ketamine and midazolam while maintaining spontaneous ventilation. Surgery was completed successfully without airway instrumentation, hemodynamic instability, or arrhythmias. This case highlights individualized anesthetic planning and the role of remifentanil infusion as a primary technique in high-risk patients where both general and spinal anesthesia pose significant challenges.