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Epidural Anesthesia in Parturient with Moderate Amyotrophic Lateral Sclerosis Undergoing Cesarean Section - Is It Safe?
Abstract Number: 33
Abstract Type: Case Report/Case Series
Amyotrophic lateral sclerosis (ALS) is a degenerative disease of motor ganglia in the anterior horn of the spinal cord and pyramidal tracts. In ALS, general anesthesia (GA) has higher risks for respiratory depression and aspiration. The safe use of regional anesthesia (RA) has been reported in ALS patients undergoing lower abdominal and lower extremity surgeries.(1) We describe here a patient with ALS in whom epidural anesthesia was used for cesarean section (c/s).
A 34 year-old G2P1001 at 38 weeks gestation presented for c/s. The patient was diagnosed with ALS four years ago, when her only symptom was nasal phonation. At that time, she had an uncomplicated c/s under spinal anesthesia. Her ALS subsequently progressed to involve hand paresthesias and foot drop, as well as dysphagia with solids. Her respiratory function remained unaffected.
An epidural catheter was inserted at L3-4 intervertebral space. RA was induced with 2% lidocaine with epinephrine, fentanyl and Duramorph, which produced a sensory blockade of T2-S2 on the right and T4-S2, left. C/s proceeded without complications.
Parturients are at increased risks for aspiration and respiratory compromise given their reduced lower esophageal sphincter tone and functional residual capacity. ALS further increases those risks by weakening protective reflexes and respiratory muscles. GA may be less preferable than RA in ALS patients, since they may be more sensitive to nondepolarizing muscle relaxants.(2)
A regional anesthetic block may depress ventilation if the anesthetic level reaches above T6, but when correctly conducted, it has minimal ventilatory depression, with only a transient decrease in vital capacity.(4) Nevertheless, respiration should be closely monitored in any patient with neurodegenerative disease.
RA may exacerbate pre-existing neurological damage; however, most reported cases involve coexisting lumbar disc herniation, spinal tumor or technical problems.(3) No data suggests a direct correlation between epidural anesthesia and deterioration of neurological function in patients with degenerative disease. Complete documentation of pre-procedural neurological functions is critical to differentiate underlying disease from complications of regional blockade and neurological consultation may be useful. In the ALS patient presented, epidural anesthesia for c/s proceeded uneventfully and avoided the potential complications of GA.
1. Kochi T, et al. Epidural anesthesia for patients with amyotrophic lateral sclerosis. Anesth Analg 1989;68:10-2
2. Rosenbaum KJ, et al. Sensitivity to nondepolarizing muscle relaxants in amyotrophic lateral sclerosis: Report of two cases. Anesthesiology 1971;35:638-41
3. Kane RE. Neurologic deficits following epidural or spinal anesthesia. Anesth Analg 1981;60:150-61
4. Hara K, et al. Epidural anesthesia and pulmonary function in a patient with amyotrophic lateral sclerosis. Anesth Analg 1996;8