Epidural Analgesia for Delivery in a Patient With Syringomyelia, Thalamic Tumor, and Morbid Obesity.
Abstract Number: F-60
Abstract Type: Case Report/Case Series
Introduction: Syringomyelia is rarely encountered in the obstetric population. It is associated with trauma or Arnold-Chiari formation, but can be idiopathic. Patients may present with neurologic symptoms including anesthesia, pain, weakness or sympathetic dysfunction. There is no consensus on whether these patients can safely have neuraxial anesthesia. We present a case of syringomyelia in a parturient with comorbidities who previously had been advised to avoid spinal/epidural.
Case report: A 28 year old G1P0 presented at 39 weeks gestation for evaluation of morbid obesity (BMI 52), T8-L1 syringomyelia, a 0.9 cm cystic thalamic tumor, dyslexia, GERD, and hyperlipidemia. She gave a 3year history of difficulty walking, leg pain, back pain, headaches, and tremors. She had a Mallampati 3 airway, limited neck mobility, limited mouth opening and 5 cm thyromental distance. She had no previous anesthetics. Neurologic exam revealed a waddling gait with mild limb weakness, and a fine resting tremor in the bilateral upper extremity. Her previous MRI scans reviewed by neuroradiology revealed normal CSF. There was concern about the risk of an intracerebral hemorrhage from the thalamic tumor if she were allowed to valsalva. It was determined that neuraxial anesthesia could be safely administered; however an MRI brain and spinal cord with contrast was recommended. The study could not be performed due to the patient’s body habitus. After extensive interdisciplinary discussion, an induction of labor (IOL) at 40 weeks gestation with planned epidural analgesia and an assisted vaginal delivery was agreed upon. Following IOL an epidural was placed at a cervical dilatation of 3cm. The depth to the epidural space was 10 cm, and the catheter was secured at 15 cm. The block was initiated with 50 mcg of fentanyl and 20 mg of bupivacaine in 4 divided doses. Labor analgesia was maintained with standard PCEA dosing. Within 20 minutes she had loss of sensation to cold bilaterally from T8 to S2. Following 5 hours of labor, her cervix was fully dilated and she had an uneventful forceps vaginal delivery. On postpartum day 1 her neurological evaluation was unchanged from baseline and she was discharged home on postpartum day 2.
Conclusion: Epidural anesthesia and a passive second stage of labor can safely facilitate vaginal delivery in a patient with syringomyelia. However the decision to use neuraxial anesthesia needs to be individualized and requires multidisciplinary management.