labor analgesia for the parturient with scoliosis & previous back surgery samina ismail...
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Labor analgesia for the parturient with scoliosis & previous back surgery
Samina IsmailAssociate ProfessorAga Khan University
Karachi, Pakistan
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Road Map
• What is Scoliosis?• Challenges faced during provision of labour
analgesia.• Is neuraxial technique possible for these
patients?• What are other options of pain relief.• Labour analgesia for patents with neural tube
defect
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What is “Scoliosis”?
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Thoracic Scoliosis Lumbar Scoliosis
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Severity of Scoliosis
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Curve of >400 require surgical correction
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• Evaluation of any associated cardiopulmonary and musculoskeletal disease.
• Evaluation of operative and radiographic reports in assessing the location and extend of vertebral anomalies.
• Discussion with the patient and family of different options of labor analgesia.
• Explanation of risk and benefits of labor epidurals.• Counseling for the possible failures of techniques.
These patients requiring obstetric anaesthesia services should be referred early in the preoperative anesthesia clinic for:
May have severe cardiopulmonary dysfunction
Increase chances in patients with neuromuscular disease
Unlike if correction is done during teenage years.
When refused by patients or technically impossible.
Intravenous PCIA is the “next –best” choice- fentanyl/ remifentanil are commonly used drugs.Fentanyl:Loading dose 50-100mcgBolus 20-40 mcgLock out time 5-10 minutesRemifentanil:Basal infusion 0-0.05 mcg/kg/minBolus 25-50 mcgLock out time 5 minutes
Evron S, Ezri T. Options for systemic labour analgesia. Curr Opin Anaesthesiol 2007; 20 :181
Explanation of risk & benefits:Failure of technique.Inadequate analgesiaIncrease likelihood of dural punctureLess potential for successfully treating PDPHHigh blockRisk of infection in case of previous surgery
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Challenges Faced!!
In providing neuraxial analgesia for patients with or without corrective surgery are:
inability to identify the epidural spacemultiple attempts before catheter insertionpatchy analgesia accidental dural puncture
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The anatomic anomalies leading to these challenges are as follow:
Distortion or absence of spinous processes, which is the key landmark of placement of neuraxial anesthesia; therefore palpation is not always the best method for the identification of space.
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In uncorrected scoliosis, there is deviation of the midline of the epidural space towards the convex aspect of the scoliosis relative to the spinous process.
In the uncorrected patient the needle should be oriented towards the convexity of the curve where the interlaminar spaces are generally larger
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Spinal surgery involves decortication of vertebrae and removal of spinous process along the extent of the curve Scar tissue in post surgical patient and bone grafts can hinder the entry of neuraxial needles into the desired space Patient with Harrington rod are unable to flex their spine.Postoperative adhesion or obliteration of the epidural space can interfere with local anesthetic spread and increase chances of inadvertent dural puncture and inadequate anesthesia
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Is neuraxial technique possible in these patients?
Despite these difficulties, successful spinal and epidural have been reported in parturient with corrected and uncorrected scoliosis.
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First two reports in 1985
Labor pain relief in patients with previous spinal instrumentation
Feldstein G, Ramanathan S. Obstetrical lumbar epidural anesthesia in patients with previous posterior spinal fusion for
khyphoscolisis. Anes Analg. 1985.
Hubbert CH. Epidural anaesthesia in patients with spinal fusion. Anes Analg. 1985.
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Successful epidural analgesia is reported in the range of 42-94%.
Can J Anesth 1989Reg Anesth 1990
Anesth Analg 2009
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Literature Review
22 articles reported 117 neuraxial techniques in parturient.
Ko J Y, Leffert R L. Clinical implication of neuraxial
anaesthesia in parturient with scoliosis. Anesth Analg 2009
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n=93
n=24
n=117
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24190
93642
Persistent back pain after epidural placement of unknown
etiology
Outcomes of Neuraxial Procedures
79%
69%
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Trouble shooting in case of inability or ineffective functioning of labor epidural:
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Ultrasonography may be helpful tool in defining the relevant anatomy at the time of initiation of neuraxial
anesthesia
Normal Spine Scoliotic Spine
Can J Anaesth 2005;52:717-20.
