Anesthesia and spinal muscle atrophy

Profound hypoxemia and hypotension during posterior spinal fusion in a spinal muscular atrophy child with severe scoliosis: a case report

BACKGROUND

Anesthesia for spinal muscular atrophy (SMA) patients undergoing spinal deformity surgery is challenging. We report an unusual case of an SMA girl who developed severe intraoperative hypoxemia and hypotension during posterior spinal fusion related with surgical positioning.

CASE PRESENTATION

A 13-yr-old girl diagnosed with SMA type 2, severe kyphoscoliosis and thoracic deformity was scheduled for elective posterior spinal fusion. She developed severe hypoxemia and profound hypotension intraoperatively in the prone position with surgical table tilted 45° to the right. Though transesophageal echocardiography (TEE) could not be performed due to limited mouth opening, her preoperative computed tomography revealed a severely distorted thoracic cavity with much reduced volume of the right side. A reasonable explanation was when the surgeons performed surgical procedure with the tilted surgical table, the pressure was directly put on the shortest diameter of the significantly deformed thoracic cavity, causing severe compression of the pulmonary artery, resulting in both hypoxemia and hypotension. The patient stabilized when the surgical table was tilted back and successfully went through the surgery in the leveled prone position.

CONCLUSIONS

Spinal fusion surgery is beneficial for SMA patients in preventing scoliosis progression and improving ventilation. However, severe scoliosis and thoracic deformities put them at risk of both hemodynamic and respiratory instability during surgical positioning. When advanced monitoring like TEE is not practical intraoperatively, preoperative imaging may help with differential diagnosis, and guide the surgical positioning to minimize mechanical compression of the thoracic cavity, thereby helping the patient complete the surgery safely.

Clinical characteristics and anaesthetic management of severe scoliosis patients with spinal muscular atrophy: case series

Introduction and importance

There is no expert consensus or guidance on perioperative anaesthesia management for spinal surgery of spinal muscular atrophy (SMA) patients with severe scoliosis (Cobb≧90°). We provide a comprehensive summary of the perioperative characteristics observed in patients with SMA and propose an optimized perioperative management strategy for anaesthesia.

Methods

This study is a retrospective single-centre research. Twenty-six SMA patients with severe scoliosis underwent posterior spinal fusion surgery from September 2019 to September 2022 were enroled. The main outcomes were to show the patients' characteristics in anaesthesia, intra- and post-operative periods.

Outcomes

Nineteen patients underwent awake transnasal/transairway intubation. The median anaesthesia time of 25 patients treated under total intravenous anaesthesia was 425 min. After operation, the Cobb angle and correction rate in the coronal plane were median 54.0° and 54.4%. The length of mechanical ventilation with endotracheal intubation in ICU was median 17.5 h in 8 patients. The ICU length of stay of postoperative hospital was median 19 days. Postoperative pneumonia developed in nine patients, atelectasis in two patients, and pleural effusion in six patients. All patients did not need special oxygen therapy after discharge.

Conclusion

Multidisciplinary consultation, lung-protective ventilation strategy, appropriate anaesthetic drugs and reasonable blood transfusion scheme and postoperative monitoring were important in anaesthesia, intraoperative and postoperative periods in the patients of severe scoliosis with spinal muscular atrophy.

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study)

BACKGROUND

Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period.

METHODS

We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome.

RESULTS

Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs.

CONCLUSION

This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Spinal Muscular Atrophy Type III Recognized After Delayed Recovery From Neuromuscular Blockade After an Orthognathic Surgery

Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by the degeneration of alpha motor neurons in the spinal cord, resulting in progressive proximal muscle weakness and paralysis. SMA is classified into types I-IV based on the age at symptom onset or maximum motor function achieved, and its clinical manifestations vary. SMA affects maxillofacial growth because of muscle dysfunction and results in abnormal maxillofacial morphology. In addition, definitive diagnosis is not often made because of the older onset age and symptoms are rarely severe. Therefore, the possibility of undiagnosed SMA in craniofacial surgeries must be considered. This report described a case of an SMA type III recognized after delayed recovery from the neuromuscular blockade in an orthognathic surgery under general anesthesia.

