spine abnormalities

68 Pages·2017·2.75 MB·English

Vem man sticka i ryggen? - spine abnormalities
Thierry Girard,

Basel Switzerland

Acta Anaesthesiol Scand 2011; 55: 910–917 r 2011 The Authors
Printed in Singapore. All rights reserved Acta Anaesthesiologica Scandinavica
r 2011 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/j.1399-6576.2011.02443.x
Review Article
Neuraxial techniques in patients with pre-existing back
impairment or prior spine interventions: a topical review
with special reference to obstetrics
1 2 3 3
M. VERCAUTEREN , P. WAETS , M. PITKA¨NEN and J. FO¨RSTER
1 2
Department of Anaesthesia, Antwerp University Hospital, Edegem, Belgium, Department of Anaesthesia, H. Hart Hospital, Lier, Belgium and
3
Department of Anaesthesia, Orthopaedic Hospital Orton, Helsinki, Finland
Many anaesthetists consider neurological disorders of all some conditions. Ultrasound technology may be of addi-
kinds as a contraindication for regional anaesthesia parti- tional help to increase the success rate. A careful pre-
cularly for neuraxial techniques. This hesitation is partly operative examination remains mandatory, while patients
rooted in fears of medicolegal problems but also in the should be sufficiently informed about technical aspects
heterogeneous literature. Therefore, the present topical and possible relapses or progression of their disease. When
review is an attempt to describe the feasibility and the necessary, patients should have additional technical and
risks of neuraxial techniques in patients with spinal injury, clinical examinations as close as possible to surgery to
anatomical compromise, chronic back pain or previous establish the actual pre-operative status. Most patients
spinal interventions, ranging from ‘minor’ types like epi- may benefit more from spinal techniques rather than
dural blood patches to major surgery such as Harrington from less reliable epidural ones. High concentrations and
fusions. Most reviews and case reports were describing volumes of local anaesthetics should be avoided at all
experiences in obstetrics as these patients are more likely times, especially in patients with nerve compression, large
to insist on neuraxial blocks. In the acute phase of new disc herniation or spinal stenosis.
neurologic injury, general anaesthesia may be the techni-
que of choice to prevent further haemodynamic and re- Accepted for publication 16 March 2011
spiratory deterioration. After the acute phase, current
r 2011 The Authors
evidence is mostly reassuring with respect to the risks of
Acta Anaesthesiologica Scandinavica
neuraxial blocks as they may even be recommendable in r 2011 The Acta Anaesthesiologica Scandinavica Foundation
T is a growing concern that neuraxial anaes- mostly inspired by anecdotal reports and studies
HERE
thetic techniques may lead to post-operative with a limited sample size.
neurological deficit or to an exacerbation of pre- Several reviews have been published during
existing neurological disorders. However, the caus- recent years on anaesthetic management of patients
1,2
ality of such post-operative deficits is not always suffering a neurological disease. The present
easy to determine. Often, regional anaesthesia is all topical review will focus on anaesthetic considera-
too easily blamed. tions rather than recommendations as regards
Many colleagues, mainly because of litigation neuraxial anaesthesia in patients with pre-existing
issues, are reluctant to consider a neuraxial techni- back problems and conditions after spinal injury or
que when there may exist whatever kind of neu- different types of spinal interventions. Mostly,
rological problem before surgery or delivery. On experiences in obstetric patients are reported be-
the other hand, not infrequently, regional anaes- cause the demand for regional anaesthesia and
thesia may be beneficial such as in the case of analgesia is more prominent as it is commonly
respiratory involvement or in obstetric patients. accepted to be safer than general anaesthesia or
As it is not always feasible to perform controlled systemic analgesia. For non-obstetrical surgery,
studies comparing general and regional techni- general anaesthesia may be an equally valuable
ques, recommendations are difficult to make and alternative in terms of safety and morbidity.
