# Effective Use of the Thoracolumbar Interfascial Plane Block With Total IV Anesthesia for Laminoplasty in a Patient With Myasthenia Gravis: A Case Report

## TL;DR

A 68-year-old man with myasthenia gravis successfully underwent surgery using a combination of regional anesthesia and minimal opioids, avoiding respiratory complications.

## Contribution

Demonstrates the safe use of TLIPB with total IV anesthesia for laminoplasty in a myasthenia gravis patient, minimizing opioid use.

## Key findings

- TLIPB combined with total IV anesthesia effectively managed pain without respiratory compromise.
- Postoperative IV-PCA with fentanyl provided adequate analgesia with minimal opioid use.
- The patient showed no signs of myasthenic crisis and was discharged on postoperative day 9.

## Abstract

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction that causes fluctuating muscle weakness and fatigue. The development of myasthenic crisis and respiratory compromise presents significant challenges in the perioperative management of these patients. Surgical pain-induced stress is a substantial risk factor for myasthenic crisis. A 68-year-old man with MG underwent L3-L5 lumbar laminoplasty under total IV anesthesia. A bilateral ultrasound-guided thoracolumbar interfascial plane block (TLIPB) was performed at the L4 level following anesthesia induction. Intraoperative opioid administration was intentionally minimized, and postoperative analgesia was provided using IV patient-controlled analgesia (IV-PCA) with fentanyl. Within 24 hours, 10 boluses (total fentanyl dose: 250 μg) were administered, and the Numerical Rating Scale (NRS) score decreased to 3 by 20 hours postoperatively, at which time IV-PCA was discontinued. The patient exhibited no respiratory deterioration or signs of myasthenic crisis and was discharged on postoperative day 9. Achieving adequate analgesia while minimizing the risk of respiratory depression is critical in the perioperative management of patients with MG. In this case, TLIPB was successfully implemented as part of a multimodal analgesic strategy combined with total IV anesthesia to facilitate an opioid-sparing approach, with postoperative pain managed using IV-PCA and scheduled non-opioid analgesics, without any respiratory compromise.