Spinal anaesthesia in a medically complex paediatric patient.

Background: Spinal anaesthesia in paediatric patients has experienced a resurgence driven by concerns regarding anaesthetic neurotoxicity and evidence demonstrating safety and efficacy. However, its application in medically complex children with multiple comorbidities remains underreported. Clinical case: We report an 11-year-old female with a his- tory of posterior fossa medulloblastoma treated with sur- gical resection, chemotherapy, and craniospinal radio- therapy at age of 2, followed by disease relapse at age of 4 requiring cervical spine surgery (C1-C5 laminectomy with fixation), high-dose chemotherapy, autologous bone marrow transplantation, and radiotherapy. She presented with bilateral proximal femoral epiphysiolysis requiring in situ fixation. Anaesthetic challenges included severe cervical spine restriction with complete inability to ex- tend the neck, limited mouth opening creating a predicted difficult airway, subglottic tracheal stenosis immediately below the vocal cords further complicating airway man- agement, and a radiation-exposed brain vulnerable to ad- ditional anaesthetic neurotoxicity. After preoperative MRI evaluation confirming no contraindications at the lumbar level, single-shot spinal anaesthesia was per- formed at L3-L4 with 6 mg of 0.5% isobaric bupivacaine plus 5 mcg fentanyl, complemented by light sedation with ketamine and propofol. The procedure was com- pleted uneventfully in 50 minutes. The patient recovered rapidly with minimal motor blockade at 90 minutes, was hemodynamically stable, comfortable, and pain-free. Discussion: This case illustrates three key advantages of spinal anaesthesia in this complex patient: (1) complete avoidance of airway instrumentation in a predicted diffi- cult airway scenario compounded by subglottic stenosis, (2) minimization of cerebral anaesthetic exposure in a pa- tient with radiation-induced brain vulnerability, and (3) demonstrated safety of neuraxial techniques in patients with prior cervical spine surgery when the lumbar spine is unaffected. The bilateral presentation of slipped capital femoral epiphysis is consistent with the 211-fold in- creased risk documented in paediatric cancer survivors receiving growth hormone therapy after total body irradi- ation. Conclusion: Spinal anaesthesia can be safely and suc- cessfully performed in medically complex paediatric pa- tients when applied with appropriate patient selection, thorough preoperative evaluation including spinal imag- ing, multidisciplinary collaboration, and meticulous tech- nique. This case supports broader consideration of spinal anaesthesia in paediatric patients with difficult airways, prior neurotoxic exposures, or conditions where general anaesthesia poses elevated risks.