910
Vertebral column abnormalities
Examples
•
Neuraxial anaesthesia
•
• Malfusion (spina bifida)
• Trauma
• Scoliosis

International Journal of Obstetric Anesthesia (2006) 15, 233–236
! 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2005.11.002
CASE REPORT
Foot drop after spinal anesthesia in a patient
with a low-lying cord
F. U. Ahmad, P. Pandey, B. S. Sharma, A. Garg
Departments of Neurosurgery and Neuroradiology, Neurosciences Centre, All India Institute of Medical Sciences,
New Delhi, India
SUMMARY. Damage to the spinal cord/conus medullaris due to incorrect identification of the lumbar space is a
known complication of lumbar puncture. However, damage to a low-lying cord using an appropriate interspace is
extremely rare. We describe a 26-year-old woman who underwent emergency caesarean section under spinal anes-
thesia. She developed right foot drop immediately after surgery, which gradually recovered over the next 10 months.
Magnetic resonance imaging revealed a low lying cord with a fatty filum terminale and intramedullary T2 hyperin-
tensity, suggestive of needle damage.
! 2005 Elsevier Ltd. All rights reserved.
INTRODUCTION spinal Quincke needle and 1.2 mL of 0.5% bupivacaine
in the left lateral position. The patient was thin and had
Damage to the spinal cord or its tip, the conus medul- obvious surface landmarks. The needle was inserted at
laris, due to incorrect identification of the lumbar space L3-4 (estimated from the intercristal line) into the spinal
1–4
is a known complication of spinal anesthesia. Fortu- canal on first attempt. She did not experience any leg
5,6
nately, severe or disabling complications are rare. pain or paraesthesia during insertion of needle, there
Incorrect identification of the lumbar interspace is was no resistance to injection and surgery was unevent-
7,8
known to occur even with experienced anesthetists. ful. After the operation she discovered that she was un-
Also, there is some variation in the normal anatomical able to move her right ankle. She presented to us one
9
position of the conus. Intuitively, the risk of direct dam- month after caesarean section with right foot drop and
age to the cord might be expected to be greater in pa- some numbness in the right lateral aspect of her ankle.
tients with a low-lying cord, even with correct There were no urinary or bowel complaints. Neurologi-
identification of the lumbar space. To the authors! cal examination revealed hypotonia and motor power
knowledge, only one similar case has been reported in grade 1/5 in the dorsiflexors of right ankle. The tone
10
English literature. and power in other muscle groups in the right lower limb
and other limbs was normal. She walked with a high
stepping gait, and had hypoaesthesia in the right L5 der-
CASE REPORT matome. The deep tendon reflex was absent in the right
ankle; the rest were normal.
A 26-year-old female underwent elective caesarean sec- Magnetic resonance imaging (MRI) revealed a low
tion. Spinal anesthesia was given using a 22-gauge lying spinal cord with its tip at L4 and a fatty filum ter-
minale (bright signal on T1-weighted image) (Fig. 1a)
tethered to a CSF-isointense intradural cyst at S3 level
Accepted November 2005
(Fig. 1a, b). The spinal cord between L1 and L3 showed
F.U. Ahmad, P. Pandey, B.S. Sharma, Professor of Neurosurgery,
a linear intramedullary hyperintensity in T2-weighted
Departments of Neurosurgery and A. Garg, Department of
Neuroradiology, Neurosciences Centre, All India Institute of Medical image (Fig. 1b). MR myelogram revealed a longitudinal
Sciences, New Delhi 110029, India.
syrinx within the lower spinal cord at the level of L1 to
Correspondence to: B.S. Sharma, Professor of Neurosurgery, L3 vertebrae (Fig. 2). Over the next six months there
Neurosciences Centre, All India Institute of Medical Sciences, New
was significant spontaneous motor recovery to grade
Delhi 110029, India. Tel.: [phone]; fax: [phone].
4/5 in her right ankle.
E-mail: [email protected].
