Spina bifida and epidural anaesthesia

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  • Myeloschisis or myeolocele : Myelomeningocele : Most common form, Cystic swelling lined by dura and arachnoid, protruding though a defect in the vertebral arches, Spinal cord & nerve roots are carried out into the fundus of the sac, The terms Spina Bifida and Myelomeningocele are often used interchangeably. most severe form, deficiency of vertebral arches, neural plate material spread out on the surface, in a shallow depression or over a cystic swelling of the meninges. Meningocele : Cystic swelling of dura and arachnoid protruding though a defect in the vertebral arches. The spinal cord is entirely confined within the vertebral arches but may show abnormalities.
  • With constant improvements in medical and surgical care, and subsequent decreases in spina bifida-related mortality and morbidity many women with these defects are reaching childbearing age. There may be no external lesion, in spina bifida occulta and the overlaying skin usually remains intact, it is not associated with any neurological symptoms and is often an incidental radiological finding.
  • The use of continuous epidural, caudal, and spinal analgesia, paravertebral sympathetic and paracervical blocks, and intravenous patient-controlled analgesia have been reported in pregnant women with spina bifida, however, all of these techniques have been associated with number of limitations, and complications.
  • Most common site for spina bifida occulta lesion is L5 S1 vertebral level which is below the level of spinal or epidural block. Spinal and epidural techniques are usually uncomplicated. However, it is recommended that the block be performed above the level of the lesion. It is also important that the possibility of patchy or higher blockade than normal in these parturients be kept in mind
  • Vaagenes and Fjaerestad described a parturient with lumbosacral meningocele (status post corrective surgery in the neonatal period) who received a lumbar epidural analgesia for pain relief in labour. Although a high intervertebral level was chosen for the epidural needle placement, deficiency of the dorsal interspinous layer of ligaments complicated the localization of the epidural space (loss of resistance technique was used). The authors noted that analgesia was accomplished very rapidly and with a lower dose of analgesic than is usually required in healthy parturients.
  • Tidmarsh and May conducted a retrospective chart review study of the anaesthetic management during labour of 16 patients with spina bifida who delivered at their tertiary care centre between March 1994 and February 1996. Of these 16 patients, 10 received an epidural analgesia for labour. Of the 10 epidurals, six resulted in symmetrical sensory block. In each case the sensory block did not extend above T10. Of the remaining four epidurals there was one dural puncture, one asymmetric block, one excessively high block, and one failure of the block to extend below the level of the spinal defect. The authors concluded that the conduct of epidural analgesia in patients with spina bifida can be technically difficult, and results often unpredictable (e.g., excessive cranial/poor perineal spread of local anaesthetics, and/or asymmetric block) .
  • The authors conSuelto and Shaw reported on the use of paravertebral lumbar sympathetic block (LSB) for labour analgesia (in the first stage of labour) in two parturients with spina bifidacluded that LSB should be considered in pregnant women with spina bifida where epidural analgesia may be precluded, however, cautioned about the limitations of LSB for labour analgesia. These limitations include short duration of action, and absence of continuous labour analgesia, and thus the subsequent need for a second anaesthetic during the second stage of labour . Other concerns associated with LSB in parturients are increased pain during placement of the block when compared to epidural anaesthesia, and maternal hypotension.
  • d/d of pdph : Pre eclampsia Tention headache Migraine Subdural haematoma Cerebral vein thrombosis Sah Meningitis Cerebral tumour Anxiety and depression Hypoglycemia Electrolyte imbalance. 70% success rate after blood patch. Repeat dural blood patch at 18 hours if needed. Analgesics NSAIDS/OPIOIDS AS NEEDED. Caffeine sod.benzoate 500mg in 1 lt of NS infused over 1 hour. 300 mg oral caffeine. Theophylline/sumatryptan. Initially 3 to 8 ml of blood used but now 15 ml to 20 ml. If blood patch done prophylactically only 10% develop headache. Saline patch 40 ml saline followed by 40ml/hr infusion for 12 hrs-24 hrs or 20 ml-30 ml dextran . Effective for short term but pdph recurs once infusion stopped. Complications of dural patch: Redo puncture 35% report back pain Neck pain/leg pain/parasthesia/radiculitis/fever/temorary cranial nerve palsies. Blood patch effective in 95% times.
