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From the Dimple to Delivery: A Case Report of Labor Analgesia in Patient with Suspected Spinal Dysraphism
Abstract Number: SUN-32
Abstract Type: Case Report/Case Series
22-yo G1P0 admitted for induction of labor for severe preeclampsia was requesting labor epidural. Medical history was unremarkable; however, on exam, sacral dimple with hair tuft was identified (Fig1A). Upon questioning, she reported left foot paresthesias and inability to dorsiflex left foot since childhood that was never investigated.
Given strong suspicion of spinal dysraphism and lack of spine imaging, remifentanil was initiated rather than neuraxial analgesia. Continuous oxygen saturation, noninvasive blood pressure, respiratory rate, and pain scores were monitored. She delivered vaginally a healthy neonate 6 hours later.
Spinal dysraphism of S2-S3 with dermal sinus extending from S3 level, low-lying conus with tip at L5, and thickened nerve roots from inferior L3 thru L4-5 were diagnosed on lumbar MRI 2 days postpartum (Fig1B).
Our patient had occult spinal dysraphism, a disorder in which neurologic signs/symptoms (left foot paresthesias and inability to dorsiflex left foot in this case) or dyschromic areas on the skin or hair puffs (our patient had both) are associated with lumbar or sacral posterior bony anomalies (1). Spinal dysraphism refers to a group of disorders of the vertebral arches, spinal cord, and meninges. It includes a range of conditions, such as myelomeningocele, spina bifida occulta, and occult spinal dysraphism. Of concern regarding neuraxial anesthesia in spinal dysraphisms are structural and vascular abnormalities, abnormal spinal cord anatomy, and low-lying spinal cord. These abnormalities may make epidural space identification more difficult and increase risk of dural puncture, incomplete analgesia or block failure, and unpredictable spread of drug solution (2). Cases have been reported of temporary and permanent neurological deficits after uncomplicated lumbar neuraxial placement in patients with undiagnosed spinal dysraphism (3,4).
With high clinical suspicion of spinal dysraphism, as was the case with our patient once her lower back was examined, MRI should be considered, especially if sensory/motor abnormalities, limb deformities, and midline cutaneous abnormalities are present. If active labor precludes obtaining MRI, strongly consider other analgesics, such as remifentanil, to avoid possible complications associated with neuraxial procedures.
1.Case Rep Obstet Gynecol 2012:472482
2.Int J Obstet Anesth 2015;24:252-63
3.Int J Obstet Anesth 1998;7:111-4
4.Int J Obstet Anesth 2006;15:233-6