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Epidural Anesthesia for Labor and Cesarean Delivery in a Patient with Spondylothoracic Dysostosis
Abstract Number: F-38
Abstract Type: Case Report/Case Series
Introduction: Patients with severe spine deformities present unique challenges in anesthetic management. This case describes a patient with severe restrictive lung disease due to spondylothoracic dysostosis (SD) requiring Cesarean delivery.
Case: A 19-year-old G1P0 with SD was admitted at 40 weeks gestation for labor induction. Obstetric anesthesia consult was obtained at 38 weeks due to her short stature (50” and 54kg), shortened trunk, and significant thoracolumbar scoliosis. Her airway exam was a Mallampati class 1 and she had a short, webbed neck with limited flexion and extension. PFTs revealed a severe restrictive defect with an FEV1 of 28% and FVC of 28% predicted, and her Pa02 was 62 on room air.
An epidural catheter was placed at L3-4 without difficulty when the patient requested analgesia at 2cm cervical dilation. The catheter was dosed with 6ml 1.5% lidocaine with epinephrine, 4ml 0.125% bupivicaine and 100mcg fentanyl over 15 minutes. A T10 sensory level was maintained with a dilute bupivicaine/fentanyl infusion, but she required multiple top-ups over a 12-hour period to remain comfortable. Despite achieving full cervical dilation, the fetal head failed to descend due to a contracted pelvis, and Cesarean delivery was planned. The epidural catheter was slowly dosed with 2% lidocaine with epinephrine and bicarbonate; a total of 17.5ml was given over 30 minutes, and a T4 level was achieved. Advanced airway equipment was ready in case of failed epidural anesthesia or respiratory compromise, and supplemental oxygen was given via nasal cannula. A classical uterine incision was made due to anterior uterine displacement, and a 3390g male with Apgar scores of 4 and 7 was delivered in breech position from the fundus. An oxytocin infusion and one dose of methylergonovine were given to achieve adequate uterine tone. The epidural catheter was removed 10 hours postoperatively, and the patient was discharged home on postoperative day 3.
Discussion: SD is a rare, autosomal recessive condition that is often fatal in the first year of life due to respiratory complications (1,2). Patients classically have fusion of the cervical and thoracic spine with posteriorly fused ribs that create a fan-like configuration (3). This leads to significant trunk shortening, limited neck mobility, scoliosis, and severe restrictive lung disease. Cesarean delivery may be necessary in many patients due to pelvic abnormalities. Neuraxial anesthesia may be difficult to place and poorly tolerated in these patients. Optimal spinal dosing is difficult to predict; incrementally dosed epidural anesthesia is likely safer. Cervical immobility may lead to a difficulty airway, especially in the parturient, and awake fiberoptic intubation should be considered if general anesthesia is necessary.
1. Ramirez N, et al. J Bone Joint Surg Am. 2007; 89(12):2663-75
2. Campbell RM. Spine. 2009; 34(17):1815-27
3. Berdon WE, et al. Pediatr Radiol. 2011; 41(3):384