Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele

NS. Sushmithaa, K. Senthil Kumar

Department of Anaesthesia, Kauvery Hospitals, Trichy

*Correspondence: [email protected]

Abstract

Spina bifida is a condition where the developing spine fails to completely enclose the neural elements in a bony canal. Failed fusion of neural arch without herniation of meninges is called as Spina Bifida Occulta. Failed fusion of neural arch with herniation of meninges is Meningocele or with herniation of meninges and neural elements- Myelomeningocele, it is called as Spina Bifida Cystica. It may occur due to multifactorial causes like nutritional, environmental and familial risk factors. Family history of neural tube defects and folate deficiency also increases the incidence of this condition. Hence, we report a case of Spina Bifida with operated Myelomeningocele with sacral bedsores due to chronic bedridden state posted for wound debridement.

Keywords: Spina Bifida Occulta, Spina Bifida Cystica, Myelomeningocele

Background

Neuraxial anaesthesia for patients with spinal abnormalities poses a great challenge for Anaesthesiologists because of their anatomical distortion. Concern exists about Neuraxial anaesthesia in patients with spinal cord deformities due to their risk of neurological complications-, Spinal Cord infarction, Aseptic Meningitis and limb damage. Risk-Benefit Analysis is always considered in such situations to arrive at a conclusive decision.

Case Presentation

Benefits-outweighing-risk-1

Fig. 1. A 45-year-old gentleman presented with complaints of bed sores in the ischial region because of his chronic bedridden state.

He was known to have COPD and anaemia. He was operated for Meningomyelocele on the 3rd day after his birth. On physical examination, he looked lean and inspection of spinal region revealed dorsolumbar scoliosis.

Benefits-outweighing-risk-2
Benefits-outweighing-risk-3

Figs. 2 and 3. Kypho-scoliotic dorsal spines and defective bony architecture in lumbar region.

On clinical assessment,

BPtd>
PRtd>
RRtd>
SPO2td>
TEMPERATUREtd>
GCStd>
125/95mmhgtd>
98/mintd>
23/mintd>
96% on RAtd>
97.5 Ftd>
15/15td>
Benefits-outweighing-risk-4

Fig. 4. He had Grade 3 Pressure ulcers over the sacral region.

He was planned for wound debridement of pressure ulcers over the sacral region under spinal anaesthesia after obtaining relevant investigations and appropriate consent.

Under ultrasound guidance, interspinous space was visualized in L1-L2-L3 level. The patient was positioned in left lateral position and after adequate skin preparation, 27 Gauge Whitacre spinal needle was inserted in midline approach for intrathecal injection of 1.8 ml of 0.5% hyperbaric bupivacaine with fentanyl to maintain an adequate level and to have reduced intraoperative hemodynamic swings. After 15 minutes, the blockade level was upto T6. The patient was positioned in left lateral position for the procedure. The surgery was uneventful. Post operative hemodynamics and his respiration were also stable.

Benefits-outweighing-risk-5
Benefits-outweighing-risk-6

Figs. 5 and 6. USG low back showing direct CSF space with no bondy architecture.

Benefits-outweighing-risk-7
Benefits-outweighing-risk-8

Figs. 7 and 8. Spinal anaesthesia performed after confirming the anatomy with USG.

Discussion

Anaesthetic considerations in patients with spina bifida are,

  1. Latex sensitivity
  2. Neurological deficits
  3. Hydrocephalus
  4. Increased ICP, VP shunt
  5. Bowel and Bladder dysfunction
  6. Flaccid paralysis
  7. Autonomic hyper reflexia

While deciding the plan of anaesthesia various factors like pulmonary conditions of the patient, effects of drugs used in general anaesthesia, resistance to non-depolarizing muscle relaxants were looked for. CT chest of the patient revealed bronchiectasis. Since the benefits in neuraxial anaesthesia overweighed the risks, spinal anaesthesia was performed in this patient with adequate measures for general anaesthesia as a backup plan.

Conclusion

Hence in our case, patient successfully underwent the procedure under Neuraxial anaesthesia without any complications.

References

  1. O’Neal MA. A pregnant woman with spina bifida: need for a multidisciplinary labor plan. Front Med. 2017;4:172.
  2. Gilbert JN, et al. Central nervous system anomalies associated with meningomyelocele, hydrocephalus, and the Arnold-Chiari malformation: reappraisal of theories regarding the pathogenesis of posterior neural tube closure defects. Neurosurgery. 1986;18(5):559-64.

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