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Management of labor analgesia and obstetrical considerations in a woman with history of Brown-Sequard Syndrome
Abstract Number: T5C-5
Abstract Type: Case Report/Case Series
Introduction: Brown-Sequard Syndrome (BSS) is a condition caused by damage to half of the spinal cord, resulting in paralysis and loss of proprioception on the side ipsilateral to the injury or lesion, and loss of pain and temperature sensation on the contralateral side of the lesion (1). Limited information is available about BSS in pregnancy and the application of spinal/epidural labor analgesia in the setting of BSS.
Case: A G2P0010 parturient with BSS presented at 39w2d for delivery of her fetus. The patient's BSS was a complication of radiofrequency ablation for intractable headaches resulting in a right C2 spinal cord lesion. Following the injury 10 yrs previously, she was hemiparetic on the right side of her body and had decreased sensation on the left side.
An epidural was placed prior to induction with pitocin due to patient anxiety about the procedure. It was placed at L4-L5 with the patient sitting. A PCEA containing 0.1% ropivacaine - 2 mcg/mL fentanyl solution was started at 10 mL/hr. After epidural placement the patient described her pain as 0/10, vital signs were stable, and her block extended to T10 bilaterally. During the course of labor the patient experienced arrest of descent and began to experience right hip, arm, and shoulder hyperalgesia relieved with ice packs and boluses of IV fentanyl. A vacuum assisted delivery was performed resulting in a 3rd degree laceration. The epidural was kept for 6 hours post repair due to concern for pain management and autonomic dysreflexia (AD). Twenty-four hours after delivery neurological exam findings were identical to those prior to labor. There were no difficulties with walking or complaints of low back pain. She spent the next 48 hours in the hospital without complication.
Discussion: There was concern for autonomic dysreflexia given that her lesion was above T6, however vital signs were stable throughout labor and delivery (2). Epidural analgesia was bilateral and adequate until late labor. The unexpected presentation of intermittent hyperalgesia in the distribution of the ipsilateral side of her lesion from her head to the T3 level and hip may have represented referred pain from labor. Post-partum BSS patients may suffer from hypogalactia post-delivery from the breast ipsilateral to the lesion (3). This patient began lactation bilaterally within 24 hours after delivery and did not show signs of hypogalactia.
1) Dawood R, et al. Pregnancy and spinal cord injury. The Obstetrician & Gynaecologist. 2014;16:99 -107
2) Krassourkov, et al. Management of labor analgesia and obstetrical considerations in a woman with history of Brown-Sequard Syndrome. Arch Phys Med Rehabil. 2009 April ; 90(4): 682-695. doi:10.1016/j.apmr.2008.10.017
3) Liu N, et al. Postpartum hypogalactia in a woman with Brown-Sequard- plus syndrome. Spinal Cord (2013) 51, 794-796