Case report: Anesthetic management for sequential Cesarean delivery and laminectomy

Abstract

Purpose: To describe the anesthetic considerations for a nearterm parturient with progressive cauda equina syndrome who required Cesarean delivery followed immediately by decompression lumbar discectomy and laminectomy in the prone position. Clinical features:A 33-yr-old woman presented at 35 weeks gestation with severe L5-S1 disc herniation causing motor and sensory neuronal dysfunction in the lower limbs accompanied by bowel and bladder dysfunction. After urgent multidisciplinary consultations, a decision was made to proceed with general anesthesia for Cesarean delivery in the supine position with left uterine displacement, followed immediately thereafter by L5-S1 discectomy and laminectomy in the prone position. Anesthesia concerns included the risks of hemorrhage from the combined surgeries and upper airway edema from the prone position, and the physiologic changes of pregnancy. The surgeries proceeded without complication, and both mother and baby recovered uneventfully. Conclusion:With a multidisciplinary approach, two surgeries in two different positions with unique anesthetic considerations were performed safely under general anesthesia in advanced pregnancy in a parturient with cauda equina syndrome. F EW cases of cauda equina syndrome during pregnancy have been reported in the literature. [1][2][3][4][5] Most of these cases involved cauda equina syndrome in parturients early in pregnancy (before 24 weeks of gestation.). Recently, Brown and Brookfield reported performing a Cesarean delivery and laminectomy in a parturient who was eight months pregnant. 5 Our case report is the first to discuss the anesthetic management of a parturient at 35 weeks gestation who underwent a Cesarean delivery followed by laminectomy in the prone position under the same general anesthetic for cauda equina syndrome. The patient gave written consent for publication of this information. CASE REPORTS/CASE SERIES 471CAN J ANESTH 54: 6 www.cja-jca

Cauda equina syndrome post‐caesarean section

“…To date, discussions in the literature of disc herniation in pregnancy have largely emphasised vigilance in diagnosis and outlined the technique and safety of surgical treatment antenatally 2,3,7–9 . We report a case of cauda equina syndrome in a patient with known lumbar disc disease following caesarean delivery.…”

Presentation of cauda equina syndrome during labour

“…Beyond 34 weeks, the risk of preterm labour during surgery rises, while the risk of neonatal pulmonary compromise decreases. Therefore, in late pregnancy, delivery of the fetus prior to surgery may be preferable 16 17…”

“…Care was taken to minimise the pressure applied to the Pfannenstiel wound, to prevent dehiscence, by placing additional gel padding on top of the Montreal mattress. Al-areibi et al 16 highlighted the potential for major blood loss when operating in the immediate postpartum period as a result of engorged epidural veins. Therefore, standard precautions for expectant blood loss were taken, including performing blood grouping and sample-saving prior to surgery, and having cell salvage available in theatre.…”

The Management of Symptomatic Lumbar Disc Herniation in Pregnancy: A Systematic Review

“…20,21,33,40 Regional anesthesia is recommended for use in shorter operations. 41 General anesthesia should be used with caution in the first trimester due to an increased risk of spontaneous abortion. 42 The ACOG recommends that regional anesthesia is preferred as it reduced fetal drug exposure.…”