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In the uncorrected patient the needle should be oriented towards the convexity of the curve where the interlaminar spaces are generally larger
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In case of unilateral block due to rotation of the spine :
Patient can be paced in the lateral position with the less blocked side in the dependent position.
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In case of patchy block:
Large volume / low concentration LA may overcome the problem.
Placement of additional epidural catheter at the level of the unblocked dermatome has been described .
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Spinal Anaesthesia
• The absence of scarring within the intrathecal space ensures unhindered spread of local anesthetic in post spinal surgery patient.
• The dose of spinal anesthetic should be reduced to half, if is used after a failed epidural
Dadarkar P, Philips J, Werdner C, Perz B, Slaymarker E, TabaczewaskaL, Wiley J, Sharma S. Spinal Anaesthesia for cesarean section following inadequate labor analgesia: a retrospective analysis. Int J Obstet Anesth 2004; 13 (4):239-43.
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Labor analgesia for spina bifida.
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What is Spina Bifida?
Type of neural tube defect (incidence 1/1000).Group of condition categorized into:Spina bifida occulta.Spina bifida cystica
Spina bifida occulta
Meningocele
Meningomyeloele
Spina bifida cysticaSpina bifida oculta
arises when the two halves of the vertebral arch fail
to fuse in the midline.
The spinal cord and nerve roots are
normal. There is no external lesion.
Spina bifida cystica is the more severe form and is defined as failed closure of neural
arch with herniation of meninges (meningocele), the meninges and neural
elements (meningomyelocele
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Meningomyeloele
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Failure of neural folds to
fuse myeloschisis
Most severe form of Spina Bifida Cystica: Myeloschisis
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Preoperative Anesthesia Evaluation
• Medical history : Coexisting defects in the genitourinary, respiratory, musculoskeletal and cardiovascular systems.
• Degree of neurological impairment must be precisely defined by imaging studies :
plain radiographs computerized tomography ideally before magnetic resonance pregnancy
delineate the exact location of the spinal defects, its extent, and will provide some guidance for the placement
of epidural for labor. Kuczkowski KM. Labor Analgesia for pregnant women with
spina bifida: What does an obstetrician needs to know? Arch Gynecol Obstet 2007 ;275: 53-66.
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How to provide labour analgesia?
• No specific guidelines for administration of labour analgesia.
• Regional techniques have been reported but with limitations and complications.
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conducted retrospective chart reviews of the anesthetic management during labor of 16 patients. The authors
concluded that the conduct of epidural analgesia in patients can be technically difficult and results often unpredictable
(e.g., excessive cranial/ poor perineal spread of local anesthetic and /or asymmetric block
Tidmarsh, May AE Epidural anaesthesia and nural tube defects. Int J Obstet Anaesth 1998; 7:111-14.
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International Journal of Obstetric AnesthesiaVolume 18, Issue 3, July 2009, Pages 258-261
Adjunct to unsatisfactory fentanyl IVPCA is reported in a 31-year-old parturient with spina bifida occulta and a tethered spinal cord reaching L5-S1.
Dexmedetomidine significantly improved the analgesic quality; increased sedation was observed, but the patient was easily rousable to verbal stimuli.
No episodes of maternal hypotension or bradycardia, or fetal heart rate irregularities occurred.
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Conclusion:
• Providing labor analgesia for these patients, pose lots of challenges to the obstetric anesthetists.
• Every patient needs to be individualized.• Assessment in the preoperative clinic for associated
medical problems and extend of lesion. • Understanding the anatomic anomalies in these
patients helps in the institution of neuraxial anesthesia.• Since regional technique is the ideal method of labor
analgesia, these patients should be given a trail after proper planning .
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Anatomical deformity should not be hindrance for the provision of pain relief for laboring
women
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In January 19, 1847 first anaesthesia using diethyl ether was used by Simpson to anaesthetize a woman with deformed pelvis.
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Remember!
“The delivery of an infant into the arms of a conscious and pain free mother is one of the most exciting and rewarding moment in medicine”
Moir DD - 1979
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Thank You