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Ultrasound-Guided Labor Epidural for a Parturient with Metastatic Spinal Leiomyosarcoma: A Case Report
Abstract Number: T-58
Abstract Type: Case Report/Case Series
Ultrasonography is now a useful tool in delineating lumbar spine anatomy. There are also few reported cases of leiomyosarcomas with osseous spinal metastatic lesions in pregnancy.1 We report the management of a parturient with leiomyosarcoma of the inferior vena cava with metastases to the lumbar vertebrae who successfully received ultrasound-guided epidural labor analgesia.
Case: A 36 year old Gravida 4 Para 2 parturient presented at 32 weeks gestation with metastatic spinal leiomyosarcoma, for induction of labor to facilitate the earliest initiation of maternal chemotherapy. An MRI was obtained of the lumbar spine to evaluate for lesions and determine if neuraxial analgesia for labor could be safely performed (Figure 1). Images were significant for a destructive L3 vertebral body lesion with extension into the spinal canal. On physical exam, the patient was 161cm tall and weighed 57kg. She had a mallampati class 1 airway with normal mouth opening and a 4 cm thyromental distance. A normal upper and lower extremity motor and sensory exam were noted. A pre-procedural ultrasound with Sonosite Micromaxx™ was used to locate the L4/L5 interspace for epidural catheter placement. The intercristal line by palpation was thought to be at the level of the L4/L5 interspace. However, by ultrasound, the intercristal line was at the level of the L3/L4 interspace. Loss of resistance to normal saline was appreciated at 4cm and a 19 gauge Duraflex™ catheter was threaded 4 cm into the epidural space. Patient-controlled epidural analgesia consisting of 0.125% bupivacaine with fentanyl 2 μg/ml at a rate of 5ml/hr, a 5 ml PCEA dose, an 8 minute lockout and a 35 ml maximum hourly limit was subsequently initiated without any immediate complications. The patient demonstrated minimal motor block and reported complete pain relief with a bilateral T10 sensory level to cold. The post-epidural neurological exam on postpartum day 1 and 2 revealed no new neurological deficits.
Discussion: Location of vertebral levels by landmark techniques only is unreliable. If only the intercristal line had been used to perform the labor epidural in this patient, the catheter would have been placed in the L3/L4 interspace at the level of the metastatic lesion. Ultrasonography allowed us to accurately indentify the L4/L5 interspace and successfully institute epidural analgesia in a parturient with a metastatic lesion to the L3 vertebra.
1. Spine. 1999; 24: 987-989.