Procedural sedation for paediatric patients with spinal muscular atrophy undergoing intrathecal treatment

AIMS

Nusinersen is administered intrathecally for treating spinal muscular atrophy (SMA). Procedural sedation is common with intrathecal treatment in children. The purpose of this study is to emphasize that intrathecal treatment of paediatric patients with SMA I, II and III can be tolerated with procedural sedation instead of general anaesthesia.

METHODS

Data were collected the from the anaesthesia charts and electronic medical records of 14 paediatric patients with SMA types I, II and III who underwent procedural sedation for repeated intrathecal treatments for SMA. Intravenous induction was performed, and patients were oxygenated with a face mask or nasal cannula while spontaneous breathing continued.

RESULTS

Fourteen patients were included in the study: one SMA I, eight SMA II and five SMA III. They underwent 88 intrathecal nusinersen injections in total. In the one SMA I patient, of 8 months, the procedure was performed under local anaesthesia. In all other patients, the treatments were performed under procedural sedation. Different combinations of midazolam, ketamine, propofol, fentanyl and remifentanil were used. The mean doses of the agents used were 0.03 mg kg-1 , 0.97 mg kg-1 , 2.71 mg kg-1 , 0.84 μg kg-1 and 0.5 μg kg-1 , respectively. There were no intraoperative or postoperative complications.

CONCLUSION

We found the procedural sedation to be sufficient, safe and effective in SMA II and III paediatric patients who underwent nusinersen treatment intrathecally, provided anaesthetic agents are titrated and administered carefully.

Management of patients susceptible to malignant hyperthermia: A surgeon's perspective

OBJECTIVES

Malignant hyperthermia (MH) susceptibility caries broad implications for the care of pediatric surgical patients. While precautions must often be taken for only a vague family history, two options exist to assess MH-susceptibility. We evaluate the use of MH precautions and susceptibility testing at a freestanding children's hospital.

METHODS

This single institution retrospective cohort study identified patients of any age who received general anesthetics utilizing MH precautions over a five-year period. The electronic medical record was further queried for patients diagnosed with MH. The indication for MH precautions and uses of susceptibility testing are assessed. Secondary outcomes included a diagnosis of bona fide MH.

RESULTS

A total of 125 patients received 174 anesthetics with MH precautions at a mean age of 114 months (0-363 months). Otolaryngology was the procedural service most frequently involved in the care of the cohort (n = 45; 26%). A reported personal or family history of MH (n = 102; 59%) was the most common indication for precautions, followed by muscular dystrophy (n = 29; 17%). No MH events occurred in the cohort and further review of ICD-9 and -10 diagnosis codes found no MH diagnoses. No study subjects received muscle biopsy and contracture testing and only 5 (4%) underwent genetic testing for genomic variants known to cause MH susceptibility. A case example is given to highlight the implications of a reported MH history.

CONCLUSION

Otolaryngologists should maintain a familiarity with the precautions necessary to manage patients at risk for MH and MH-like reactions. Without an accessible test to rule out susceptibility, surgeons must rely on a careful history to appropriately utilize precautions. An inappropriate label of "MH-susceptible" may result in decreased access to care and treatment delays.

Anaesthetic considerations in posterior instrumentation of scoliosis due to spinal muscular atrophy: Case series of 56 operated patients

BACKGROUND

Spinal muscular atrophy (SMA) is a rare illness that often leads to severe kyphoscoliosis. This case series adds to the heretofore sparse information as regards the anaesthetic management of SMA scoliosis patients.

METHODS

This retrospective study reviewed the charts of 79 SMA patients (type II n = 34 and type III n = 45) presenting for possible scoliosis surgery during the time period 2007-2019. Special attention focused on preoperative assessment and clearance requirements, anaesthesia protocol and postoperative handling.

RESULTS

Out of 79 patients, 17 did not receive clearance for the procedure mostly due to grave respiratory insufficiency. Out of 62 patients with clearance for both surgery and anaesthesia, 56 patients [44 females, 12 males; age mean ± SD (range) 22 ± 7.3 (10-40) years] underwent the procedure. Their forced vital capacity and forced expiratory volume in 1 s were mean ± SD (range) 1.41 ± 0.53 (0.61-2.65) L and 1.26 ± 0.47 (0.52-2.27) L, respectively. Intubation difficulties and their resolution, e.g. with the help of fibreoptic technique and video laryngoscopy, are described. All 56 patients were extubated in the operating room postoperativley. Patients stayed at the postanaesthesia care unit for one (n = 48) or two (n = 8) nights. A considerable amount of the patients (19/56) developed hypokalaemia postoperatively.

