Dual Role of Ramped Positioning in Severe Ankylosing Spondylitis: Facilitating Awake Flexible Bronchoscopic Intubation and Surgical Positioning

Airway management and positioning of a patient with ankylosing spondylitis is often challenging because of fixed spinal deformities and restricted neck movement. We report a case of a 63-year-old female with long-standing ankylosing spondylitis and severe thoracolumbar kyphosis posted for lower limb surgery. The major difficulty in our case was achieving an appropriate airway management position and positioning the patient on the operating table for surgery. A modified ramped position with multiple pillows was used to improve the patient’s alignment. Awake flexible bronchoscopic intubation was performed through a BlockBuster LMA inserted after topicalization with lignocaine spray. Although flexible bronchoscopic intubation in this position was technically demanding due to altered airway axis and limited maneuverability, the ramped position provided the best possible alignment. The use of LMA also helped simplify and speed up flexible bronchoscopy-guided intubation.