  • Spina bifida and epidural anaesthesia

    1. 1. Dr Wahid altaf. Dr Gabriella Iohom. Cork University Hospital.
    2. 2. Case Report <ul><li>24 year old Primi gravida fit and healthy woman,56 kg and 168 cm was admitted at term with spontaneous rupture of membranes. </li></ul><ul><li>Her past history included diagnosis of spina bifida occulta as a child with no follow up. No pregnancy related problems. </li></ul><ul><li>A plan was developed by obstetrics and anaesthesia called for vaginal delivery with regional anaesthesia. </li></ul>
    3. 3. Anaesthetic evaluation . <ul><li>ASA Grade 1 patient. </li></ul><ul><li>Past medical history: Spina bifida occulta with no follow up or investigation results available. </li></ul><ul><li>No known drug allergies. </li></ul><ul><li>Hairy patch on skin of sacral region. </li></ul>
    4. 4. Anaesthetic management. <ul><li>. After proper explanation of epidural anaesthesia and associated risks especially with spina bifida she was consented . </li></ul><ul><li>. Regular blood pressure monitoring was started. </li></ul><ul><li>. Sixteen gauge iv canula on left hand with one litre of Hartman’s solution was started. </li></ul>
    5. 5. <ul><li>Aseptic technique. </li></ul><ul><li>Sitting position.L2-3 space used. </li></ul><ul><li>18 G Tuohy needle with LOR to air technique used. </li></ul><ul><li>At 2 cm from tip of needle free flow CSF noted. </li></ul><ul><li>Needle removed promptly. </li></ul>
    6. 6. <ul><li>Site of needle insertion changed to L3-4. </li></ul><ul><li>Loss of resistance to water at 2 cm from tip of needle. No free flow CSF. </li></ul><ul><li>Epidural end hole catheter was secured after threading 4cm into the epidural space. </li></ul><ul><li>Test dose of 2 % Lignocaine lead to heavy legs . </li></ul><ul><li>5 ml of .25% L-bupivacaine used as first top-up </li></ul>
    7. 7. <ul><li>Good pain relief for the whole duration of labour and patient delivered vaginally a female baby after 5 hours of epidural. </li></ul><ul><li>Patient discharged to ward from the labour room after removing the epidural catheter. </li></ul>
    8. 8. Next Morning <ul><li>C/O Symptoms suggestive of Post Dural puncture headache. </li></ul><ul><li>Management of Dural tap discussed with patient. </li></ul><ul><li>After 12 hours patient still complaining of headache which was worse now. </li></ul><ul><li>Blood patch discussed. </li></ul>
    9. 9. Blood patch. <ul><li>White cell count and temperature of patient normal. </li></ul><ul><li>Prophylactic Intravenous antibiotics given. </li></ul><ul><li>Patient positioned in right lateral position. </li></ul><ul><li>Aseptic precautions. </li></ul><ul><li>18 g Tuohy needle at L3-4 space with LOR to air used to locate epidural space. Epidural space located at 2 cm from needle tip. </li></ul>
    10. 10. <ul><li>After 15 ml of autologous blood was injected into epidural space patient complained of discomfort in back and the injection was stopped. </li></ul><ul><li>Patient advised bed rest for 4 hours and to avoid straining for 12 hours. </li></ul>
    11. 11. On follow up <ul><li>No headache or neck stiffness after the blood patch. </li></ul><ul><li>Patient discharged home next day. </li></ul>
    12. 12. Spina bifida.