CONCLUSION

This analysis is one of the bigger series of its kind and adds insight into the preoperative clearance process, the anaesthetic protocol and some of the postoperative complications, e.g. the tendency for developing postoperative hypokalaemia which has not been reported previously.

Spinal Muscular Atrophy Type II: Anesthetic Challenges and Perioperative Management

Spinal muscular atrophy (SMA) is a group of genetic diseases that cause weakness and wasting in voluntary muscles of infants and children and more rarely in adults. It is caused by inadequate production of a protein called survival motor neuron (SMN) protein coded by SMN1 gene on chromosome 5. Anesthetic challenges in patients of SMA include their sensitivity toward induction agents such as thiopental, opioids, muscle relaxants, and their incomplete reversal with anticholinesterases. They also have weakness of respiratory muscles and inadequate laryngeal reflexes, which make them prone to aspiration. Although spinal and epidural anesthesia have been described in adults with SMA, but general anesthesia in these patients is very challenging. In this case, successful perioperative management of such a patient scheduled for correction of dislocated hip has been described.

A case series of paediatric patients with spinal muscular atrophy type I undergoing scoliosis correction surgery

Spinal muscular atrophy is a neuromuscular disorder with degeneration of spinal motor neurons. Type I is a severe variant that was recently shown to be amenable to treatment with the antisense oligonucleotide nusinersen. As a result of increased life expectancy with this treatment, more children with spinal muscular atrophy type I are presenting for spinal correction surgery. In this case series, we present four such patients who underwent spinal surgery at our institution over the course of one year. Pre-operative assessment showed evidence of reduced respiratory function requiring nocturnal non-invasive ventilation in all four patients. A difficult airway was encountered in two of the four patients. Postoperative complications were ubiquitous and included CSF leak, poor wound healing, metal frame exposure, frame instability and wound infection. There were no postoperative respiratory complications and all four children returned to their respiratory baseline postoperatively. All patients underwent successful lumbar puncture and intrathecal nusinersen injection following their spinal surgeries. Given the risk of complications and prolonged recovery following spinal surgery, a detailed family discussion is advisable.

Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy

BACKGROUND

Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).

METHOD

We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.

RESULTS

We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS.

CONCLUSION

Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.

[Anesthesia for patients suffering from neuromuscular diseases]

Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.

Regional anesthesia in pediatric patients with preexisting neurological disease

Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue and, as such, create additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in this vulnerable population.

Children With Spinal Muscular Atrophy With Prior Growth-Friendly Spinal Implants Have Better Results After Definite Spinal Fusion in Comparison to Untreated Patients

BACKGROUND

Almost all children with spinal muscular atrophy (SMA) develop a scoliosis during childhood and adolescence. In the last decades, growth-friendly spinal implants have been established as an interim solution for these patients until definite spinal fusion can be performed. The effect of those implants on the final outcome has yet to be described.

OBJECTIVE

To assess the effect of prior growth-friendly spinal surgical treatment on the outcome after spinal fusion in SMA children in comparison to untreated SMA patients through the prospective study.

METHODS

A total of 28 SMA patients with (n = 14) and without (n = 14) prior surgical treatment with growth-friendly implants were included. Average surgical treatment prior to definite spinal fusion was 4.9 yr. Scoliotic curve angle, pelvic obliquity, spinal length, kyphosis, and lordosis were evaluated for children with prior treatment and before and after dorsal spondylodesis for all children.

RESULTS

The curve angle before definite spinal fusion averaged at 104° for SMA patients without prior treatment and 71° for patients with prior treatment. Spondylodesis reduced the scoliotic curve to 50° and 33°, respectively, which equals a correction of 52% vs 54%. Pelvic obliquity could be improved by spinal fusion in all patients with better results in the pretreated group. Results for spinal length, kyphosis, and lordosis were similar in both groups.

