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The spina bifida occulta challenge for anaesthesia during labor: 11AP2-4

Martín Mestre, C.; Pagès, L.; Raduá, V.; Cabello, R. M.; Poch, P.

European Journal of Anaesthesiology: June 2012 - Volume 29 - Issue - p 165
Obstetric Anaesthesia
Free

Hospital General de Granollers, Department of Anaesthesiology and Pain Medicine, Granollers, Spain

Introduction: Spina bifida occulta is a congenital spinal column defect (prevalence from 5 to 40%) usually located at L5-S1 level. It is frequently diagnosed by chance, on radiologic tests performed for other reasons. The epidural approach is the anaesthesia technique of choice for labor. This anaesthesia technique may be challenging in spina bifida occulta patients, because of changes in sacrolumbar anatomy, dural puncture risk and unpredictable anaesthesic distribution.

Case report: We report the case of a 39 year-old woman with history of previous cesarean performed under general anaesthesia and subsequent diagnosis of spinal column dysmorphogenesis at lumbosacral region with spina bifida occulta, involving L4-L5 and L5-S1 levels. An epidural approach was used for anaesthesia management during labor. With the patient in sitting position, the puncture in L1-L2 epidural level was performed using the “loss of resistance to saline” technique with a Tuohy 18 G needle. The epidural space was finally located 5 cm deep from the skin and an epidural catheter introduced 9 cm. An intradural or intravascular location was previously ruled out by injection of 3 mL of a 0,25% bupivacaine solution. An initial dose of 6 mL of bupivacaine 0,25% + fentanyl 50 μg was administered through the catheter 5 minutes after the puncture, followed by a perfusion of bupivacaine 0,0625% + fentanyl 2 μg/mL at 12 mL/h, initiated 15 minutes later. The patient was stable for the whole procedure, without neurological complications. Vaginal delivery occurred six hours later, without complications. There were no differences in spreading, dose requirements and duration of the anaesthesia compared to the regular epidural technique. No complications were reported during the 24 hours post-delivery and long-term.

Conclusion: Spina bifida occulta represents a challenge for epidural anaesthesia technique, poorly reported in literature. Nevertheless, known benefits of epidural anaesthesia for labor make the adaptation of this technique in this challenging situation preferable to general anaesthesia. As shown, epidural anaesthesia may be still feasible in patients with spina bifida occulta.

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        © 2012 European Society of Anaesthesiology