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Spine imaging and sequential combined spinal epidural (CSE) in a parturient with acromesomelic dysplasia undergoing cesarean delivery
Abstract Number: SU-25
Abstract Type: Case Report/Case Series
Acromesomelic dysplasia is a rare genetic condition characterized by short stature, short limbs and hands, and skeletal abnormalities of the spine 1(Fig.1A). Anesthetic challenges with dwarfism have been described.2 Unlike achondroplasia, the spinal canal is proportionately short. Regional anesthesia with acromesomelia has not been reported.
A 28-year-old G1P0 (114cm, 36K) was scheduled for elective cesarean delivery (CD) at 37 weeks. She tolerated the 3rd trimester well. Her history was significant for asthma. Her airway and facies were normal. She had no past anesthetics and desired an awake delivery. MRI one year prior for sciatic pain showed vertebral dysplasia, flattened lumbar spine, bulging discs and narrowing of the spinal canal (Fig.1B).
Proper spinal dosing of patients with torso-proportional dwarfism is unknown. Spine anomalies can lead to unpredictable spread. We chose to perform an ultrasound-guided sequential CSE. Ultrasound (US) clarified the level, depth and path to the epidural space. We used a pediatric BP cuff, had size appropriate airway equipment available, and discussed the slow induction of anesthesia with the team, with external fetal monitoring (ECM) to be maintained for induction.
The CSE was done at L3-4 in the sitting position (17G Weiss, 25G Whitacre, 20G single port Arrow Flex-tip). Ligamentous feel was firm. Loss of resistance was well-defined. The epidural depth was 3cm as seen on US. Spinal drugs included 2.25mg of 0.75% hyperbaric bupivacaine, 5mcg fentanyl and 30mcg hydromorphone. The epidural catheter was threaded 3cm. The initial level after 10 minutes (5 minutes sitting plus 5 minutes reclining in the surgical position) was T10. Over the next 30 minutes, a total of 6mL of 2% lidocaine with epinephrine was administered in divided does via the epidural to achieve a level of T5. CD proceeded uneventfully with the delivery of a healthy baby (2980g).
Acromesomelia is a form of dysplasia that includes axial skeletal anomalies with proportional shortening of the spinal canal. The information obtained from the MRI and US were useful adjuncts to clarify anatomy and depth of needle insertion. The utilization of slow titration of anesthesia with sequential CSE technique, communication with the obstetric team and continued EFM allowed for a controlled, non-stressful induction of anesthesia with minimal hemodynamic and respiratory compromise.
1Radiol 137:349-55 Nov1980