Authors: Tanimoto S et al.
Journal: Cureus, Volume 18, Issue 1, Article e102532
Summary
This case report describes perioperative anesthetic and analgesic management for lumbar laminoplasty in a patient with myasthenia gravis, a population at increased risk for postoperative respiratory failure and myasthenic crisis. The primary anesthetic challenge was achieving adequate surgical analgesia while minimizing opioid exposure, neuromuscular blockade–related complications, and respiratory depression.
A 68-year-old man with stable, non-thymomatous myasthenia gravis underwent L3–L5 laminoplasty under total IV anesthesia. After induction and tracheal intubation, bilateral ultrasound-guided thoracolumbar interfascial plane blocks were performed at the L4 level. The block targeted the dorsal rami by depositing local anesthetic between the multifidus and longissimus muscles, aiming to attenuate posterior spinal and paraspinal muscle pain.
Opioid use was intentionally minimized intraoperatively, and postoperative analgesia relied on bolus-only IV patient-controlled fentanyl without a basal infusion, supplemented by scheduled non-opioid analgesics. Over the first 24 hours, the patient required a total of 250 µg of fentanyl, approximately half of the institution’s typical postoperative opioid dose for similar lumbar procedures. Pain scores peaked early postoperatively but steadily improved, reaching acceptable levels by 20 hours, at which point IV-PCA was discontinued.
Neuromuscular blockade was carefully managed using quantitative train-of-four monitoring, and reversal with sugammadex was guided by objective measurements. Extubation occurred only after repeated confirmation of adequate neuromuscular recovery. The patient exhibited no postoperative respiratory deterioration, no signs of myasthenic crisis, and no prolonged neuromuscular weakness. He was discharged on postoperative day 9 without complications.
This case highlights the feasibility of combining thoracolumbar interfascial plane block with total IV anesthesia as part of an opioid-sparing, respiratory-protective strategy in myasthenia gravis patients undergoing lumbar spine surgery.
What You Should Know
• Myasthenia gravis increases sensitivity to opioids and neuromuscular blockers.
• Surgical pain and respiratory depression are key triggers for postoperative myasthenic crisis.
• TLIP block targets posterior spinal pain while avoiding motor weakness.
• Opioid-sparing, bolus-only IV-PCA may reduce respiratory risk in vulnerable patients.
• Quantitative neuromuscular monitoring and cautious extubation are essential.
Key Points
• Patient: stable myasthenia gravis without prior crisis.
• Surgery: L3–L5 lumbar laminoplasty.
• Technique: bilateral ultrasound-guided thoracolumbar interfascial plane block plus total IV anesthesia.
• Outcome: effective analgesia with reduced opioid use and no respiratory complications.
• Clinical message: regional fascial plane blocks can support safer perioperative care in MG.
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