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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 104-106

An unexpected lumbar lesion


Department of Anaesthetics, Russells Hall Hospital, Dudley, United Kingdom

Date of Web Publication7-Oct-2016

Correspondence Address:
Dr. Laura Beard
Department of Anaesthetics, Russells Hall Hospital, Dudley
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.191596

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  Abstract 

This case report details an interesting case of suspected spinal bifida in an obstetric patient who presented for an elective cesarean section. A large scarred/dimpled area, surrounded by significant hair growth in the region of the lumbar spine had been missed in multiple antenatal and preoperative assessments and was recognized on the day of the surgery as the patient was being prepared for spinal anesthesia. The patient was uncertain regarding the pathology of the lesion, and all investigations relating to this had been undertaken in Pakistan where she lived as a child. General anesthesia was undertaken because magnetic resonance imaging had not been performed and tethering of the spinal cord could not be ruled out clinically. The patient suffered from significant blood loss intra and postoperatively, requiring a two unit blood transfusion. She was discharged after 5 days in the hospital. This case highlights the need for thorough examination in all obstetric patients presenting to the preoperative clinic, focusing on the airway, vascular access, and lumbar spine. Patients may not always disclose certain information due to a lack of understanding, embarrassment, forgetfulness, or language barriers. Significant aspects of their care may have been undertaken abroad and access to these notes is often limited. Preoperative detection of the lesion would have allowed further investigation and imaging of the lesion and enabled more comprehensive discussions with the patient regarding anesthetic options and risk.

Keywords: Obstetric anesthesia, regional anesthesia, spina bifida


How to cite this article:
Beard L, Downs A. An unexpected lumbar lesion. J Obstet Anaesth Crit Care 2016;6:104-6

How to cite this URL:
Beard L, Downs A. An unexpected lumbar lesion. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Dec 9];6:104-6. Available from: http://www.joacc.com/text.asp?2016/6/2/104/191596


  Introduction Top


Spina bifida describes a group of conditions usually categorized as spina bifida occulta and spina bifida cystica. In spina bifida occulta, there is incomplete midline fusion of the vertebral arch, and these patients are commonly asymptomatic. Spina bifida cystica is defined as failed closure of the neural arch with herniation of the meninges (meningocoele) or herniation of meninges and neural tissue (meningomyocoele), this group frequently presents with neurological symptoms.[1],[2]

The incidence of spina bifida is quoted to range from 5 to 25% of the population and is decreasing due to antenatal folate supplementation.[2],[3] Dimpling of the skin and/or a hairy region at the base of the spine may be present. There is also evidence that those with spina bifida, including the occulta variety, may have a tethered cord even when there are no neurological signs or symptoms.[3],[4]

Patients with known or suspected spina bifida requiring analgesia or anesthesia for labor and delivery present a unique set of challenges to the anesthetist. These patients require a thorough preoperative assessment and work up prior to admission. Magnetic resonance imaging (MRI) scan is often suggested prior to the performance of regional techniques to exclude the presence of a tethered spinal cord.


  Case Report Top


A 26-year-old primigravida, pregnant with twins (breech positioning), presented for an elective cesarean section. The patient was in theatre being prepared for spinal aaesthesia when the consultant anesthetist observed a large scarred and dimpled area, surrounded by significant hair growth in the region of the lumbar spine [Figure 1] and [Figure 2]. She had attended all her antenatal appointments and was seen in a preoperative clinic the day before surgery, however, the lesion was not recognized or noted in any of these encounters.
Figure 1: The patient's lumbar region

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Figure 2: A closer view of the lesion

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The patient subsequently reported possibly having had an operation on this area many years previously as a child in Pakistan but was uncertain as to the exact nature of the surgery. She stated that she had never had any neurological symptoms. There was a concern that the examination findings represented spina bifida, and as such spinal anesthesia was contraindicated without a MRI. The patient was re-consented and general anesthesia was performed.

