Spinal Anesthesia for Cesarean Section in a Patient with a Spinal Cord Stimulator
Abstract Number: 36
Abstract Type: Case Report/Case Series
This case report illustrates successful spinal anesthesia for cesarean delivery in a parturient with a spinal cord stimulator. To our knowledge, there are no case reports demonstrating this.
A 40-year-old primigravida with severe preeclampsia presented for urgent cesarean section. She reported a 19-year-history of reflex sympathetic dystrophy (RSD) involving her left lower extremity. Her past treatment course included oral medications, nerve blocks, transcutaneous electrical nerve stimulation (TENS), and lumbar spinal cord stimulator placement in 1990 requiring revision in 2003. This device was known to be nonfunctional; her current RSD treatment regimen included only oral medications (gabapentin, cyclobenzaprine, and acetaminophen with codeine). The patient had recently presented to our facility requesting removal of the device, but it had not yet been removed prior to presentation for cesarean delivery.
Physical examination revealed a height and weight of 66 inches and 106 kilograms, respectively. Her baseline vital signs were: blood pressure 172/90, heart rate 94, oxygen saturation 100%, and respiratory rate 18. Airway examination demonstrated a Mallampati IV classification with marginal mouth opening. Examination of her back revealed surgical scarring at ~L2/L3 level. Computed tomography of the spine performed one month earlier illustrated a pulse generator in the right gluteal soft tissues with its lead terminating in subcutaneous tissue ~1cm posterior to the L2 spinous process. There was no evidence of a lead or foreign body in the spinal canal.
In preparation for the procedure, large-bore peripheral intravenous access and invasive arterial monitoring was established. Aspiration prophylaxis, antibiotics, and an appropriate preload were administered. In sterile fashion, a spinal was performed atraumatically using a Pencan 25gauge needle. Bupivicaine 10.5 mg, fentanyl 10mcg, duramorph 0.2 mg, and epinephrine 100mcg were given. No parasthesias were elicited. The patient was placed supine with left uterine displacement and 100% oxygen via facemask. A level of T3 was obtained. The cesarean delivery proceeded uneventfully, and a healthy male infant was born.
RSD is used to describe a wide group of conditions associated with burning pain in an extremity; dystrophic changes; allodynia; and autonomic dysfunction. A multimodal approach is often used in the treatment of this complex chronic pain syndrome.
The use of spinal cord stimulators for treatment of RSD is increasing. Anesthesia providers should be familiar with considerations for providing safe neuraxial anesthesia in this growing patient population. There are no absolute statements to be made regarding anesthetic management. Each case should be evaluated individually. All care providers should be in communication early with each other and the patient to ensure the most appropriate decision and best patient outcome