CONCLUSION

These data show the positive effect of prior growth-friendly surgical treatment on radiographic results of spinal fusion in children with SMA. Both scoliotic curve angles and pelvic obliquity showed significantly better values when patients had growth-friendly implants before definite spinal fusion.

Anaesthesiological approach to the floppy child

Children with symptoms of hypotonia (reduction of postural tone of lower limbs and trunk with or without changes in phasic tone) are frequently anaesthetized for diagnostic and therapeutic interventions. This review outlines the underlying causes and classifications, and the anaesthesiologic pre- and peri-operative management of hypotonic children. Hypotonia may have a large range of aetiologies that be categorized into central and/or peripheral hypotonia. A multidisciplinary approach towards the (differential) diagnosis of the underlying cause of the symptoms in cooperation with a paediatrician and/or paediatric neurologist is emphasized. Anaesthetic management involves the anticipation of an increased risk in difficult airway management because of macroglossia, reduced mouth opening, obesity and limited neck mobility, which increases with age. There are no specific restrictions towards the use of intravenous or inhalational anaesthetics. Short acting opioids and hypnotics, avoiding neuromuscular blockade, and locoregional techniques are preferred. Most patients are sensitive to the cardiac and depressive effects of anaesthetics and all dystrophic myopathies are considered at risk of malignant hyperthermia. Depolarizing neuromuscular blockers are contraindicated. The use of a peripheral nerve stimulator is recommended to detect the severity of muscle relaxation before extubating. Accurate control and management of IV fluids, electrolytes and temperature is mandatory. Adequate postoperative pain treatment is essential to limit stress and metabolic alteration. Preferably a locoregional technique is used to reduce the increased risk of respiratory depression. A multidisciplinary preoperative approach taking into account the differential diagnosis of the underlying disease of the floppy child is recommended.

Continuous lengthening potential after four years of magnetically controlled spinal deformity correction in children with spinal muscular atrophy

Magnetically controlled growing rods (MCGR) are commonly implanted for the treatment of early-onset scoliosis. While most authors report favorable short-term results, little is known about long-term deformity correction. This prospective cohort study assesses spinal deformity control in a homogeneous spinal muscular atrophy (SMA) patient group treated with MCGR implants, a standardized lengthening protocol and a minimum follow-up of four years. 17 SMA patients with progressive scoliosis were treated with MCGR implanted parallel to the spine with rib-to-pelvis fixation. Radiologic measurements were performed before and after MCGR implantation and during external lengthening procedures. These included measurements of the scoliotic curve, kyphosis, lordosis, pelvic obliquity and the spinal length. Additional clinical data of the complications were also analyzed. 17 children (mean age 7.4 years) were surgically treated and underwent a total of 376 lengthenings. Complication rates were 3.5% in respect to all interventions or 41% of the patients had complications during 3.5% of the lengthening sessions. The initial implantation significantly reduced the main scoliotic curve by 59%, with the correction remaining constant throughout the follow-up. Pelvic obliquity was also significantly and permanently corrected by 72%, whereas kyphosis and lordosis were not influenced. The spinal length could be significantly increased mostly during the first year of treatment. Bilateral implantation of MCGRs for correction of spinal deformity in children with SMA showed no decrease of the lengthening potential during a four-year follow-up. Therefore, the previously described ‘law of diminishing returns’ could not be applied to this patient population.

Level of Evidence/Clinical relevance: Therapeutic Level IV.

Peri-operative management of children with spinal muscular atrophy

Background and Aims:

Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol.

Methods:

A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate.

Results:

Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0.

Conclusion:

Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II.

Is prophylactic formal fusion with implant revision necessary in non-ambulatory children with spinal muscular atrophy and growing rods who are no longer lengthened?

STUDY DESIGN

Single center, retrospective chart review.

OBJECTIVES

To determine if routine posterior spinal fusion (PSF) is unnecessary in non-ambulatory growing rod graduates with SMA. Most non-ambulatory children with SMA develop early-onset scoliosis (EOS). Posterior growing rods (GR) have been shown safe and effective in managing spinal deformities in these children. The best management of these children, once graduated from their GR, is currently unknown. In this study, we report the clinical results of managing these children without routine definitive fusion following a course of GR treatment.

