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Anesthetic Management of a Parturient with Neurosarcoidosis
Abstract Number: S-32
Abstract Type: Case Report/Case Series
Neurosarcoidosis is a rare neurologic manifestation of the systemic disease sarcoidosis. Patients with neurosarcoidosis can have manifestations in cranial nerves, meninges and spinal cord. This case report will present the management of a nulliparous parturient with neurosarcoidosis involving the spinal cord that successfully underwent a Cesarean section with epidural anesthesia.
A 42yo G1P0 who presented at 39 weeks for induction of labor. Past medical history is significant for pulmonary and neurologic sarcoidosis. Her symptoms included pain and numbness from the waist downward on the left side and intermittent headaches. An MRI revealed lesions in her lung, thoracic spine and pons. She had taken prednisone for approximately one year that had lead to shrinkage in the size of her spinal cord lesions. Due to concerns over teratogenicity, she did not take prednisone during her pregnancy. Physical exam was significant for left sided lower extremity weakness (3/5) compared with the right side (5/5) and decreased sensation to light touch and pinprick in all dermatomes of her left lower extremity vs. the right. She had a Mallampati class III airway with normal dentition.
The patient required a cesarean section due to failure to progress. Prior to the cesarean section, an epidural was placed at the L3/L4 level. A lumbar epidural was chosen because her lesions were in the thoracic spine. Loss of resistance to air technique was used to locate the epidural space. LORTA occurred at 6cm from the skin, a catheter was left at 11cm. The epidural catheter was dosed with Lidocaine 2% with Epinephrine to obtain a T4 level. There were no intra-operative complications. The catheter was removed 24 hours after delivery and within subsequently the patient was back to her neurologic baseline.
Sarcoidosis is a systemic inflammatory condition. Neurological involvement occurs in less than 10% of patients with sarcoidosis, and of those with nervous system involvement, the spinal cord is involved in 6-8% of those patients. It is an important condition to consider in the parturient because those who are affected are commonly females of child bearing age.
Neurosarcoidosis can affect both the central and peripheral nervous systems. Symptoms of neurosarcoidosis affecting the spinal cord include weakness, paresthesias, myelopathy, bowel/bladder disturbances and radicular pain. The only definitive method to diagnose neurosarcoidosis is with tissue confirmation showing the presence of non-caseating epithelial granulomas. Management of patients with neurosarcoidosis involves immunosuppression, most frequently with prednisone. However prednisone in the parturient is risky because it carries a Class C teratogen risk. In this case we demonstrate successful management of a parturient with spinal neurosarcoidosis with a lumbar epidural.