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Epidural labor analgesia in a parturient with intradural extramedullary spine tumor - case report
Abstract Number: S-11
Abstract Type: Case Report/Case Series
INTRODUCTION: Literature on neuraxial instrumentation in parturients with spinal cord tumors is scarce. We describe epidural labor analgesia in a patient with a known intradural extramedullary (IDEM) tumor.
CASE REPORT: 34 year-old, G3P2 with myasthenia gravis, psoriasis and chronic back pain requested neuraxial labor analgesia. Lumbar MRI showed IDEM mass posterior and inferior to the conus medullaris at L1-L2, measuring 8x6x7mm, deemed likely a schwannoma. Repeat imaging a year after diagnosis revealed tumor size was unchanged. Prior to IDEM mass diagnosis, the patient had undergone neuraxial techniques for both Cesarean and vaginal delivery.
On admission, a round psoriatic lesion was noted over the L1-L3 spinous processes. To avoid both psoriatic and IDEM lesions, ultrasound (US) imaging was performed to identify the L4-L5 interspace prior to attempting epidural placement. Subsequently, the epidural space was uneventfully identified by a loss of resistance to saline technique. A catheter was threaded 5 cm into the space and 10 mL of bupivacaine 0.0625% with fentanyl 3 mcg/mL was administered, followed by infusion of this solution at 12 mL/hr. The patient obtained a T10 sensory level bilaterally and was comfortable throughout labor. The remainder of her course was uneventful.
DISCUSSION: IDEM tumors account for 40% of all spinal tumors and originate within the dura but outside the spinal cord. [1,2] Schwannomas are slow-growing, benign, encapsulated tumors that originate sporadically from Schwann cells in the myelin sheath of nerve fibers. [3,4] Pain is the most common presenting symptom. Treatment is directed at surgical resection. [2,4]
Neuraxial techniques in such cases present significant risks including tumor spread, epidural hematoma, medullar coning, local anesthetic toxicity, alteration of pressures within epidural and intrathecal spaces resulting in neurologic deficits, and inadequate neuraxial block.
Our patient presented two potential contraindications to neuraxial analgesia: a spinal mass and a psoriatic lesion. We successfully used US imaging to identify a lumbar interspace below both lesions. This approach allowed for a safer neuraxial technique.
The choice to pursue a neuraxial technique in this case was based on several factors: tumor size and location below the conus medullaris, which reduces the likelihood of neurological consequences as a result of intrathecal pressure changes due to neuraxial instrumention, a lack of neurologic symptoms to indicate cord compression, and the ability to identify the desired lumbar interspace by US. Labor analgesia consisted of a low concentration local anesthetic to minimize motor blockade and make neurologic change promptly identifiable.
In the presence of an unobstructive spinal mass, US imaging can invaluably allow for a safer neuraxial technique.
REFERENCES:CurrProblDiagnRadiol 2007;36:185-8 AnesthAnalg 1992;75:844-6 Neurosciences 2011;16:366-8 LancetOncol 2007;8:35-45