A rapid sequence induction with thiopentone and suxamethonium was performed. Induction of anesthesia and intubation of the trachea were uneventful. Intraoperative blood loss was estimated to be 1.2 litres due to uterine atony that improved with intramuscular administration of ergometrine and carboprost. An oxytocin infusion (10 IU/h) was started and the patient transferred to a high dependency room on the delivery suite. The patient suffered a postpartum hemorrhage in the following 24 hours, losing a further 1.5 litres of blood. Her hemoglobin concentration dropped to 7.5 g/dl from a preoperative baseline of 10.7 g/dl. Her vital signs remained stable following multiple fluid boluses and a two unit red blood cell transfusion. Clotting indices, fibrinogen concentration, and platelet count were all within normal limits.

She was discharged after 5 days in hospital. The patient and her general physician were advised that, if she planned any future pregnancies, a MRI spine would be indicated to ascertain whether there was any spinal cord tethering. This would allow a decision to be made as to whether she would be suitable for spinal or epidural anaesthesia for future deliveries.


  Discussion Top


This case highlights the need for thorough examination in all obstetric patients presenting to the preoperative clinic, focusing on the airway, vascular access, and lumbar spine. Patients may not always disclose certain information due to a lack of understanding, embarrassment, forgetfulness, or language barriers. Significant aspects of their care may have been undertaken abroad and access to these notes is often limited.

Had this patient's lumbar lesion been detected preoperatively, an MRI scan could have been performed prior to her elective section. This may have enabled a subarachnoid block to have been undertaken if spinal cord tethering was excluded. There are reports of regional anesthesia being undertaken without an MRI, however, MRI scans are now commonly performed prior to neuroaxial techniques to reduce the associated risks.[4]

Because the lesion was noticed on the morning of surgery, a general anesthetic was performed. It is impossible to know how much the general anesthesia contributed to the increased blood loss, however, there is a possibility that this may have been less with a neuraxial technique.

There is little literature on spina bifida and obstetric anesthesia, which mainly consist of case reports. These reports highlight the difficulties that the anesthetist can encounter with both regional and general anesthesia in this patient group. The performance of regional anesthesia can be technically difficult due to the presence of abnormal anatomy from incomplete vertebral arch formation, muscle and ligament atrophy, and increased paravertebral fat.[2],[5] There is an increased risk of dural tap with epidural anesthesia and complications with dural spread including excessive cranial spread or incomplete caudal spread requiring a second epidural catheter below the level of the lesion.[2] A spinal catheter can be used to overcome this issue and manipulate the block height, however, there are reports of increased risk of spinal cord damage and hematoma formation with subarachnoid block compared to the general population.[5] General anesthesia obviously avoids the complications associated with regional anesthesia in this population, however, spina bifida is associated with an increased risk of difficult intubation.

This case highlights the need to recognize patients with known or suspected spina bifida preoperatively, not only to obtain further imaging (e.g. MRI) but to enable adequate discussion and consent regarding anesthesia where the complication risk is higher. A discussion detailing that regional anesthesia might take longer than expected or fail due to anatomical differences would also be necessary.

Acknowledgements

Published with the written consent of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kuczkowski KM. Labour analgesia for pregnant women with spina bifida: What does and obstetrician need to know? Arch Gynecol Obstet 2007;275:53-6.  Back to cited text no. 1
[PUBMED]    
2.
Griffiths S, Durbridge J. Anaesthetic implications of neurological disease in pregnancy. CEACCP 2011;11:157-61.  Back to cited text no. 2
    
3.
McGrady EM, Davies AG. Spina bifida occulta and epidural anaesthesia. Anaesthesia 1988;43:867-9.  Back to cited text no. 3
    
4.
May AE, Fombon FN, Francis S. UK registry of high risk obstetric anaesthesia: Report on neurological disease. Int J Obstet Anesth 2008;17:31-6.  Back to cited text no. 4
[PUBMED]    
5.
Valente A1, Frassanito L, Natale L, Draisci G. Occult spinal dysraphism in Obstatrics: A case report of caesarean section with subarachnoid anaesthesia after remifentanil infusion for labour. Case Rep Obstet Gynecol 2012;1:1-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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