METHODS

A single-center, retrospective chart and radiographic review was performed on children with SMA treated with posterior distraction GR, with a two-year minimum follow-up since final lengthening. Electronic medical records and radiographs were reviewed for demographic variables, Cobb measurements, implant revisions, occult radiographic implant failure, symptomatic failure, and/or conversion to PSF.

RESULT

12 patients (2 type 1, 9 type 2, 1 type 1/2) met inclusion criteria. Mean age at growing rod insertion was 6.2 years of age (range 4.1-8.2) and age at final lengthening 10.3 years of age (range 9.3-11.9). The mean time between last lengthening and latest clinical or radiographic review was 5.5 (range 2.1-9.0) years. Average mean pre, post, final Cobb angles were 71°, 27° (p < 0.001), 25°. Following final lengthening, only one patient required hardware revision and conversion to definitive fusion in attempts to alleviate chronic hip pain, which was unsuccessful. One additional patient was found to have an occult rod failure that has not required treatment.

CONCLUSION

While limited by sample size, this single-center cohort of non-ambulatory SMA patients with EOS treated with similar constructs suggests that routine, definitive fusion in SMA GR graduates may be unnecessary.

LEVEL OF EVIDENCE

Level IV.

Ten-year experience with standardized non-operating room anesthesia with Sevoflurane for MRI in children affected by neuropsychiatric disorders

Background

Children require anesthesia for MRI to maintain immobility and reduce discomfort; clear indications about the best anesthesiologic management are lacking and each center developed its own protocol. Moreover, children with neuropsychiatric disorders more likely require sedation and are described in literature as more prone to general and respiratory complications. Aim of this study was to analyze the applicability of a sevoflurane-based approach, to describe general and respiratory complications and to identify risk factors in a pediatric neuropsychiatric population.

Methods

Retrospective cohort study, university Hospital (January 2007–December 2016). All the 1469 anesthesiologic records of children addressed from Neuropsychiatric Unit to undergo MRI under general anesthesia were analyzed; 12 patients equal or older than 18-year-old were excluded. We identified post-hoc nine macro-categories: static encephalopathies, metabolic/evolutive encephalopathies, epileptic encephalopathies, neuromuscular diseases, autistic spectrum disorders, migraine, psychiatric disorders, intellectual disabilities, others. A logistic regression model for events with low frequency (Firth’s penalized likelihood approach) was carried out to identify the mutually adjusted effect among endpoints (complications) and the independent variables chosen on the basis of statistical significance (univariate analysis, p ≤ 0.05) and clinical judgment.

Results

Of 1457 anesthesiologic records (age 4.0 (IQR 2.0 to 7.0) year-old, males 891 (61.2%), weight 17.0 (IQR 12.0 to 24.9) kg), 18 were cancelled for high anesthesiologic risk, 50 were cooperative, 1389 were anesthetized. A sevoflurane-based anesthesia was feasible in 92.3%; these patients required significantly less mechanical ventilation (8.6 vs. 16.2%; p = 0.012). Complications’ rate was low (6.2%; 3.1% respiratory). The risk for general complications increases with ASA score > 1 (OR 2.22, 95 CI% 1.30 to 3.77, p = 0.003), male sex (OR 1.73, 95% CI 1.07 to 2.81, p = 0.025), multi-drug anesthesia (OR 2.98, 95 CI% 1.26 to 7.06, p = 0.013). For respiratory complications, it increases with ASA score > 1 (OR 2.34, 95 CI% 1.19 to 4.73, p = 0.017), autumn-winter (OR 2.01, 95 CI% 1.06 to 3.78, p = 0.030), neuromuscular disorders (OR 3.18, 95 CI% 1.20 to 8.41, p = 0.020). We had no major complications compromising patients’ outcome or requiring admission to ICU.

Conclusions

Sevoflurane anesthesia is feasible and safe for children affected by neuropsychiatric disorders undergoing MRI. Specific risk factors for general and respiratory complications should be considered.

