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Perioperative management of a parturient undergoing discectomy for cauda equina syndrome
Abstract Number: T-67
Abstract Type: Case Report/Case Series
Cauda equina syndrome (CES) is a neurologic condition in which damage to the spinal nerve roots below the Conus medullaris causes various degrees of sensory or motor nerve dysfunction. CES is a neurologic emergency that requires immediate surgical decompression of the spinal canal to avoid permanent deficits. Here, we describe the perioperative management of a 40 year old parturient at 24 wks EGA requiring emergency surgical decompression to relieve CES caused by an L5/S1 disk extrusion.
The patient presented to the emergency department with acute onset of bilateral leg and lower back pain, urinary retention, saddle anesthesia, and lack of rectal tone. MRI revealed a large disc extrusion with significant spinal canal compromise at the L5/S1 level. Given the presentation, the decision was made to proceed with emergent surgical decompression. Following a multidisciplinary family meeting, the plan was made to monitor fetal heart rate tracings (FHTs) throughout the operation. In the unlikely event of a nonreassuring FHT, the care team would undertake efforts to improve maternal hemodynamics and in turn fetal status, such as subtly changing the patient’s position, or elevating her blood pressure with vasoactive medications. If these maneuvers failed, it was the explicit desire of the patient and her family not to proceed to an emergency cesarean delivery to resuscitate the fetus.
The patient was taken to the operating room and placed supine with left uterine displacement. Induction of general anesthesia and intubation were uneventful. The patient was placed in a prone position on a Jackson table, avoiding abdominal compression, and FHT monitoring was re-initiated. For this purpose, an obstetric nurse was sitting under the operating room table applying the FHT monitor manually to the abdomen of the patient throughout the surgery. The surgeons performed posterior partial laminectomies of L5 and S1 levels and a posterior discectomy of the L5/S1 disc. During the uneventful three-hour intraoperative course, anesthesia was maintained with desflurane and intermittent intravenous boluses of fentanyl, as well as an infusion of phenylephrine. Throughout, the FHT remained stable between 130 and 140/min.
A follow-up visit with her surgeon two weeks post-operatively revealed complete resolution of leg pain and autonomic dysfunction, while her sensory deficit at the S1 dermatome persisted. A follow up visit with her obstetrician at 26 wks EGA showed a vital and healthy-appearing fetus.
While multiple case reports describe emergency cesarean delivery followed by laminectomy in cases of CES during the 3rd trimester, to our knowledge this is the first reported case of continuous FHT monitoring for potential intrauterine resuscitation during lumbar discectomy. Based on this experience, we recommend considering continuous monitoring of the fetal heart rate, as it can alert the care team of fetal distress and allow early intervention by optimizing maternal status.