Cesarean section in a patient with syringomyelia

Management of Chiari malformation type I and syringomyelia during pregnancy and delivery

OBJECTIVE

Although a recurrent question in clinical practice, the management of Chiari malformation type I (CMI) and/or syringomyelia during pregnancy and delivery is still debated. The aim of this study was to investigate the modalities of delivery and anesthesia in women presenting with CMI and/or syringomyelia at a national reference center, and to question their potential role in the natural history of these conditions.

STUDY DESIGN

We conducted a retrospective cohort study using a standardized questionnaire, a customized clinical severity score and data from medical records.

RESULTS

83 patients were included in the final analysis: 32 had CMI without syringomyelia, 27 had CMI with syringomyelia and 24 had non-foraminal syringomyelia. Most patients (55/83) were not diagnosed at the time of their pregnancy, 12 had surgery before being pregnant and 16 were diagnosed but not operated. Most women underwent vaginal delivery (62 %) and neuraxial (i.e. epidural or spinal) anesthesia (69 %). However, the proportion of cesarean procedures increased to 53.6 % and even 83.3 % when considering only patients already diagnosed or operated on, respectively. Nonetheless, neither vaginal compared to cesarean delivery (change in clinically severity score: -1.5 ± 0.4 versus -0.9 ± 0.4, p = 0.4) nor neuraxial compared to general anesthesia (-1.2 ± 0.3 versus -1.5 ± 0.6, p = 0.7) were associated with increased clinical deterioration.

CONCLUSION

Although individual evaluation is mandatory, this study supports that neither delivery nor anesthesia modalities affect the natural history for the vast majority of patients with CMI and/or syringomyelia.

Combined spinal-epidural analgesia for laboring parturient with Arnold-Chiari type I malformation: a case report and a review of the literature

Anesthetic management of laboring parturients with Arnold-Chiari type I malformation poses a difficult challenge for the anesthesiologist. The increase in intracranial pressure during uterine contractions, coughing, valsalva maneuvers, and expulsion of the fetus can be detrimental to the mother during the process of labor and delivery. No concrete evidence has implicated high cerebral spinal fluid pressure on maternal and fetal complications. The literature on the use of neuraxial techniques for managing parturients with Arnold-Chiari is extremely scarce. While most anesthesiologists advocate epidural analgesia for management of labor pain and spinal anesthesia for cesarean section, we are the first to report the use of combined spinal-epidural analgesia for managing labor pain in a pregnant woman with Arnold-Chiari type I malformation. Also, we have reviewed the literature and presented information from case reports and case series to support the safe usage of neuraxial techniques in these patients.

Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia

Background:

Type I Arnold–Chiari malformation (ACM) has an adult onset and consists of a downward displacement of the cerebellar tonsils and the medulla through the foramen magnum. There is paucity of literature on the anesthetic management during pregnancy of residual ACM Type I, with cervical xyphosis and persistent syringomyelia.

Case Description:

A 34-year-old woman with surgically corrected ACM Type I presented for Cesarean delivery. A recent MRI demonstrated worsening of cervical xyphosis after several laminectomies and residual syringomyelia besides syringopleural shunt. Awake fiberoptic intubation was performed under generous topical anesthesia to minimize head and neck movement during endotracheal intubation. We used a multimodal general anesthesia without neuromuscular blockade. The neck was maintained in a neutral position. Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

Conclusions:

The present case demonstrates that patients with partially corrected ACM, syringomyelia, cervical kyphosis, and difficult intubation undergoing Cesarean delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

Anaesthesia for caesarean section in a patient with lumbar syringomyelia

BACKGROUND AND OBJECTIVES

Syringomyelia is a rare neurological condition characterized by the presence of an expansive cystic cavity in the spinal cord, resulting in several neurologic manifestations. The objective of the present report was to address the safety of general anesthesia in this group of patients.

