Caesarean section conducted under subarachnoid block in two sisters with spinal muscular atrophy

Spinal muscular atrophy is a rare chronic neurological condition characterised by degeneration of the anterior horn cell. Experience with the anaesthetic management of the pregnant patient with this condition is limited. We report the clinical details of two wheelchair-bound sisters, who underwent elective caesarean section within a few weeks of one another. Both patients were safely managed with subarachnoid anaesthesia without any deterioration of their underlying neurological condition. It is hoped that this report will add to the evidence that subarachnoid anaesthesia can safely be used for caesarean section in chronic neurological conditions and, in particular, spinal muscular atrophy.     

Spinal anaesthesia for caesarean section in a patient with cervical cord compression

The anaesthetic management a of 42-year-old woman with significant symptomatic cervical cord compression, who presented for emergency caesarean section, is presented. She declined to have general anaesthesia in any circumstance and had the surgery conducted under spinal anaesthesia, without developing any postoperative neurological deterioration. The implications of various anaesthetic options are discussed along with the role of patient's wishes in anaesthetic decision-making.     

Coma after spinal anaesthesia in a patient with an unknown intracerebral tumour

Spinal anaesthesia is contraindicated in patients with elevated intracranial pressure or space‐occupying intracranial lesions. Drainage of the lumbar cerebrospinal fluid (CSF) can increase the pressure gradient between the spinal, supratentorial and infratentorial compartments. This can result in rapid herniation of the brain stem or occluding hydrocephalus. We present a case of a female patient with an occult brain tumour who received a spinal anaesthesia for an orthopaedic procedure. The primary course of anaesthesia was uneventful. Several hours after surgery, the patient became increasingly disoriented and agitated. The next day, she was found comatose. A computed tomogram of the head revealed herniation of the brain stem, resulting in an occluding hydrocephalus due to a prior not known infratentorial mass. By acute relieving of the intracranial pressure by external CSF drainage, the mass was removed 2 days later. The further post‐operative course was uneventful and the patient was discharged from the hospital without neurological deficit 3 weeks after the primary surgery.     

Neurologic symptoms after epidural anaesthesia. Report of three cases

We describe 3 patients, who exhibited neurological symptoms after single dose epidural anaesthesia. In patient 1 an unrecognized spinal arteriovenous fistula (AVF) caused paraparesis following epidural block. The dilated veins draining an AVF are space–occupying structures and the injection of the anaesthetic solution may have precipitated latent ischaemic hypoxia of the spinal cord due to raised venous pressure. In patient 2, epidural block was followed by postoperative permanent saddle pain and hypoaesthesia. The injection of the anaesthetic in a narrow spinal canal with multiple discal protrusions and restriction of interlaminar foramina may have acutely produced mechanical compression of the spinal cord or roots. Patient 3 exhibited post–epidural block spinal arachnoiditis. Although the few reported cases of this syndrome exhibit severe neurological damage, our patient presented with scarse symptoms.
Our cases point out the importance of accurate neurological history and examination of candidates for epidural anaesthesia and of accurate anaesthetic history for neurological patients.     

Spinal or epidural anaesthesia for elective caesarean section? A Swedish experience

Ninety seven women undergoing elective lower segment caesarean section were randomly divided into two groups, group 1 received spinal anaesthesia with hyperbaric bupivacaine and group 2 received mepivacaine 20 mg/ml with adrenaline 5 microg/ml via an epidural catheter. All patients were given a preload of Ringer acetate and Macrodex prior to onset of anaesthesia. Ephedrine 5 mg was given if the systolic blood pressure fell below 100 mmHg. There was a small (<30%) but significant (P<0.01) fall in blood pressure in both groups of women. Six women in the epidural group required supplemental analgesics during the operation compared to only 1 patient in the spinal group (P<0.01). Muscle relaxation was judged to be inadequate in 3 patients in the spinal group and in 5 patients in the epidural group. One patient in the spinal group had a characteristic post-spinal headache lasting 3 days. The injection-delivery time was shorter (P<0.01) in the spinal group compared to the epidural group. The Apgar scores at 1 and 5 min were similar in both groups. The results from our study suggest that spinal anaesthesia is a good alternative to epidural anaesthesia for elective caesarean section. A fall in blood pressure, which is equally possible in both groups of patients, should be prevented by adequate fluid preload and treated immediately by intravenous ephedrine.     

