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NEURAXIAL ANESTHETIC MANAGEMENT IN A PREGNANT PATIENT WITH REPAIRED TETHERED CORD SYNDROME
Abstract Number: T-69
Abstract Type: Case Report/Case Series
Introduction: Tethered cord syndrome[TCS] is a rare disorder caused by restriction of the normal mobility of the spinal cord. Neuraxial procedures for patients with repaired TCS present challenges. Inadvertent dural puncture is more common given post-surgical changes[PSC] affecting technique while a low-lying conus medullaris increases risk of neurologic damage. This case offers insight into decision-making necessary to create an anesthetic plan for pregnant patients with repaired TCS undergoing neuraxial management for labor.
Case: A 28 year old G1P0 at 36’5 weeks with history of repaired TCS presented for anesthesia consultation. Sacral dimpling and imaging during childhood confirmed TCS without concurrent neurologic deficiencies. Surgery was performed at age two. She remained asymptomatic with normal development and was released from specialty follow-up at age twelve. During prenatal evaluation, her obstetrician recommended consultation to assess safety of epidural placement. Exam revealed extensive scarring from L2–L5 without neurologic deficits. Given limited records and potential for underlying pathology, a MRI was ordered. Results demonstrated a low-lying conus medullaris at L3 without cord retethering. Significant PSC from L2-S1 and L5-disc bulging were also noted. Utilizing ultrasound, PSC were most minimal at L4-5. The devised anesthetic plan entailed having a senior anesthesiologist attempt [ideally L4-5] epidural placement for labor.
She was admitted for ruptured membranes at 38’1 weeks. Labor was augmented and epidural placement was soon requested. The epidural space was easily accessed at L4-5 and later L3-4 with failure to thread the catheter at both locations. A new provider attempted needle advancement at L3-4 resulting in dural puncture, abandonment of the procedure and an adjusted plan for serial spinal injections as needed. An hour later, cesarean-section was performed for failure to progress. A single-shot spinal consisting of 12mg 0.75% bupivacaine, 10mcg fentanyl and 0.2mg morphine was smoothly performed at L3-4.
Her course was complicated by a post-dural puncture headache which initially responded to conservative management, but ultimately required a blood patch.
Conclusion: Compared to intravenous medication, neuraxial anesthesia is preferred in labor to limit maternal and fetal risk. Complication and failure rates are elevated in patients with repaired TCS. Preop management with MRI imaging allows identification of the optimal interspace for procedures. For patients with PSC, consider epidural placement outside the affected region or serial spinal injections throughout labor to minimize complications. This case demonstrates how advanced planning, clinical judgement of anatomical barriers and careful technique are essential to managing patients with lumbosacral anomalies.
Reference: Ji-xiu X et al.Accidental conus medullaris injury following CSE in a pregnant woman with unknown TCS.Chin Med J 2013;126:1188-89.