    13. 13. General Facts <ul><li>Spina bifida : </li></ul><ul><li>- group of disorders including failure of development of vertebral arches and abnormalities in the development of structures derived from the neural tube & the meninges. </li></ul><ul><li>Neural tube defect : congenital anomaly, abnormal closure of the neural tube. </li></ul><ul><li>- abnormal innervations of the organs supplied by the affected part of the spinal cord. </li></ul><ul><li>- Multiple organ involvement : effects on the bladder and bowel & denervation of muscles+sensory organs. </li></ul>
    14. 14. Aetiology <ul><li>Multifactorial pattern of inheritance. </li></ul><ul><li>The inheritence seems to be polygenic. </li></ul><ul><li>Environmental factors : </li></ul><ul><ul><li>Folate deficiency & other vitamins </li></ul></ul><ul><ul><li>Absence of selenium from the regional soil </li></ul></ul><ul><ul><li>Poor maternal nutrition </li></ul></ul><ul><ul><li>High maternal alcohol intake </li></ul></ul><ul><ul><li>Maternal diabetes mellitus </li></ul></ul><ul><ul><li>Fever at a critical stage of pregnancy and other factors. </li></ul></ul>
    15. 15. Incidence <ul><li>Varies in différent areas. </li></ul><ul><li>Racial différences and seasonal variations. </li></ul><ul><li>Highest incidence : Ireland, Wales, North of England : 5 per 1000 live births . </li></ul><ul><li>Compared to North America & Australia : less than 1 per 1000 live births. </li></ul>
    16. 16. Pathology <ul><li>2 conditions due to abnormalities of separation of the skin from neural tissue during the closure of the neural tube : </li></ul><ul><li>Spina bifida cystica (a visible cyst is present). </li></ul><ul><li>Spina bifida occulta : </li></ul><ul><ul><li>Hidden defect </li></ul></ul><ul><ul><li>Suspicion based on presence of a dimple, patch of hair, pigmentation or a lipoma. </li></ul></ul>
    17. 19. <ul><li>Many women with these defects are reaching childbearing age. </li></ul><ul><li>Spina bifida occulta a hidden defect. </li></ul>
    18. 20. <ul><li>Labour analgesia in pregnant women with spina bifida continues to be a challenge. </li></ul><ul><li>Debate on different types of analgesia techniques for labour offered. </li></ul><ul><li>Specific guidelines for administration of labour analgesia in these patients are not available. </li></ul>
    19. 21. Neuraxial anaesthetic considerations in patients with spina bifida occulta. <ul><li>Most common site for spina bifida occulta lesion is L5 S1 vertebral level. </li></ul><ul><li>Spinal and epidural techniques are usually uncomplicated. </li></ul><ul><li>It is recommended that the block be performed above the level of the lesion. </li></ul><ul><li>Possibility of patchy or higher blockade than normal. </li></ul>
    20. 22. <ul><li>Vaagenes and Fjaerestad described an epidural in a parturient with spina bifida occulta where analgesia was accomplished very rapidly and with a lower dose of analgesic than is usually required in healthy parturients. </li></ul>
    21. 23. Tidmarsh and May study of the anaesthetic management during labour of 16 patients with spina bifida <ul><li>Of the 10 epidurals </li></ul><ul><li>six resulted in symmetrical sensory block. </li></ul><ul><li>one Dural puncture. </li></ul><ul><li>one asymmetric block. </li></ul><ul><li>one excessively high block. </li></ul><ul><li>one failure of the block to extend below the level of the spinal defect. </li></ul><ul><li>Conclusion :Epidural analgesia in patients with spina bifida can be technically difficult, and results often unpredictable. </li></ul>
    22. 24. Conselto and Shaw reported use of paravertebral lumbar sympathetic block. <ul><li>They Concluded that LSB should be considered in pregnant women with spina bifida where epidural analgesia may be precluded, however, cautioned about the limitations of LSB for labour analgesia. </li></ul><ul><li>Short duration of action, and absence of continuous labour analgesia, need for a second anaesthetic during the second stage of labour , increased pain during placement of the block when compared to epidural anaesthesia, and maternal hypotension. </li></ul>
    23. 25. Ultrasound in Epidural block <ul><li>Easily accessible tool. </li></ul><ul><li>Removes guesswork. </li></ul><ul><li>Increases accuracy in locating vertebral interspace. </li></ul><ul><li>Depth estimation to expect loss of resistance. </li></ul>
    24. 26. Management of Dural tap. <ul><li>Typical symptoms. </li></ul><ul><li>Rule out other causes. </li></ul><ul><li>Left untreated: 75% resolve in 1 week, 88% by 6 weeks. </li></ul><ul><li>Conservative treatment: Adequate hydration, regular analgesics, bed rest. </li></ul><ul><li>Epidural blood patch remains gold standard but not without complications. </li></ul><ul><li>Use blood patch as treatment or prophylactic tool. </li></ul><ul><li>Saline/ low molecular weight dextran patch. </li></ul>
    25. 27. <ul><li>Given the complexity and heterogeneity of these defects, the most prudent approach to labour analgesia in pregnant woman with spina bifida is one of individuality. </li></ul>
    26. 28. Thanks. <ul><li>Any Questions </li></ul>

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