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///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-05:00

Epidural Anesthesia in a Parturient with a History of Spina Bifida and Tethered Cord: an Algorithmic Approach to Evaluate the Safety of Neuraxial Anesthesia

Abstract Number: F-80
Abstract Type: Case Report/Case Series

Lisa Leffert M.D.1 ; Andrew Chalupka M.D.2; Michael Hermann M.D.3; Michael Scott M.D.4

Spinal dysraphisms result from abnormal development of embryonic neural and vertebral precursors with deformities of the axial skeleton and distal spinal cord that can impact the safety and efficacy of obstetric neuraxial anesthesia. We present a case of pregnant woman with a history of spina bifida and tethered spinal cord and suggest an algorithm for her care.

A 38 year-old G2P1 at 36 weeks gestation presented for cesarean delivery of twins. Spina bifida with tethered cord was diagnosed radiologically at age 11 during an enuresis workup when a lumbar skin tag was noted. She then had two spinal cord release procedures (age 11, 20) after which she could void but required self-catheterization for bladder emptying.

Before her first vaginal delivery, she was deemed not to be a candidate for epidural labor analgesia (outside records unavailable; details unknown by patient). She did, however, receive a labor epidural analgesic. There were no complications, but her rapid delivery obscured appraisal of epidural catheter function.

Physical exam this admission showed a favorable airway and well healed scar from her coccyx to L4. Lower extremity sensory and motor exams were normal, but the left calf girth was less than the right.

Multidisciplinary anesthetic planning with her neurosurgeon followed structured questions with a novel algorithm that can be generalized to other patients.(Fig) Spinal anesthesia was felt to have a low chance of success due to intrathecal scarring from prior surgeries. Although there was also concern about epidural scarring, neither spinal nor epidural techniques were deemed unsafe. As the patient strongly preferred neuraxial anesthesia and understood the possible need for conversion to GA, an epidural catheter was placed under ultrasound-guidance (L2-L3 interspace). After a test dose, 10cc of 3% chloroprocaine was given to quickly demonstrate an appropriate rising sensory level, followed by 15+cc of 2% lidocaine. The epidural anesthetic functioned optimally, intraoperatively, with a bilateral T4 sensory level and no neurologic complications.

The approach to neuraxial anesthesia in parturients with spinal dysraphisms varies by pathology and provider. A recent review of relevant anesthetics estimates only 52 reported cases of epidural and 15 spinal anesthetics.(1) We present a successful case of epidural anesthesia with an algorithm to evaluate the safety of neuraxial anesthesia in this population.

1.Murphy, Int J Obstet Anesth. 2015

SOAP 2017