Discitis after spinal anesthesia for transurethral resection of the prostate

We described a case of discitis and meningitis following spinal anaesthesia for transurethral resection of the prostate. The patient received antibiotics for a month before surgery, because of Klebsiella prostatitis. Spinal anaesthesia was performed in L3-L4 interspace by using 22G Quincke needle. Bacteriaemia occurred during the first postoperative hours. Ten days after spinal anaesthesia, patient suffered from lumbar pain, exacerbated by vertebral percussion, and motor weakness within lower limb, which was marked on right side. MRI examination showed L3-L4 discitis with psoas abcess in regard, and epiduritis marked around L3 right spinal root. CSF examination confirmed meningitis but no bacteria was found. Antibiotics were administered over a 6 weeks period, and then patient discharged from hospital without neurological sequellae. Infectious discitis related to disk puncture during spinal anaesthesia and postoperative bacteriaemia was likely in our patient.     

Cranial subdural haematoma after spinal anaesthesia treated by blood patch

The authors report a case of subdural haematoma after spinal anaesthesia. A 36-year-old woman underwent phlebectomy under spinal anaesthesia. Two days later, she complains of severe headache without neurological signs, not responding to bed rest and analgesics. Magnetic resonance imaging showed a small acute subdural haematoma in the right parieto-occipital region. On the forth day, she was given a blood-patch, which improved rapidly the patient. Recovery was complete.     

Spinal anaesthesia and dysfibrinogenaemia

We report the case of a 34-year-old woman who presented to the delivery unit at 36 weeks' gestation with spontaneous rupture of membranes. She had a triplet pregnancy following in vitro fertilisation. An elective caesarean section was performed under spinal anaesthesia 4h after admission. The patient had a massive postpartum haemorrhage in the recovery area at which time she mentioned that she was known to have 'low fibrinogen'. Further investigation showed that she suffered from dysfibrinogenaemia, as did several members of her family. We can find no reported cases of the use of central neural blockade in a patient with untreated dysfibrinogenaemia. Central neural blockade is often considered contraindicated in patients with disorders of fibrinogen; there were fortunately no neurological sequelae following spinal anaesthesia in this patient.     

Spinal anaesthesia for Caesarean section in a patient with a cervical arteriovenous malformation

Purpose

Arteriovenous malformations (AVM) of the spinal cord are rare. We report the successful management of a patient with a cervical spinal cord AVM undergoing Caesarean section delivery, using a spinal anaesthetic.

Clinical features

Based on previous radiological investigations, the patient was known to have an AVM at the third cervical level of her spinal cord. After application of monitors and intravenous administration of 1 L normal saline, a 25 g Whitacre needle was inserted into the subarachnoid space at the L_3–4 interspace. Spinal anaesthesia was established with a solution consisting of hyperbaric spinal bupivacaine 12 mg, fentanyl 12.5 μg and epidural morphine 0.25 mg. There was no neurological deficit during hospital stay or after discharge.

Conclusion

The safe outcome of spinal anaesthesia for our patient is encouraging. The presence of spinal cord AVM at the cervical region is not an absolute contraindication to spinal anaesthesia.     

