Labor analgesia for the parturient with
scoliosis & previous back surgery
Samina Ismail
Associate Professor
Aga Khan University
Karachi, Pakistan
Road Map
• What is Scoliosis?
• Challenges faced during provision of labour
analgesia.
• Is neuraxial technique possible for these
patients?
• What are other options of pain relief.
• Labour analgesia for patents with neural tube
defect
What is “Scoliosis”?
Thoracic Scoliosis Lumbar Scoliosis
Severity of Scoliosis
Curve of >400 require surgical
correction
These patients requiring obstetric anaesthesia
When refused
by patients
or technically
services
should
beimpossible.
referred early in the
preoperative
anesthesia
clinic
for:
Intravenous
PCIA is the “next
–best” choicefentanyl/
remifentanil are commonly used drugs.
•Fentanyl:
Evaluation of any associated cardiopulmonary and
musculoskeletal
disease.
Loading
dose 50-100mcg
May
have
severe
cardiopulmonary
dysfunction
•Bolus
Evaluation
ofmcg
operative
and
radiographic
reports in
20-40
Explanation
of
risk
& benefits:
assessing
the location
and extend of vertebral
Lock
out
time
5-10
minutes
Failure of technique.
anomalies.
Remifentanil:
Increase
chances
in patients with neuromuscular disease
Inadequate
analgesia
infusion
mcg/kg/min
•Basal
Discussion
with0-0.05
the patient
and family of different
Increase
likelihood
of dural puncture
options
of
labor
analgesia.
Bolus
25-50
mcg
Unlike
if correction
is done during
teenage
Less potential
for successfully
treating
PDPHyears.
•Lock
Explanation
of 5risk
and benefits of labor epidurals.
out time
minutes
High block
Evronfor
S, Ezri
T. Optionsfailures
for systemic
labour analgesia.
• Counseling
the possible
of techniques.
Risk of infection in caseCurr
of previous
surgery 2007; 20 :181
Opin Anaesthesiol
Challenges Faced!!
In providing neuraxial analgesia for patients with
or without corrective surgery are:
inability to identify the epidural space
multiple attempts before catheter insertion
patchy analgesia
 accidental dural puncture
The anatomic
anomalies leading to
these challenges are as
follow:
Distortion or absence
of spinous processes,
which is the key
landmark of
placement of neuraxial
anesthesia; therefore
palpation is not always
the best method for
the identification of
space.
In uncorrected
scoliosis, there is
deviation of the
midline of the epidural
space towards the
convex aspect of the
scoliosis relative to the
spinous process.
In the uncorrected
patient the needle
should be oriented
towards the convexity
of the curve where
the interlaminar
spaces are generally
larger
Spinal surgery involves
decortication of vertebrae
and removal of spinous
process along the extent of
the curve
Scar tissue in post
surgical patient and bone
grafts can hinder the entry
of neuraxial needles into
the desired space
Patient with Harrington
rod are unable to flex their
spine.
Postoperative adhesion
or obliteration of the
epidural space can
interfere with local
anesthetic spread and
increase chances of
inadvertent dural puncture
and inadequate anesthesia
Is neuraxial technique possible in
these patients?
Despite these difficulties, successful spinal and
epidural have been reported in parturient
with corrected and uncorrected scoliosis.
First two reports in 1985
Labor pain relief in patients with previous spinal
instrumentation
 Feldstein G, Ramanathan S. Obstetrical lumbar epidural
anesthesia in patients with previous posterior spinal fusion for
khyphoscolisis. Anes Analg. 1985.
 Hubbert CH. Epidural anaesthesia in patients with spinal
fusion. Anes Analg. 1985.
Successful epidural analgesia is reported in the
range of 42-94%.
Can J Anesth 1989
Reg Anesth 1990
Anesth Analg 2009
Literature Review
22 articles reported 117 neuraxial techniques in
parturient.
Ko J Y, Leffert R L. Clinical implication of
neuraxial anaesthesia in parturient with
scoliosis. Anesth Analg 2009
n=24
n=93
n=117
Outcomes of Neuraxial Procedures
24
19
0
79%
93
64
2
69%
Persistent back pain after
epidural placement of unknown
etiology
Trouble shooting in case of inability or
ineffective functioning of labor epidural:
Ultrasonography may be helpful tool in defining the
relevant anatomy at the time of initiation of neuraxial
anesthesia
Normal Spine
Scoliotic Spine
Can J Anaesth 2005;52:717-20.
