Spinal dysraphisms in the parturient: implications for perioperative anaesthetic care and labour analgesia

A Case Report of Fluoroscopically Guided Epidural Catheter Placement in a Parturient with History of Tethered Cord, Super-Morbid Obesity, and Risk for Difficult Airway

Tethered cord syndrome results from adherence of the conus medullaris to the sacrum and may be associated with high complication rates from neuraxial anesthesia. We present the case of a 32-year-old gravida 2 para 0 patient with a history of lipomyelomeningocele (one of several types of spina bifida) and tethered cord status post repair, residual low-lying conus medullaris, supermorbid obesity (body mass index of 58), and Mallampati IV airway, who underwent successful fluoroscopically guided epidural catheter placement for vaginal delivery. Risks and benefits of epidural catheter utilization and methods of placement are reviewed.

Ultrasonographic images of spina bifida before obstetric anesthesia: a case series

BACKGROUND

Spina bifida is a relatively common congenital malformation. As the functional prognosis of patients with spina bifida has improved over time, the number of cases resulting in pregnancy and delivery has increased. Lumbar ultrasonography has become a standard and helpful technique before neuraxial anesthesia. We believe that it might be valuable if we use lumbar ultrasonography to evaluate pregnant women with spina bifida before obstetric anesthesia.

CASE PRESENTATION

We performed lumbar ultrasonography to evaluate four pregnant women with spina bifida. Patient 1 had no history of surgery. Lumbar radiography before pregnancy showed a bone defect from L5 to the sacrum as a result of incomplete fusion. Magnetic resonance imaging showed a spinal lipoma and a bone defect of the sacrum. Lumbar ultrasonography showed similar findings. We performed general anesthesia for emergency cesarean delivery. Patient 2 underwent surgical repair immediately after birth. Lumbar ultrasonography showed the same bone defect as well as a lipoma beyond the bone defect. We performed general anesthesia for cesarean delivery. Patient 3 had vesicorectal disorders but no prior surgery. Lumbar radiography before pregnancy showed congenital abnormalities such as incomplete fusion, scoliosis, rotation, and a notably small sacrum. Lumbar ultrasonography showed the same bone defect. We performed general anesthesia for cesarean section with no complications. Patient 4 complained of lumbago a few years after her first delivery and received a diagnosis of spina bifida occulta by lumbar radiography, with the incomplete fusion of only the 5th vertebra. Lumbar ultrasonography indicated the same abnormalities. We placed an epidural catheter to avoid the bone abnormality and achieved epidural labor analgesia with no complications.

CONCLUSIONS

Lumbar ultrasonography shows anatomic structures easily, safely, and consistently, without X-ray exposure or the need for more expensive modalities. It is a helpful technique to explore anatomic structures potentially complicated by spina bifida before anesthetic procedures.

Pregnancy in spina bifida patients: a comparative analysis of peripartum procedures and complications

PURPOSE

Spina bifida (SB) is caused by a failure in neural tube closure that can present with lower extremity sensory deficits, paralysis, and hydrocephalus. Medical advances have allowed increased pregnancies among SB patients, but management and pregnancy-associated complications have not been thoroughly investigated. The objective is to delineate peripartum procedures and complications in patients with SB.

METHODS

A national de-identified database, TriNetX, was retrospectively queried to evaluate pregnant SB patients and the general population. Procedures and complications were investigated using corresponding ICD-10 and CPT codes within 1 year of pregnancy diagnosis.

RESULTS

11,405 SB patients were identified and compared to 9,269,084 non-SB patients. SB patients were significantly more likely to undergo cesarean delivery (1.200; 95% CI [1.133-1.271]) and less likely to receive neuraxial analgesia (0.406; 95% CI [0.383-0.431]). Additionally, patients with SB had an increased risk of seizures (3.922; 95% CI [3.529-4.360]) and venous thromboembolism (VTE) (3.490; 95% CI [3.070-3.969]). Risks of preeclampsia and hemorrhage were comparable. SB patients with hydrocephalus and Chiari malformation type 1 (CM-1) or type 2 (CM-2) were compared to patients without these comorbid conditions. This sub-group analysis showed a significantly increased risk of having cesarean deliveries (SB with hydrocephalus: 12.55%, S.B. with CM-1 or CM-2: 12.81% vs. SB without hydrocephalus or CM, 6.16%) and VTE (3.74%, 2.43% vs. 0.81%). There were also increased risks of hemorrhage and seizures and decreased use of neuraxial analgesia, but the sample size was insufficient.

CONCLUSION

SB patients were more likely to undergo cesarean section and exhibit peripartum complications compared to those without SB.

