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A CASE REPORT OF A PARTURIENT WITH A TETHERED SPINAL CORD FOR DELIVERY-MANAGEMENT AND IMPLICATIONS FOR NEURAXIAL ANESTHESIA
Abstract Number: T-81
Abstract Type: Case Report/Case Series
INTRODUCTION A tethered spinal cord occurs when the spinal cord gets attached to tissue around the spine, most commonly at the base. Acquired causes include tumor, infection and scar tissue from previous surgery. The spinal cord is unable to move freely in the canal and becomes stretched with growth, causing damage. The progression of neurological signs and symptoms is highly variable, and includes sensory, motor, bowel and bladder control issues referred to as tethered cord syndrome.
CASE A 21year old patient G1P0 was admitted for pyelonephritis at 33 weeks gestation. An anesthesia consult was requested due to history of lipomyelomeningocele repair at birth. Her medical history was significant for neurogenic bladder needing intermittent catheterization since adolescence. She reported good exercise tolerance with no other neurological deficit. She had latex allergy, was 5’1” tall and weighed 76 kg. Airway exam was unremarkable.
An MRI lumbosacral spine done showed an anterior unsegmented bar from L2-L4 and a large spinal dysraphic defect from L5 to sacrum, with associated lipomyelomeningocele and tethered spinal cord. A discussion with neurosurgeons confirmed a high risk of spinal cord injury with neuraxial anesthesia. An elective cesarean section was scheduled at 39 weeks due to surgery for imperforate anus and rectovaginal fistula that she had in childhood. The patient received GA for her cesarean section without any complications.
DISCUSSION A lipomyelomeningocele is a spinal dysraphism that is inherently associated with a tethered spinal cord. Neurosurgical repair attempts to prevent further cord tethering, however re-tethering may occur,as perhaps in our patient.(1) Surgery for tethered cord release after the primary repair is a decision based on neurological function rather than radiological findings.(2)
A concern when performing neuraxial blockade is a possible low lying or tethered spinal cord. Permanent nerve injuries and spinal hematoma have been reported in such patients,who received spinal anesthesia.(3-5) Ultrasound is not sufficiently validated to detect low lying cords.MRI is recommended to clarify anatomical abnormalities, and exclude tethering before attempting neuraxial anesthesia.
1.Murphy CJ et al. IJOA 2015;24:252-263
2.Sarris CE et al. Neurosurg Focus 2012: 33(4) E3
3.Wood GG et al. Anesthesiology 1997;83:983-4
4.Liu JJ et al. Medicine(Baltimore.2016 Jul;95(29):e4289
5.Kim YY et al. Anesth pain Med 2015;10:171-74