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Spine imaging to assist in an approach to neuraxial block in a parturient with a history of spina bifida and lipomyelomenigocele
Abstract Number: SU-96
Abstract Type: Case Report/Case Series
Patients with significant congenital spine defects are often not considered good candidates for neuraxial anesthesia. Parturients with these conditions pose significant challenges to obstetric anesthesiologists. While there is a desire to be awake and comfortable for delivery, there is sparse literature on the feasibility and safety of neuraxial techniques in parturients with spina bifida. We report a strategy of regional anesthesia for such a patient.
A 34-year-old G1P0 at 39 weeks with a history of spina bifida and lipomyelomeningocele (LMC) who is scheduled for an induction strongly desires an awake delivery with neuraxial analgesia. She states that she had an epidural for a femoral osteotomy 6 years prior (L1-2 epidural and GA LMA). The epidural was utilized for postoperative analgesia. Her neurological history is significant for excision of LMC and closure at 3 months of age, cord untethering at age 10 years and revision untethering 5 years ago. An MRI 2 years prior showed postoperative changes from L2-L3 down to the sacral area. A thin intrathecal spinal cord was seen at L1. An enlarged thecal sac is seen at S3, 4.5 cm from the surface of the skin (Figure 1). She self-catheterizes, has baseline proximal weakness in her lower extremities, and mild foot numbness. A multidisciplinary discussion with the obstetrician, neurologist, and patient was done to clarify feasibility, safety, and expectations for delivery.
We believe that epidural analgesia can be safely placed at a level T12-L1 or L1-L2. The area above appears clear and we believe Stage 1 analgesia can be achieved. If epidural spread is not sufficient to cover Stage 2, an approach to administer a small amount of intrathecal medicine at S3 is possible. Previous case reports have utilized surface anatomy or plain films to assist approach.2 We report the utilization of MRI to assist in a reasonable strategy for neuraxial labor analgesia. Induction is scheduled February 7 and we hope to report our experience at the SOAP meeting.
1. Neal RAPM 2015;40(5):401-30
2. Murphy IJOA 2015;(24):252-63