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Successful use of epidural anesthesia for cesarean section in a parturient with paraplegia of both upper extremities from central cord syndrome and low lying cerebellar tonsils with sagging mid brain from traumatic brain injury
Abstract Number: S4C-5
Abstract Type: Case Report/Case Series
Introduction: Central cord syndrome (CCS) is an incomplete spinal cord injury that results from hyperextension or trauma of the cervical spine. It is characterized as a disproportionate impairment of motor function in the upper extremities to the lower extremities, bladder dysfunction and varying degrees of sensory loss below the level of injury.1,2 It is very rare for this syndrome to be seen in obstetric patients. These parturients pose unique challenges to the anesthesiologist. We present the successful use of epidural anesthesia for cesarean section in a parturient with paraplegia of both upper extremities from central cord syndrome as well as low lying cerebellar tonsils with sagging midbrain from traumatic brain injury.
Case Presentation: A 24 year-old female G2P1 at 37 weeks of gestation was admitted for an elective repeat cesarean section with bilateral tubal ligation. Her past medical history includes motor vehicle accident 4 years prior, which resulted in traumatic brain injury, central cord syndrome, seizure disorder and bilateral pulmonary embolism. The most recent MRI showed diffuse pachymeningeal thickening and enhancement suggestive of persistent cerebral edema and intracranial hemmorhage with borderline low-lying cerebellar tonsils and sagging of the midbrain. She is 5’6’’ and 211 lbs with a Mallampati score of 3. She had bilateral weakness of her upper extremities, with contractures from the elbow to the hands. Her sensation on both arms was intact to light touch but not to pain and temperature. Neurosurgery recommended fiberoptic intubation with minimal neck extension if general anesthesia would be needed. After reviewing the risks and benefits of general, spinal and epidural anesthesia, we elected to do an epidural. A lumbar epidural was placed successfully; an adequate neuraxial block for cesarean section was achieved. She was hemodynamically stable throughout the surgery. She was discharged on post-operative day 4 in stable condition.
Conclusion: Very limited evidence are available in literature regarding the management of parturients with CCS during labor and delivery. General, spinal and epidural anesthesia are all viable options for cesarean delivery in these parturients to prevent autonomic dysreflexia. We avoided general anesthesia as the first option due to her restricted neck mobility and the possible difficult airway. Spinal anesthesia could pose the possible risk of tonsillar herniation given her recent MRI finding. Risk and benefits were discussed with the patient and the obstetric team. This case illustrates the successful management of a patient with central cord syndrome utilizing epidural anesthesia.
1. Nowak DD, Lee JK, Gelb DE, et al. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec. 17(12):756-65.
2. McKinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007. 30(3):215-24.