233
234 International Journal of Obstetric Anesthesia
Int J Obstet Anesth. 2006;15(3):233–6.
Fig. 1 Sagittal T1-weighted (a) and T2-weighted (b) lumbosacral MRI show low lying spinal cord at L4 level. The filum is thick and fatty (white
arrow in figure 1a) and is attached to a CSF-isointense intradural cyst at S3 level (black arrow in Fig. 1a and b). The spinal cord showed increased
signal between L1 to L3 level on T2 (white arrow in Fig. b).
1
DISCUSSION UK. All patients were women, six obstetric and one
surgical. All women experienced pain while inserting
With the introduction of atraumatic needles and the use the needle, which was usually believed to be inserted
of better anesthetic solutions, spinal anesthesia has be- at L2-3. Unilateral sensory loss persisted in all, six
come the most popular form of anesthesia for cesarean had foot drop and three had urinary symptoms. MRI
11
section. Several potentially devastating neurological showed a spinal cord of normal length in all, while six
complications can occur following spinal and epidural patients had a syrinx in the conus. She recommended
anesthesia, including spinal cord or nerve root injury that utmost care be taken in identifying the interspaces
from direct needle puncture, local anesthetic toxicity, and that anesthetists need to relearn the rule that a spinal
spinal epidural or subdural hematoma, epidural abscess, needle should never be inserted above L3.
4
bacterial or aseptic meningitis and anterior spinal artery Hamandi et al. reported five patients with damage to
syndrome. Fortunately, the incidence of such complica- the distal spinal cord following spinal anesthesia. The
tions is rare. In the largest prospective study, Auroy patients developed leg weakness and sensory distur-
5
et al. noted the total incidence of neurological sequelae bances. MRI showed an abnormal area of high signal
to be 6 in10 000 spinal anesthestics, with permanent def- within the conus medullaris in all patients. Wegner
6 10
icits occurring in <1:10000. Aromaa et al. reported a et al. described an adult patient in whom previously
complication rate after epidural anesthesia of 0.35 in undiagnosed diastematomyelia, a low conus and teth-
10000 and after spinal anesthesia to be 0.42 in 10000. ered cord were diagnosed only when neurological symp-
There have been several reports of spinal cord dam- toms followed spinal anesthesia.
1–4,12,13
age after spinal anesthesia. Reynolds presented Though many anesthetists are confident that they can
seven cases of conus medullaris damage following identify lumbar interspaces accurately, in a study with
7
spinal anesthesia, collected over an eight-year period humbling results, Broadbent et al. found that when a
through medico-legal work from different parts of the group of experienced anesthetists believed that they
Spina bifida, tethered cord and regional
anaesthesia
25 weeks gestation, vaginal bleeding

•
premature rupture of membranes
Spina bifida occulta
•
Bladder surgery @ age 4
•
self-catheterised
•
Regional anaesthesia considered possible (other hospital)
•
Anaesthesia.2005;60(11):1149–50.
Anaesthesia.2005;60(11):1149–50.
Tethered cord
Correspondence Anaesthesia, 2005, 60, pages 1144–1155
......................................................................................................................................................................................................................
a maximum exercise tolerance of 50
yards on the flat and was on supple-
mental home oxygen. On examination,
she was short of breath on minimal
exertion, with a respiratory rate of 32
breaths per minute, a peripheral blood
oxygen saturation of 90% on air, fine
«…spontaneous vaginal
bibasal crepitations, and a scattered
wheeze. In view of her poor cardio-
delivery a few hours
respiratory function, but in light of
potentially curative surgery and after a
later…»
lengthy discussion with the patient, her
daughter and the surgeon, we decided
to perform the procedure under an
interpleural block with sedation.