Complicated Neuraxial Anesthesia in a Patient With Tethered Spinal Cord

Spinal anesthesia is a common anesthetic used in many surgical procedures. Anatomical variations and diseases make this procedure require extra considerations. Extra care should be taken into consideration in the pre-anesthesia evaluation when neuraxial anesthesia is planned.

We present the case of a patient undergoing cesarean section for the arrest of labor, who had a complicated labor course due to unrecognized history of a tethered spinal cord leading to inadequate analgesia, requiring replacement of epidural analgesia and spinal anesthesia. Ultimately, the decision was made to proceed with general anesthesia due to the patient’s discomfort. Exhaustive chart review after surgery showed a past MRI with evidence of a tethered spinal cord.

Epidural Placement in a Patient With a Type 2 Split Cord Malformation in the Interventional Pain Management Setting: A Case Report

Split cord malformations are rare spinal dysraphisms in which 2 separate spinal cords are present. Despite its diagnosis in all age groups, split cord malformations are not well described. The clinical presentation and symptom severity are highly variable. Anesthesiologists may encounter patients with known or unknown split cord malformations without much information to guide clinical decision-making and procedural risks of neuraxial anesthesia. This is the first case to the authors' knowledge of utilizing a caudal epidural injection for pain management in a patient with a diagnosed split cord malformation.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Guideline for the management of pre-, intra-, and postpartum care of women with a spinal cord injury

The German Association of the Scientific Medical Societies guideline for pregnancy, childbirth, and puerperium in women with a spinal cord injury (SCI) addresses a range of topics from the desire to have a child to different stages of pregnancy and birth. Given that a generally accessible and evidence-based presentation of this complex issue does not yet exist, this new guideline contributes to the standardization of gynecological, obstetric, and maternal care of women with SCI. This guideline aims to provide practice-oriented support for the care and counseling of women in the pre-, intra-, and postpartum periods; to close identified gaps in medical care; foster collaboration among clinicians of relevant disciplines; and inspire research.

Anaesthetic management for caesarean section of a parturient with a known difficult airway and closed spinal dysraphism

Many anaesthetists consider patients with existing neurological deficits, untreated spinal pathology or those having undergone major spinal intervention to be precluded from undergoing neuraxial anaesthesia. While this is partly rooted in fears of litigation there is also a lack of consensus of the best practice in the anaesthetic management of these patients. We present our management of a parturient who attended our institution, having a number of anaesthetic complexities including a known difficult airway, spinal fusion and persistent spinal cord tethering. She successfully underwent delivery under neuraxial blockade for the delivery of her fourth child. We believe that by undergoing a thorough multidisciplinary clinical evaluation, including the extensive use of neuroimaging and ultrasound, it may be possible to plan and perform safe neuraxial anaesthesia.

A Pregnant Woman with Spina Bifida: Need for a Multidisciplinary Labor Plan

Women with spina bifida present both obstetrical and anesthesia challenges. They are more likely to require a caesarian delivery and traditionally neuraxial anesthesia has been avoided due to concerns of worsening neurologic disability. The case of a pregnant woman with a history of a surgically corrected lipomeningocele and tethered cord is presented to illustrate the need for a comprehensive labor plan.

Experiences and unmet needs of women with physical disabilities for pain relief during labor and delivery

BACKGROUND

Childbirth is widely acknowledged as one of the most painful experiences most women will undergo in their lifetimes. Alleviating labor and delivery pain for women with physical disabilities can involve an additional level of complexity beyond that experienced by most women, but little research has explored their experiences.

OBJECTIVE

The purpose of this study was to explore the experiences of women with physical disabilities with respect to pain relief during labor and delivery with the goal of informing their care.

METHODS

Data were collected using semi-structured interviews with twenty-five women with physical disabilities from across the United States.

RESULTS

Women expressed specific preferences for the method of pain relief. Some confronted systemic barriers in exploring their options for pain relief, while others were given a choice. At times, anesthesiologists lacked knowledge and experience in caring for women with disabilities. Conversely, some women described how the administration of anesthesia was meticulously planned and attributed their positive labor and delivery experiences to this careful planning.

CONCLUSIONS

Advanced, individualized planning and evaluation of their options for pain relief was most satisfying to women and enabled them to make an informed choice. This approach is consistent with the recommendations of clinicians who have successfully provided pain relief during labor to women with complex physical disabilities. Clinicians who have successfully delivered babies of women with these and similar disabilities emphasize the importance of a team approach where the anesthesiologist and other specialists are involved early on in a woman's care.