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Lumbar Epidural Catheter Placement for Control of Labor Pain in a Patient with Spinal Cord Stimulator
Abstract Number: RF1BA-253
Abstract Type: Case Report Case Series
Spinal Cord Stimulators (SCS) are used in the treatment of chronic pain. Its periprocedural management is sparsely commented on in literature, and what is available is confusing.1 Some anesthesiologists may be unfamiliar with SCS management particularly when complicated by pre-existing device-related problems. We present the care of a laboring parturient with implanted SCS and percutaneous leads for complex regional pain syndrome type 1 (CRPS type 1).
30-year-old female G1P000 with 3-year history of CRPS type 1 of right ankle from traumatic sprain presents to L&D suite for induction of labor at 38 weeks & 6 days. SCS was implanted 3 years prior followed by incision & drainage of the generator pocket for infection. This resulted in significant scarring and atypical anatomy. On exam, paramedian scar extended well below L5-S1. The SCS generator is mobile, dangling in the pocket, and can be flipped from side-to-side. At night, patient’s husband moves her SCS off her spinous process as she lay supine. Outside records were unavailable. Patient requested epidural catheter (EC) for labor analgesia. Other options for pain management were unavailable or patient-declined.
After extensive discussion with patient and consultation with pain management specialists, an anteroposterior (AP) x-ray was ordered and reviewed. EC was placed uneventfully using real-time ultrasound identification of the path of extension wires. Satisfactory pain control was achieved. EC was removed without complication after vaginal delivery and she was discharged home.
Successful management of labor pain using epidural analgesia is possible in parturient with implanted SCS. Gathering pertinent data and learning takes time and reiterates the importance of pre-operative assessment, record obtaining, and plan formulation by a multidisciplinary team.2 Of primary importance is locating the hardware and wire entry points. Some authors avoided neuraxial technique if extension wires were near L3-L4 intervertebral space.2 AP x-ray and ultrasound can be used to locate and avoid critical components if patient records are unavailable.3 Generic recommendation to “insert below the scar” was unhelpful; her scar extended to just above her intergluteal cleft. Other recommendations for parturient with SCS include SCS inactivation over concerns of teratogenicity and avoidance of monopolar electrocautery.2,3
1. Harned ME, Gish B, Zuelzer A, Grider JS. Anesthetic Considerations and Perioperative Management of Spinal Cord Stimulators: Literature Review and Initial Recommendations. Pain Physician. 2017;20(4):319-329.
2. Patel S, Das S, Stedman RB. Urgent cesarean section in a patient with a spinal cord stimulator: implications for surgery and anesthesia. Ochsner J. 2014;14(1):131-134.
3. Young AC, Lubenow TR, Buvanendran A. The parturient with implanted spinal cord stimulator: management and review of the literature. Reg Anesth Pain Med. 2015;40(3):276-283.