Lumbar laminotomy for the intrathecal administration of nusinersen for spinal muscular atrophy: technical note and outcomes

Nusinersen (Spinraza) is a US Food and Drug Administration-approved intrathecal medication for the treatment of spinal muscular atrophy (SMA). Adult patients with SMA often undergo thoracolumbar fusion to treat neurogenic scoliosis, preventing thecal access. The authors report a laminotomy technique and the ease of intrathecal access in three SMA patients with prior thoracolumbar fusions.Patients were positioned in the lateral decubitus position or prone. Lumbar laminotomy was performed below the conus, between the lateral longitudinal rods, to preserve mechanical stability. Fluoroscopy provided real-time identification of instruments. Hardware was contoured with a carbide drill bit to develop the surgical window. Fiducial screws were placed along the perimeter for demarcation. Sublaminar wire removal caused dural defects that were repaired with a layer of dural substitute onlay and sealant. All patients successfully received nusinersen thecal injections via lumbar puncture by an interventional radiologist. Fluoroscopy time ranged from 6 to 36 seconds. No postoperative pseudomeningoceles, cerebrospinal fluid leaks, or wound complications occurred.For patients with SMA and posterior fusion from prior scoliosis treatment, lumbar laminotomy is an effective method for creating thecal access for the administration of nusinersen.

Ultrasound-guided cervical puncture for nusinersen administration in adolescents

BACKGROUND

Spinal muscular atrophy (SMA) is an autosomal-recessive disease affecting motor neurons and is the most common genetic cause of death in infants. Intrathecal nusinersen is the only therapy approved by the U.S. Food and Drug Administration for SMA. Deformities and spinal instrumentation from orthopedic surgeries are common in children with SMA, complicating traditional intrathecal access for nusinersen delivery. Cervical punctures are routinely performed in adults for cervical myelograms and should be considered for children with SMA as a viable form of intrathecal access.

OBJECTIVE

This retrospective study assessed technical feasibility and complications of ultrasound-guided cervical puncture for nusinersen administration.

MATERIALS AND METHODS

We reviewed 14 consecutive ultrasound-guided cervical punctures for nusinersen administration with local anesthesia. We reviewed technical success and complications.

RESULTS

All procedures were technically successful. There were no major complications. Two minor complications included headaches that resolved by observation within 24 h after the procedure.

CONCLUSION

Our series describes a successful novel method of ultrasound-guided cervical spine access for intrathecal administration of nusinersen, adding to the armamentarium of procedures for delivering nusinersen to adolescents with challenging lumbar spine access caused by scoliosis and spinal instrumentation. This technique has the advantages of real-time ultrasound guidance and potential avoidance of general anesthesia in children.

A retrospective cohort study of children with spinal muscular atrophy type 2 receiving anesthesia for intrathecal administration of nusinersen

INTRODUCTION

Spinal muscular atrophy is characterized by loss of motor neurons in the anterior horn of the spinal cord with resultant proximal muscle weakness. Intrathecal nusinersen has revolutionized the treatment of spinal muscular atrophy. We reviewed the perioperative care of 61 anesthetics performed on eight patients with spinal muscular atrophy type 2 who received nusinersen over 30 months in conjunction with nusinersen's phase 3 clinical trials.

METHODS

Anesthesia was induced in all patients with sevoflurane, nitrous oxide, and oxygen (30%) via facemask. A peripheral intravenous line was placed after the loss of consciousness in all but three procedures. General anesthesia was maintained in 58 anesthetics with a propofol infusion at 250-300 μg/kg/min, while the remainder was maintained with inhalational anesthetics. The airway was managed via facemask or nasal cannula in all but two procedures, in whom a laryngeal mask airway was placed. We analyzed patient demographics, duration of anesthesia and of postanesthesia care unit stay, discharge destination, preprocedure oxygen saturation (SaO₂ ), postanesthesia care unit discharge oxygen saturation, and occurrence of unanticipated admission or postdischarge hospitalization.

RESULTS

Eight American Society of Anesthesiologists physical status three patients (3 male: 5 female) with a median age of 4.1 (2.1-7.8) years and median weight of 13.2 (10-24.7) kg, underwent 61 anesthetics for nusinersen administration or sham procedure. There were no intraoperative anesthetic complications of unanticipated cardiovascular instability, major neurologic events, respiratory failure, or death. Anesthesiologists performed 83% of the procedures.

CONCLUSION

Nusinersen has revolutionized the care of patients with spinal muscular atrophy type 2 and anesthesiologists will be involved in its administration. We found that routine anesthetic care was safe and effective.