Full monitoring and intravenous
access were established, and the patient
was positioned in the right lateral posi-
tion. The sixth rib was identified, and
5 ml lidocaine 2% was infiltrated into
the skin, subcutaneous tissues and down
to the periosteum. A 19 G Tuohy
Figure 3 MRI scan showing tethered cord (arrowed).
needle, attached to a continuous infu-
sion of normal saline for detection of
loss of resistance [1], was introduced at
to carry out regional anaesthetic tech- Anesthesia: Principles and Practice, 2nd the angle of the rib and walked off the
niques. edn. St. Louis: Mosby, 1999: 956–8. upper border until loss of resistance was
Spinal bifida occulta is present in up to 2 James CCM, Lassman LPS. Introduction achieved. A reinforced epidural catheter
20% of the general population [4] and is and Pathology, Spina Bifida Occulta. was then inserted with ease, and secured
thought to be a normal variant. In its true London: Academic Press, 1981: 1–7. with the tip 13 cm from the skin. The
form it involves failure of fusion of only 3 James HE, Wash F. Spinal dysraphism. patient was maintained in the right
one arch, there is no external lesion and Current Problems in Paediatrics 1981; 11: lateral position, and 20 ml bupivacaine
spinal cord and nerves are normal. It is 1–25. 0.25% with 1 : 200 000 epinephrine
often picked up as an incidental radio- 4 Page LK. Occult spinal dysraphism and was injected through the catheter.
logical finding. In these cases spinal or related disorders. In: Wilkins RH, Surgery commenced 20 min later, with
epidural techniques are usually uncom- Rengachary SS, eds. Neurosurgery. New the patient placed semi-recumbent.
plicated and it is recommended that the York: McGraw-Hill, 1985: 2053–7. During the procedure, the regional
block should be performed above the 5 Vaagenes P, Fjaerestad I. Epidural block was supplemented with ketamine
level of the lesion [5]. However, in a block during labour in a patient with 30 mg, midazolam 0.4 mg, and alfent-
)1
patient with spina bifida occulta the spina bifida cystica. Anaesthesia 1981; anil 0.1 mg, and oxygen at 2 l.min .
possibility of spinal dysraphism should 36: 299–301. A further 10 ml bupivacaine 0.25%
always be kept in mind. Patients with 6 Wood GG, Jacka MJ. Spinal hematoma with 1 : 200 000 epinephrine was
neurological abnormalities, cutaneous following spinal anesthesia in a patient required in recovery, and an infusion
manifestations or involvement of more with spina bifida occulta. Anesthesiology of bupivacaine 0.25% was commenced
)1
than one lamina may have a tethered 1997; 87: 983–4. at 5 ml.h for postoperative analgesia
cord and it is incumbent upon the for 48 h. The patient also received
anaesthetist to understand fully the ter- paracetamol. A chest X-ray taken in
minology and extent of the defect before recovery demonstrated satisfactory posi-
Interpleural anaesthesia for
performing neuraxial anaesthesia [6]. tioning of the intrapleural catheter,
mastectomy
without evidence of a pneumothorax.
L. Ali
The patient was discharged on the
G. M. Stocks
An 83-year-old lady with a complex
third postoperative day following an
Queen Charlotte’s & Chelsea Hospital
medical history presented for a left-
uneventful recovery.
London, UK
sided mastectomy for invasive adeno-
Interpleural regional analgesia is a
carcinoma. She had severe chronic
well established method of providing
References obstructive pulmonary disease, paroxys-
both intra- and postoperative pain relief
1 Crosby ET. Musculoskeletal disorders. mal atrial fibrillation, and ischaemic
for breast surgery [2], open cholecys-
In: Chestnut DH, ed. Obstetric heart disease and orthopnoea. She had
1150
! 2005 Blackwell Publishing Ltd
Anaesthesia.2005;60(11):1149–50.
«…Although the patient told us that she had spina
bifida occulta, in fact she probably had occult
spinal dysraphism. Confusingly, the terms spinal
bifida occulta and occult spinal dysraphism are
often used interchangeably, but spinal dysraphism
is not a benign entity like spina bifida occulta…»