Post-operative paraplegia following spinal cord infarction

Thoracic epidural analgesia is a frequently utilised technique. Neurological complications are uncommon, but of grave consequence with significant morbidity. Spinal cord infarction following epidural anaesthesia is rare. We present a case where a hypertensive patient underwent an elective sigmoid colectomy under combined general/epidural anaesthesia for a suspected malignant abdominal mass. An epidural infusion was used for intra-operative and post-operative analgesia. During surgery, the blood pressure was labile and she was hypotensive. Postoperatively, the patient became confused, pyrexial and tachycardic and developed systemic inflammatory response syndrome requiring intensive care management. She developed a flaccid paralysis at L3 level with areflexia, analgesia and impaired sensation. A spinal cord infarct in the region of the conus extending into the thoracic cord was diagnosed. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia and the post-operative period may be misjudged or underestimated when they appear after a delay, if neurological signs are masked by lack of patient cooperation and drowsiness or if the epidural anaesthesia is prolonged by long-acting drugs. New neurological deficits should be evaluated promptly to document the evolving neurological status and further testing or intervention should be arranged if appropriate. The association with epidural anaesthesia as a cause of paraplegia is reviewed. The aetiological factors that may have contributed to this tragic neurological complication are discussed.     

Anaesthesia for Caesarean section in a patient with myotonic dystrophy receiving warfarin therapy

A 31-yr-old parturient with myotonic dystrophy and asthma presented for elective Caesarean section. The patient was receiving warfarin having had two previous episodes of thromboembolism. Anticoagulation was subsequently provided by heparin in the weeks prior to delivery. The combination of the patient’s medical conditions and the continuing need for anticoagulation presented a considerable anaesthetic problem in planning anaesthesia and analgesia for both elective and emergency delivery. Heparin was discontinued on the day prior to surgery and restarted immediately after surgery. During surgery flowtron anti-embolitic boots were used. Warfarin therapy was recommenced on the seventh postoperative day. Anaesthesia for Caesarean section was provided using a combined spinal epidural technique using a separate needle, separate interspace method. Postoperative pain was relieved by using a continuous epidural infusion, transcutaneous nerve stimulation and diclofenac. No new neurological problems arose despite the use of epidural analgesia in the presence of heparin anticoagulation. This method of providing anaesthesia and postoperative analgesia without the use of opioids in an anticoagulated, asthmatic, myotonic parturient has not been described elsewhere.     

Spinal haematoma following epidural anaesthesia in a patient with eclampsia

A patient with a twin pregnancy required a Caesarean section for severe pre-eclampsia. Her platelet count was 71 x 10(9).l-1. Epidural anaesthesia was performed after platelet transfusion. A spinal epidural haematoma was diagnosed postoperatively. A generalised tonic-clonic seizure sparing the lower limbs enabled early diagnosis to be made. The patient recovered with no permanent neurological damage after laminectomy and clot removal. The risks and benefits of regional techniques require careful consideration, and postoperative monitoring for recovery of neural blockade is essential.     

Spinal anaesthesia and spina-bifida occulta

We describe a patient with unexpected spina bifida who underwent spinal anaesthesia for trans-urethral resection of prostate and developed serious neurological signs. An unexpected spinal tumour was removed two weeks later. This report demonstrates that not all neurological problems associated with spinal anaesthesia should be blamed on the technique.     

Multiple sclerosis disclosed by spinal anesthesia

A case is reported of an acute onset of previously undiagnosed multiple sclerosis, revealed by an oculomotor paralysis following spinal anaesthesia performed for minor orthopaedic surgery. The need for a complete preoperative physical examination is underlined by this case, looking for latent neuromuscular disorders before undertaking such techniques, and for a thorough neurological work-up should such a complication arise. The harmlessness of regional anaesthesia in multiple sclerosis patients is controversial; without entering into such a debate, the direct relationship between spinal anaesthesia and acute exacerbation of the disease in our patient seemed more than likely.     

Low-dose combined spinal-epidural anaesthesia for caesarean section in a patient with Eisenmenger’s syndrome

A 34-year-old woman (G3,P0) with Eisenmenger’s syndrome and positive HIV serology presented to hospital at 16 weeks of pregnancy. She was hospitalised at 20 weeks under the care of a multidisciplinary team. At 33 weeks caesarean section was performed under low-dose combined spinal-epidural anaesthesia using a needle-through-needle technique. Over a period of 10 min, spinal anaesthesia produced a sensory block to T4 which did not alter oxygenation or blood pressure. Epidural supplementation was not required. The caesarean section proceeded uneventfully without pain or discomfort. The post-partum period was without major incident. Low-dose combined spinal-epidural techniques combine the advantages of spinal and epidural blockade; the versatility allows its use in a wide range of clinical conditions, combining effective anaesthesia with cardiovascular stability.     