CASE REPORT

This is a 28-year old primipara with lumbar syringomyelia scheduled for lower segment cesarean section (LSC). Surgery was performed under general anesthesia without complications. General anesthesia was chosen for this patient to avoid manipulation of the subarachnoid space during neuraxial anesthesia, which could cause changes in intracranial pressure or worsening neurological symptoms. We used rocuronium considering that it avoids rising in cerebrospinal fluid pressure and hyperkalemia that can be seen with succinylcholine.

CONCLUSIONS

General anesthesia can be safely used in patients with syringomyelia. Care should be taken to prevent increase in intracranial pressure and neuromuscular blockade should be monitored.

Epidural anesthesia for Cesarean delivery in a patient with post-traumatic cervical syringomyelia

PURPOSE

To illustrate the successful management of a patient with post-traumatic syringomyelia (PTS) and chronic pain syndrome who presented for elective Cesarean delivery under epidural anesthesia.

CLINICAL FINDINGS

A 30-yr-old gravida 3 para 1 woman, with a known diagnosis of cervical PTS secondary to a whiplash injury sustained three years earlier, presented to the labour and delivery unit at 31 weeks' gestation. She had severe pain in the cervical and lumbar spine, motor and sensory deficits in the upper extremities, tender mass in her left trapezius muscle, and history of dizziness and syncopal episodes. She was taking oxycodone 120 mg·day(-1) Magnetic resonance imaging of her spine revealed a syrinx of 2 mm in diameter extending from C4 to T1 levels with disc protrusions in the C4-C6 region. There was no evidence of Arnold-Chiari malformation or elevated intracranial pressure. On airway examination, her Mallampati score appeared normal, but there was a limitation in the range of her neck movements in all directions. An elective Cesarean delivery was planned at 39 weeks' gestation. An epidural catheter was placed using ultrasound guidance, and the procedure was performed without complications.

CONCLUSIONS

The successful management of this case suggests that epidural can be considered in women with cervical PTS presenting for a Cesarean delivery.

Laparoscopic cholecystectomy in a morbidly obese patient with Chiari I malformation and craniocervical anomalies

Chiari I malformation is the downward herniation of cerebellar tonsils through the foramen magnum, and is frequently associated with craniocervical anomalies. Laparoscopic surgery can cause an increase in intracranial pressure due to the obstruction of the foramen magnum. The successful administration of general anesthesia in a 50-year-old, morbidly obese woman with a difficult airway, scheduled for laparoscopic cholecystectomy, who was incidentally diagnosed with Chiari I malformation associated with craniocervical anomalies, is presented.

Anaesthesia for caesarean section in a patient with syringomyelia and Arnold-Chiari type I malformation

A 37-year-old primiparous woman with syringomyelia and Arnold-Chiari type I malformation was scheduled to undergo elective caesarean section for a fetus in the breech presentation. Caesarean section was performed under general anaesthesia without complications; all we observed was an exaggerated response to atracurium. The patient was discharged home 7 days after the operation without neurological deterioration. General anaesthesia was chosen in this patient to avoid any spinal manipulation that could increase intracranial pressure or reduce intraspinal pressure and cause deterioration of neurological symptoms. Syringomyelia is a progressive myelopathy characterised by cystic degeneration within the spinal cord, which causes severe neurological deficits. The anaesthetic management is discussed.

Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiari malformation

IMPLICATIONS

We report the successful management and outcome of spinal anesthesia for Cesarean delivery in a woman with a surgically corrected Arnold Chiari Type 1 malformation, a seizure disorder, and idiopathic thrombocytopenia of pregnancy.

Post-traumatic syringomyelia: a review

More than a quarter of spinal cord injured patients develop syringes and many of these patients suffer progressive neurological deficits as a result of cyst enlargement. The mechanism of initial cyst formation and progressive enlargement are unknown, although arachnoiditis and persisting cord compression with disturbance of cerebrospinal fluid flow appear to be important aetiological factors. Current treatment options include correction of bony deformity, decompression of the spinal cord, division of adhesions, and shunting. Long-term improvement occurs in fewer than half of patients treated. Imaging evidence of a reduction in syrinx size following treatment does not guarantee symptomatic resolution or even prevention of further neurological loss. A better understanding of the causal mechanisms of syringomyelia is required to develop more effective therapy.