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Perioperative Management of a Parturient with a Spinal Cord Stimulator
Abstract Number: RF4BD-239
Abstract Type: Case Report Case Series
Parturients with in-situ spinal cord stimulators (SCS) have unique considerations for neuraxial analgesia and anesthesia. Needle insertion can potentially damage the SCS components or impede the epidural spread of neuraxial medication leading to an inadequate block. Furthermore, there are theoretical concerns that an epidural catheter may entangle with or displace SCS wires. We report a parturient with a SCS who successfully received an epidural for labor analgesia and conversion for operative delivery.
A 30 yo G1P0 at 38+4 weeks with an in-situ lumbar SCS presented in active labor requesting epidural analgesia. The SCS was placed for complex regional pain syndrome (CRPS) following a crush injury to her left foot from a motor vehicle accident. No contraindications were identified for epidural placement during her antenatal clinic visit, but she was advised of the possibility of inadequate analgesia. During the pregnancy, the SCS was turned off due to the unknown effects of neuromodulation on fetal development, and her CRPS was well controlled. Previous operative notes showed the SCS leads were inserted at L2-3, positioned in the epidural space at T10 with the generator in the right flank. The electrode loops were at the 4th lumbar vertebrae crossing over the L3-4 interspace, but the L4-5 and L5-S1 interspaces remained vacant. No markers of a difficult airway were found.
For the epidural placement, ultrasound was used to determine the L4-5 interspace for needle entry. A standard epidural solution of 0.08% bupivacaine with 2mcg/mL of fentanyl using programmed intermittent bolus regimen provided adequate analgesia without any physician intervention during labor. Due to dystocia, the patient required operative delivery and her epidural was successfully converted to surgical block using a total of 15mL of 2% lidocaine with 1:200,000 epinephrine and 100mcg epidural fentanyl. Post-operatively, analgesia was controlled with 2.5mg of epidural morphine, tylenol, naproxen, and oral hydromorphone PRN. She was discharged home on postoperative day 2 and the pain clinic detected no change in her neurostimulation mapping.
In collaboration with an interventional pain specialist, a parturient with a SCS can be effectively managed perioperatively using a standard epidural technique for labor analgesia and caesarean delivery. There is a theoretical risk of SCS damage with placement of a neuraxial technique, although the risk is reduced with prior knowledge of the generator, lead locations and precise land-marking of the lumbar spine. Also, epidural catheters are unlikely to cause migration of SCS wires as fibrous deposits anchor the wires to the supraspinous ligament. SCS are becoming more common for patients of child-bearing age  and anesthesiologists should become familiarized with implications of the device.
1. Harned ME et al. Pain Physician 2017
2. Young AC et al. RAPM 2015
3. Sommerfield D et al. IJOA 2010