Awake oral fibreoptic intubation for caesarean section

A 35-week pregnant patient with ankylosing spondylitis and a known previous failed intubation required an elective caesarean section for intrauterine growth retardation. Regional anaesthesia was prevented by extensive spinal fusion. The anaesthetic management involved an awake oral fibreoptic intubation followed by induction and maintenance of general anaesthesia allowing delivery of a live infant without harm to the mother.     

An unusual intracranial tumour presenting in pregnancy

We describe a patient who presented in late pregnancy with deteriorating neurological status due to an intracranial capillary haemangioma causing mass effect and raised intracranial pressure. She became confused and uncooperative leading to practical difficulties in performing adequate radiological imaging. Decision regarding timing of delivery and craniotomy was not straightforward and required discussion between the neurosurgeon, obstetrician and anaesthetist based on assessment of fetal maturity and the need to perform a craniotomy to excise what was initially thought to be a meningioma. Caesarean section was performed under general anaesthesia. The tumour was resected three weeks later. Management of obstetric patients with brain tumours is complex, requiring knowledge of the physiological effects of pregnancy on tumour size and labour on intracranial pressure. Both of these may influence the choice of labour analgesia or anaesthesia for caesarean section. Anaesthetists must be aware of the difficulties of radiological imaging during pregnancy, particularly in confused patients. The conflicting requirements of general anaesthesia for craniotomy and caesarean section should be considered.     

Acute subdural haematoma after accidental dural puncture during epidural anaesthesia

A case is reported of acute intracranial subdural haematoma following accidental dural puncture during epidural anaesthesia. A 36-year-old primigravida with a gestation of 37 weeks and 3 days underwent caesarean section for which epidural anaesthesia was initially planned. An 18-gauge Tuohy needle was inserted into the L3-4 interspace but accidental dural puncture occurred. The needle was removed and general anaesthesia was initiated for surgery. On the second day post partum, the patient described a headache in both occipital area and neck that was relieved by lying down. On the seventh post-partum day she suffered tonic-clonic convulsions and underwent computerised tomography (CT). Despite different analgesic treatments and a normal CT, the patient suffered severe headaches in the following days. Magnetic resonance imaging revealed a 4-mm subdural hematoma in the right frontal area. The persisting headache decreased on day 12 and disappeared on day 14. The patient was discharged from hospital on day 15. The presence of post dural puncture headache complicated by atypical neurological deterioration following epidural anaesthesia should prompt the anaesthetist to consider the existence of intracranial complications and to seek immediate clinical and radiological diagnosis.     

Ephedrine requirements are reduced during spinal anaesthesia for caesarean section in preeclampsia

BACKGROUND: Despite controversy over the haemodynamically safest blockade for caesarean section in women with severe preeclampsia, an increasing number of anaesthetists now opt for spinal anaesthesia. In a previous study we found that spinal compared to epidural anaesthesia offered an equally safe but more effective option for these patients. The current study was designed to compare the hypotension induced by spinal anaesthesia, as measured by ephedrine requirement, between 20 normotensive and 20 severely preeclamptic but haemodynamically stabilised women. METHOD: Standardised spinal anaesthesia was instituted and ephedrine was given in boluses of 6 mg if the systolic pressure fell >20% from the baseline, or if the patient exhibited symptoms of hypotension. RESULTS: The mean ephedrine requirement of the normotensive group (27.9+/-11.6 mg) was significantly greater (P<0.01) than that of the preeclamptic group (16.4+/-15.0 mg). CONCLUSION: This suggests that the hypotension induced by spinal anaesthesia in women with severe but haemodynamically stabilised preeclampsia, is less than that of normotensive patients.     

Are urological procedures in tetraplegic patients safely performed without anesthesia? a report of three cases

Background

Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.

Case presentation

We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia. In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia. The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.

Conclusion

These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia.