Combined Urgent Cesarean Section (C/S) and Thoracic Decompression/Fusion for Acute Paralysis Due to Neoplastic Fracture Following Trauma
Abstract Number: 136
Abstract Type: Case Report/Case Series
Introduction: Thoracolumbar fractures are rare in pregnancy especially associated with a malignancy. We present a case of acute paralysis due to a neoplastic fracture following trauma in a pregnant patient.
Case: A 21 y/o G2P1 Hispanic patient presented at 36 weeks gestation to the ED with back pain after falling down 7 stairs. No imaging was performed. Two weeks later she complained of progressive lower extremity weakness and incontinence. MRI revealed a T4-T6 lytic lesion and a paraspinal mass with cord compression. IV steroids and morphine were given. External FHR monitoring was reassuring and tocography demonstrated irregular contractions every 3 minutes. The patient was taken for urgent C/S followed by T1-T8 posterior decompression/fusion. Anesthetic goals consisted of protecting the spinal cord and maintaining fetal well-being. After a rapid sequence induction with propofol and rocuronium, anesthesia was maintained with 0.5 MAC sevoflurane and 50% N2O in O2. Monitors included an arterial line, foley catheter, BIS, and SSEPs/MEPs. C/S was performed without fundal pressure to minimize further spinal injury. APGARs of 5 & 8 at 1 & 5 min were attributed to maternal morphine administration. Inhalation agents were stopped and TIVA (sufentanil/ propofol) was then utilized to optimize evoked potential monitoring. MAP was maintained above 90 mmHg to maximize spinal cord perfusion. Tumor debulking and T1-T8 decompression/fusion proceeded after biopsy revealed a malignant tumor. Following surgery, the patient was transferred to the ICU for further monitoring and management. In the subsequent two weeks, she regained partial motor function in both lower extremities.
Discussion: We believe this is the first case report of a neoplastic thoracic fracture diagnosed during pregnancy. Thoracolumbar fractures are rare in pregnancy and are generally associated with underlying osteoporosis of pregnancy(1). Symptoms of cancer are often mistakenly attributed to physiologic changes of pregnancy(2); early imaging and diagnosis may have prevented paralysis in this case. Our goal to protect the spinal cord was achieved using TIVA (optimize neurophysiological monitoring), IV steroids, avoiding fundal pressure during delivery, and maintaining spinal cord perfusion. Acute spinal injury in pregnancy requires a multidisciplinary approach to avoid further spinal injury.
References: (1) Bayram S. J Bone Spine. 2006; 73:564-6. (2) Donega WL:CA Cancer J Clin.1983; 33:194-214.