In the
uncorrected
patient the
needle should
be oriented
towards the
convexity of the
curve where the
interlaminar
spaces are
generally larger
In case of unilateral block due to
rotation of the spine :
Patient can be paced in the lateral position with
the less blocked side in the dependent
position.
In case of patchy block:
Large volume / low concentration LA may
overcome the problem.
Placement of additional epidural catheter at
the level of the unblocked dermatome has
been described .
Spinal Anaesthesia
• The absence of scarring within the intrathecal
space ensures unhindered spread of local
anesthetic in post spinal surgery patient.
• The dose of spinal anesthetic should be reduced
to half, if is used after a failed epidural
Dadarkar P, Philips J, Werdner C, Perz B, Slaymarker E,
TabaczewaskaL, Wiley J, Sharma S. Spinal Anaesthesia for
cesarean section following inadequate labor analgesia: a
retrospective analysis. Int J Obstet Anesth 2004; 13 (4):23943.
Labor analgesia for spina bifida.
What is
Spina Bifida?
Type ofbifida
neuraloculta
tube
Spina
defect (incidence
arises when the
1/1000).
two halves of the
Group of condition
vertebral
categorizedarch
into: fail
to fuse in the
Spina bifida occulta.
midline.
Spina bifida cystica
The spinal cord and
nerve roots are
normal. There is no
external lesion.
Spina bifida cystica is the more severe form
and is defined as failed closure of neural
Spina
bifida
arch with herniation
of meninges
(meningocele), the meninges
and neural
occulta
elements (meningomyelocele
Spina bifida cystica
Meningocele
Meningomyeloele
Meningomyeloele
Most severe form of Spina Bifida Cystica:
Myeloschisis
Failure of
neural folds to
fuse
myeloschisis
Preoperative Anesthesia
Evaluation
• Medical history : Coexisting defects in the genitourinary,
respiratory, musculoskeletal and cardiovascular systems.
• Degree of neurological impairment must be precisely
defined by imaging studies :
delineate
the exact location of the spinal defects, its
 plain
radiographs
extent, and will
provide some guidance
for before
the placement
 computerized
tomography
ideally
of epidural for labor.
 magnetic resonance
pregnancy
Kuczkowski KM. Labor Analgesia for pregnant women with
spina bifida: What does an obstetrician needs to know?
Arch Gynecol Obstet 2007 ;275: 53-66.
How to provide labour analgesia?
• No specific guidelines for administration of
labour analgesia.
• Regional techniques have been reported but
with limitations and complications.
Tidmarsh, May AE Epidural anaesthesia and nural
tube defects. Int J Obstet Anaesth 1998; 7:111-14.
conducted retrospective chart reviews of the anesthetic
management during labor of 16 patients. The authors
concluded that the conduct of epidural analgesia in patients
can be technically difficult and results often unpredictable
(e.g., excessive cranial/ poor perineal spread of local
anesthetic and /or asymmetric block
International Journal of Obstetric Anesthesia
Volume 18, Issue 3, July 2009, Pages 258-261
 Adjunct
to unsatisfactory fentanyl IVPCA is reported in a 31-year-old
parturient with spina bifida occulta and a tethered spinal cord
reaching L5-S1.
Dexmedetomidine significantly improved the analgesic quality;
increased sedation was observed, but the patient was easily rousable
to verbal stimuli.
No episodes of maternal hypotension or bradycardia, or fetal heart
rate irregularities occurred.
Conclusion:
• Providing labor analgesia for these patients, pose lots
of challenges to the obstetric anesthetists.
• Every patient needs to be individualized.
• Assessment in the preoperative clinic for associated
medical problems and extend of lesion.
• Understanding the anatomic anomalies in these
patients helps in the institution of neuraxial anesthesia.
• Since regional technique is the ideal method of labor
analgesia, these patients should be given a trail after
proper planning .
Anatomical deformity should not be hindrance
for the provision of pain relief for laboring
women
In January 19, 1847 first anaesthesia using
diethyl ether was used by Simpson to
anaesthetize a woman with deformed pelvis.
Remember!
“The delivery of an infant
into the arms of a
conscious and pain free
mother is one of the most
exciting and rewarding
moment in medicine”
Moir DD - 1979