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Successful utilization of the Decision Tree proposed by Leffert et al. to assess the neuraxial anesthesia risk in two symptomatic Arnold Chiari type 1 patients scheduled for Cesarean Delivery.
Abstract Number: T-70
Abstract Type: Case Report/Case Series
Arnold Chiari type 1 malformation (CM1) is a rare neurologic defect resulting in herniation of the cerebellar tonsils into the foramen magnum. Elevated intracranial pressure (ICP) has been associated with CM1 patients, potentially prohibiting neuraxial anesthesia (1). Reports of safely performed obstetric neuraxial anesthesia, including Combined-Spinal-Epidural (CSE), exist. A review of parturients with intracranial pathologies by Leffert et al. provided a decision tree to assess feasibility of neuraxial anesthesia (2).
Briefly, if no evidence of mass effect or obstructed CSF flow are present, intrathecal anesthesia is deemed minimal risk for herniation.
We report two primiparous with symptomatic CM1, presenting for primary Cesarean delivery (CD), where this decision tree was successfully applied do determine eligibility for a spinal anesthetic.
27 year-old at 38+5 wks gestational age (ga) with history of mixed connective tissue disease, SLE complicated by symptomatic CM1. Surgical decompression was performed 3 years ago and she reported residual visual symptoms, positional headaches, and vomiting. A pre-admission MRI of brain and spinal cord due to worsening of symptoms during pregnancy was negative for midline shift or hydrocephalus.
After assessment in our high risk clinic, a routine Spinal anesthesia (SPA) was performed for her CD. The intra, - and post operative course was uneventful and she was discharged on POD2 with no new or worsening neurologic symptoms. At her 6 week post-partum check neurological symptoms were unchanged.
30 year-old at 39 wks ga with obesity, status post gastric-bypass, sleep apnea, chronic low-back pain, multiple psychiatric comorbidieties, and symptomatic CM1 scheduled for decompression post-partum. Neurological symptoms included stable upper extremity radiculopathy, headaches, and balance issues. Her MRI showed significant tonsillar herniation 14mm below the foramen magnum with peg-like tonsils and a small syrinx from C6 to T1. There was no evidence of mass effect, hydrocephalus or midline shift. The patient strongly desired neuraxial anesthesia over GA for maternal-infant bonding.
A routine Combined-Spinal-Epidural (CSE) anesthesia, due to unknown surgical duration, was performed for her uneventful CD. The patient was discharged on POD2 with stable neurologic symptoms which remained unchanged at the 6 week post-partum check. Her neurosurgical decompression is pending.
Conclusion: Both CM1 patients presented with neurological symptoms but absent hydrocephalus or increased ICP, and were deemed amendable for a spinal anesthetic, the standard of care for CD.
The decision tree by Leffert and al. (2) helped with and structured the risk assessment for these neurologically complex parturients with symptomatic CM1, potentially avoiding an unwanted general anesthetic.
1. Hopkins AN, Semin Perinatol. 2014
2. Leffert LR, Anesthesiology. 2013