Single-center experience with intrathecal administration of Nusinersen in children with spinal muscular atrophy type 1

BACKGROUND

Spinal muscular atrophy (SMA) is a neuromuscular disorder mainly characterized by proximal muscle weakness. There have been enormous advances in therapeutic development with the possibility to influence the clinical course of the disease. Nusinersen is the first approved drug to treat SMA. It is administered intrathecally and acts as splicing modifier of the SMN2 gene.

METHODS

Lumbar punctures were performed using a standardized protocol. To evaluate safety and feasibility of the intrathecal treatment, vital signs and the need for sedation, analgesia or mechanical ventilation during the procedure were monitored. Furthermore, the number of puncture attempts, the injection site and the macroscopic appearance of cerebrospinal fluid were documented.

RESULTS

Treatment with Nusinersen was initiated in 20 children aged from 2 to 50 months. Administration of a local anesthetic cream on the puncture site and a peripheral analgesic led to an adequate pain management. We observed a beneficial distraction through the possibility to watch a movie or listen to music during the procedure. In some cases, an additional sedation was necessary. In patients accustomed to non-invasive ventilation, this was used during lumbar punctures. On average, 1.5 ± 1.0 puncture attempts were performed between L 4/5 and L 2/3. If required, the position of the medullary cone was identified by ultrasound to guarantee a safe puncture above L 3/4.

CONCLUSIONS

Lumbar punctures for intrathecal administration of Nusinersen could be performed without any relevant complications. With the described approach lumbar punctures were tolerated well in all investigated age groups.

Magnetically Controlled Devices Parallel to the Spine in Children with Spinal Muscular Atrophy

Background:

Children with severe spinal deformity frequently are managed with growth-friendly implants. After initial surgery, externally controlled magnetic rods allow spinal deformity correction during growth without further surgical intervention. The ability to lengthen the spine without additional surgical procedures is especially beneficial in high-risk children, such as those with spinal muscular atrophy (SMA). The purpose of the present study was to assess the level of control of spinal deformity in a homogeneous group of patients with SMA who were managed with magnetically controlled implants for 2 years.

Methods:

This prospective, nonrandomized study included 21 non-ambulatory children with type-II SMA and progressive scoliosis who were managed bilaterally with a magnetically controlled implant that was inserted parallel to the spine with use of rib-to-pelvis hook fixation. Radiographic measurements of scoliotic curves, kyphosis, lordosis, pelvic obliquity, and spinal length were performed before and after implantation of the magnetically controlled device and during external lengthening. The mean duration of follow-up was 2 years.

Results:

The mean main curve of patients without prior vertical expandable prosthetic titanium rib (VEPTR) treatment decreased from 70° before implantation of the magnetically controlled device to 30° after implantation of the device. Correction was maintained during the follow-up period, with a mean curve of 31° at the time of the latest follow-up at 2.2 years. Pelvic obliquity was surgically corrected by 76% (from 17° to 4°) and remained stable during follow-up. Thoracic kyphosis could not be corrected within the follow-up period. Spinal length of children without prior spinal surgery increased by >50 mm immediately after device implantation and steadily increased at a rate of 13.5 mm/yr over the course of treatment. During treatment, 4 general complications occurred and 6 lengthening procedures failed, with 3 patients requiring surgical revision.

Conclusions:

Bilateral implantation of an externally controlled magnetic rod with rib-to-pelvis fixation represents a safe and efficient method to control spinal deformity in children with SMA, achieving sufficient and stable curve correction as well as increased spinal length. The complication rate was lower than those that have been described for VEPTR and other growing rod instrumentation strategies.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative considerations in infantile neuroaxonal dystrophy

Infantile neuroaxonal dystrophy is a rare neurological disorder that is universally fatal with life expectancy under 10 years. A 10-year-old boy with infantile neuroaxonal dystrophy and severe neuromuscular scoliosis underwent posterior spinal fusion following halo traction. He was successfully extubated to bilevel positive airway pressure on postoperative day 3 and discharged home on postoperative day 11. Infantile neuroaxonal dystrophy presents several perioperative challenges including concerns for difficult intubation and respiratory dysfunction.

Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist

Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.